How to Create a Research Protocol
The Research Protocol is a statement of the researcher's project design and a description of
his/her responsibilities toward the human subjects involved in the research.
To ensure an effective review by the Institutional Review Board, a full description of the planned
research must be submitted with the Application for IRB Review. A research protocol provides
the reader with background information of the problem under study, including the study
rationale, a detailed plan for conducting the research involving human research participants, and
a discussion of the potential importance of the research.
1. Objectives
The purpose of the study (research questions and / or study objectives) should be clearly and
succinctly stated. In experimental designs, objectives may be stated as hypotheses to be tested.
2. Background and Rationale
Summarize and synthesize the available research (including published data) to provide
justification for the study. Evaluate prior research for relevance to the research question under
study. Describe the significance of the research including potential benefits for individual
subjects or society at large.
3. Procedures
The procedures should include the following:
a) Research Design
The research design should be identified and should be appropriate to answer the research
question(s) under study. Describe the type of research proposed (e.g. experimental, correlational,
survey, qualitative) and specific study design that will be used.
b) Sample
Describe the sampling approach to be used. Identify the procedures that will be used to recruit,
screen, and follow study volunteers. Specifically define the study sample (number of subjects to
be enrolled, characteristics of subjects to be included in and excluded from the research, and
whether this will be a random or convenience sample).
c) Measurement/Instrumentation
Identify the variables of interest and study endpoints (where applicable). Justify measurement
techniques selected. Provide information regarding the validity and reliability of selected
measures.
d) Detailed study procedures
Methods for collecting data and for avoiding / minimizing subject risks should be included.
Include a timeline for subject participation in the project. Identify how subject confidentiality
will be safeguarded (plans for coding data and for securing written and electronic subject
records). Indicate how long personal information will be stored once the study is completed.
Methods will vary with the research approach used (qualitative, quantitative). The selected
methods should be sufficiently described to justify the use of the approach for answering the
defined research question. Methods should also be described in adequate detail so that IRB
members may assess the potential study risks and benefits.
e) Internal Validity
Threats to internal / external validity should be considered. Describe measures that have been
taken to avoid study bias.
f) Data Analysis
Specify the analytic techniques the researcher will use to answer the study questions. Indicate the
statistical procedures (e.g. specific descriptive or inferential tests) that will be used and why the
procedures are appropriate. For qualitative data, specify the proposed analytic approaches.
4. Bibliography
Include a reference list of literature cited to support the protocol statement.
What does literature reports about anti-inflammatory, anti-oxidant dietary approaches to mitigate fibromyalgia symptoms? A literature Review
Lorraine M. Justiniano, RDN, MS Candidate
FDNT 680 – Research Seminar
Dr. Anjejo
Andrews University
April 24, 2020
1
INtroduction
2
Fibromyalgia
Chronic Neurological Disease that amplifies pain perception throughout all body muscles (ACR, 2019).
3
Fibromyalgia
4
Severe Pain Sensitivity
Chronic Fatigue
Headaches
Anxiety
Memory/Concentration
Sleeping disorders
Inflexibility (especially in the morning)
Epidemiology
Between 4 to 5 millions of US adults.
Women
Middle age
75% to 90% of all cases
Symptoms: more prominent or intensified
(CDC, 2017; NFA, n.d. & Weird et. Al. 2006)
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Risk Factors
6
Traumatic Events (Physical and/or Mental)
Family History (8x greater)
Virus infections
Obesity
Lupus
Rheumatoid Arthritis
* Irritable Bowel Syndrome (IBS) & Non-Celiac Gluten Sensitivity co-exist with FM.
*70% of FM patients reports IBS symptoms.
etiology
7
Premature aging of nervous system
Brain’s Chemical Defect (Neurotransmitters)
Hormonal Imbalances
Inability of the body to detoxify appropriately
Treatment
Conventional Treatment
Pain Killers
Alternative Treatments
Aerobic exercise
Yoga
Tai Chi Martial Arts
Stress Management with
Cognitive Behavior Therapy
Acupuncture
Chiropractic / Physical Therapy
Massages
Nutritional Therapy
Lightly Studied
No official treatment
Could play a key role
8
Aim of literature review
To discuss what studies show about anti-inflammatory/anti-oxidant dietary approaches, including supplementation, on Fibromyalgia symptoms in women.
rationale
FM has been strongly linked with:
High Levels of Oxidative Stress & Weak Antioxidant Capacity.
Nutritional Deficiencies.
Mostly plant-based diets have been linked with less oxidative stress, due to high intake of anti-inflammatory & antioxidant food sources.
9
Methodology
10
Search Strategy
Search dates | Research Engines | Target Population | Study Designs | Inclusion Criteria | Exclusion Criteria |
October 2019 – April 2020. | Ebscohost, PubMed, Deep Dyve, Google Scholar. | Adult women diagnosed with FM. | Experimental or Quasi Experimental, Crossover & Clinical Trial. | Peer-Reviewed Human Studies. | Observational studies Systematic or Meta-analysis reviews Subjects requiring specific nutritional interventions. Pregnant women Breastfeeding women |
11
Table: characteristics of the included studies
12
Results
13
Vegetarian/Vegan Diets
Significant decrease in musculoskeletal pain. As consequence, participants also improved quality of life (p = 0.005).
Some of them reported significant decrease/improvement in general health (p = 0.02), stiffness (p = 0.0001) and sleep (p = 0.0001).
However, Martínez-Rodríguez, et. al. (2017) reached statistical significance only when vegetarian diet was followed along with core exercise. The control group following a vegetarian diet with no exercise didn’t experience changes in symptoms.
14
Igubac diet/fodmap diet inflammatory gut-brain axis control diet
The use of FODMAP diet by itself reached significant decrease (p < 0.01) in all FM symptoms including musculoskeletal pain, muscle tension and gastrointestinal symptoms.
IGUBAC Diet intervention mostly showed a non-significant tendency to improve FM symptoms such as pain and fatigue. It reached significant decrease in Pain Catastrophizing (p = 0.011) and pain intensity (p < 0.05).
15
supplementation
Modified Myer’s-Formula (intravenous nutrient therapy) promoted a significant decrease in pain and fatigue (p = 0.005). Energy level was increased. No dietary intervention (usual diet was not described).
Supplementation with olive oil showed some improvement in Pain Catastrophizing questionnaire and Fatigue Severity Scale, both not significant.
Turmeric supplement ( + IGUBAC diet) showed a moderate change for Fatigue Severity Scale. Statistical significance for pain intensity (p < 0.05)
16
What other reviews say?
A healthy diet in conjunction with other interventions might represent a decrease in fatigue and/or pain symptoms, improving quality of life. However, they couldn’t establish a solid diet – FM association due to the lack of rigorous studies (da Silva, A.F., et.al., 2017).
Mitigation of FM symptoms can be reach on patients adopting a diet rich in antioxidants and when excitotoxin substances such as MSG and aspartame are eliminated from diet (Rossi, A. et.al., 2015 & Firestone, K., et. al., 2012).
17
mechanisms
18
Weight
Vegetarian/vegan diets tend to promote weight loss (levels of pro-inflammatory cytokines & CRP ↓.
Increase
Increase
Increase intake of antioxidants; decrease Reactive Oxygen Species (ROS); Mitochondrial functioning improvement; More ATP for muscle & neural cells; Less Pain.
Supplementation
Supplementation with phytochemical-rich medical food (targeting nutrients that FM patients tend to lack) will support the expression of Metallothionein mRNA, promoting the binding function of this protein with toxic elements such as Mercury, Cadmiun, Lead, Arsenic. As consequence; decrease in ROS.
Increase intake of antioxidants; decrease the production of FREE SUPEROXIDE RADICALS. In turn, synthesis of TNF-ALFA & IL-BETA (cytokines involved in inflammatory pain) will be interrupted.
mechanisms
19
Decrease
Decrease lipid peroxidation by antioxidant/anti-inflammatory components will decrease phospholipids damage in cell membranes of the brain; less alteration to neurotransmitters system; improve in depressive symptoms. Less ROS, less inflammatory cytokines. (For instance: olives)
Support
Increase in Vit. B complex and Vit. C; support production of neurotransmitters responsible for changing pain perception.
Limit
Limit processed food intake; limit the intake of excitatory neurotransmitters such as MSG & Aspartame; less neurotoxicity; mitigation of FM symptoms.
Pain and discomfort
The use of low FODMAP Diet decrease bacterial fermentation; less pain and discomfort.
Strengths & limitations
Strength
Results could be generalized to all women with FM that otherwise are not suffering from other serious chronic disease or allergies.
Limitations
All studies had very small samples.
Short period of intervention.
Many studies lack control group.
Lack of more recent & rigorous studies.
20
Conclusions
21
Overall findings & Public health implications
Dietary interventions focusing on anti-inflammatory and anti-oxidant rich food and the elimination of pro-inflammatory/oxidant substances, may have the potential to ease FM symptoms and to deliver a better quality of life to women suffering from FM.
Its effects can even be more pronounce when use along with other medical and non-medical approaches according to individual needs.
Long-term RCT studies are deeply needed and encourage to be able to develop an official nutritional intervention.
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Vegetarianism and Prevalence of Mental Health Disorders in Adults
Amara Sims
FDNT 680
Dr. Dixon Anjejo
April 28, 2020
Table of Contents
Self-perceived mental health 7
Prevalence of mental health disorders 8
Motivators of a vegetarian dietary pattern 9
Conclusion and Implications 13
Abstract
Background: Mental health disorders are becoming one of the leading causes of disability worldwide. Adopting a plant-based diet has been an effective lifestyle approach to preventing noncommunicable diseases, including cardiovascular disease and some cancers. Only 36.9% of individuals diagnosed with mental health disorders receive treatment, thus an intervention involving diet may be more feasible at a population level to reduce the risk of depression, and mood and anxiety disorders.
Objective: A systematic review to summarize the association between following a vegetarian diet by habitual intake or intervention and the measures of self-perceived mental health or the prevalence of mental health disorders.
Exposure and Outcome: The exposure was following a vegetarian diet by habitual intake or intervention; while self-perceived mental health and the prevalence of mental health disorders are the outcomes.
Methods: Articles were selected from several peer-reviewed databases (Google Scholar, EBSCO, PubMed, SAGE Journals, ScienceDirect/Elsevier, Web of Science, Oxford Academic, Wiley Online Library) and subsequent reference lists were also scoured. Advanced search tools were used to narrow down the results, including keywords such as “vegetarian,” “vegetarianism,” “mental health,” “depression,” and “anxiety.” Studies were eligible whether they detailed human observational and intervention studies over the past 10 years that clearly defined the dietary patterns. Studies were excluded if they were an animal study or human cell line study or failed to measure self-perceived mental health or the prevalence of mental health disorders.
Results: 118 articles were identified from the peer-reviewed databases and 17 from reference lists. 120 articles were excluded due to being duplicates, or after screening the titles, abstracts, keywords, and full-text. Overall, there is evidence that shows following a vegetarian diet with the right motivators is associated with a decrease in the risk of mental health disorders by 26-35%.
Conclusion and Implications: The results of this review have built upon evidence in the literature that investigates the potential of vegetarian diets in mediating the risk of mental health disorders and could direct health promotion and policy changes. This systematic review reflects on and supports the present knowledge in literature which includes contrary evidence. Thus, there still exists a need for future research to ultimately determine the role of a vegetarian dietary pattern in the prevention of mental health disorders.
Background and Rationale
Mental health disorders are becoming one of the leading causes of disability worldwide. In the United States, almost 1 in 5 adults will experience depression or have an anxiety disorder annually; unfortunately, only 36.9% of those 40 million individuals will seek treatment, such as cognitive-behavioural therapy and pharmacological intervention (Anxiety and Depression Association of America, 2020) because of social stigma, accessibility, or lack of knowledge or awareness. Women carry a heavier burden compared to their male counterparts, being twice as likely to be affected by symptoms of these disorders (Anxiety and Depression Association of America, 2020). The risk factors include personality, life events, gender, age, life events, and family or genetic history (Anxiety and Depression Association of America, 2020).
Preventing the prevalence of chronic mental health disorders at the population level is the most ideal approach, especially if these chronic conditions can be addressed by lifestyle changes, including diet. A plant-based diet has shown many benefits for other noncommunicable diseases, including cardiovascular disease and some cancer types (Craig, et al., 2018). Studies investigating the impact of vegetarian diets on mental health disorders have provided conflicting results, but the evidence should be revisited. This systematic review will compile this research conducted over the past ten years, while also summarizing the mechanisms that affect the risk of mental health disorders. The aim of this study is to summarize the association between following a vegetarian diet by habitual intake or intervention as the exposure or independent variable and the measures of self-perceived mental health or the prevalence of mental health disorders as the outcome.
Methods
Search strategies
The database searches were conducted in early February 2020. Articles were selected from several peer-reviewed databases (Google Scholar, EBSCO, PubMed, SAGE Journals, ScienceDirect/Elsevier, Web of Science, Oxford Academic, Wiley Online Library) and subsequent reference lists were also scoured. Advanced search tools were used to narrow down the results, including keywords such as “vegetarian,” “vegetarianism,” “mental health,” “depression,” and “anxiety.”
Study selection
Articles were screened for relevance based on title, abstract, and then the full content of the article. The following criteria were used to include relevant studies for this systematic review: (i) observational and intervention human studies across a variety of cultures; (ii) published within the past ten years; and (iii) clearly defined the dietary patterns studied. Articles were excluded if they (i) were an animal study or human cell line study, or (ii) did not measure self-perceived mental health or prevalence of mental health disorders. Figure 1 (Appendix A) outlines the identification, screening, eligibility, and inclusion processes that refined a final literature sample of fifteen studies.
Data extraction
Each study was analyzed based on the number of participants and their demographics. Dietary patterns were clearly defined and re-organized for ease of comparison. Exposure to a vegetarian diet through habitual intake or intervention were compared, as well the outcome of mental health disorders, as indicated by verified self-perceived health measures (e.g. Depression and Anxiety Stress Score (DASS) or Profile of Mood States (POMS)) or by the prevalence of mental health disorders. Authors were not contacted to discuss missing data.
Results
Description of studies
In total, 118 articles were identified from the peer-reviewed databases and seventeen from reference lists. However, after removing duplicates, 104 articles remained. An additional 42 articles were excluded after screening the titles, abstracts, and keywords. Sixty-two full-text articles were assessed and 47 were excluded on the basis that they were published over 10 years or did not clearly define the dietary plans. This process has been chronicled in Figure 1 (Appendix A). Therefore, fifteen studies were included in this systematic review, including two randomized controlled trials, nine cross-sectional studies, three cohort studies, and one case-control study. There was no artificial inflation of sample size since the participants from the studies did not overlap. Tables 1 and 2 (Appendix B) outlines the characteristics of these studies, including study designs, main objectives, exposures, measured outcomes, main findings, rationale or mechanisms, study limitations and gaps, and research recommendations from those eligible articles. The collection of study sample sizes ranged from 35 to 90 380 participants, aged 15 to 84 years old, in North America, Europe, China, Iran, and Australia. Overall, there is evidence that shows following a vegetarian diet with the right motivators is associated with a decrease in the risk of mental health disorders by 26-35%.
Self-perceived mental health
Nine studies employed a self-perceived mental health questionnaire to mental health while seeking to determine the difference between vegetarian and omnivore dietary patterns. The DASS was used by four studies, the POMS was used twice, in addition to the post-traumatic stress diagnostic scale (PDS) and SF-36. In a small study of 138 participants, vegetarian fatty-acid intake was not shown to negatively affect the mood; in fact, vegetarians had significantly lower DASS scores (8.32; p < 0.001) and POMS scores (0.10; p = 0.007) compared to omnivores; concluding that low EPA, DHA, and arachidonic acid (AA) intakes, and high intakes of ALA and LA, were associated with better mood ( p < 0.05; Beezhold et al., 2010). By restricting meat consumption, and thus, lowering AA intake, in a small study of 39 participants, Beezhold & Johnston (2012) reinforced the protective effect of vegetarianism on DASS ( p = 0.045), and later in 2014, Beezhold and colleagues studied a group of 620 participants, concluding that both age and veganism were significantly inversely associated with DASS scores ( p < 0.05 and p < 0.001, respectively); vegetarian and vegan males were associated with lower anxiety compared to omnivores (vegetarian: p = 0.022, CI95 = -0.401– -5.140; vegan: p = 0.002, CI95 = -1.03– -4.56); and vegan females were linked to significant lower stress scores compared to control ( p = 0.007; CI95 = -0.56– -3.51).
These gender results were also noted in a study of 3 846 adults by Hosseinzadeh et al. (2016): female vegetarians were 35% less likely to have depression (CI95 = 0.46–0.91); females following the traditional Iranian diet were 42% more likely to have depression (CI95 = 1.01–1.99) and 56% more likely to have anxiety (CI95 = 1.00–2.42); while male following the Western diet are 73% more likely to have depression (CI95 = 1.07–2.81). A close investigation of 74 participants who were randomly assigned to a vegetarian diet (60% carbohydrates, 15% protein, 25% fat) or the control diet (50% carbohydrates, 20% protein, 30% fat) showed a significant decrease in Beck depression scores after 24 weeks in the vegetarian cohort ( p < 0.001; Kahleova et al., 2013).
However, other studies showed the opposite evidence. The largest study in this review ( N = 90 380) found that depressive symptoms were 43% more likely in pesco-vegetarians (CI95 = 1.19–1.72) and 36% more likely in and lacto-ovo-vegetarians (CI95 = 1.09–1.70; Matta et al., 2018); as well as Burkert and colleagues (2014), who found, in a sample of 15 474 participants, a significantly higher prevalence of mental illnesses (including anxiety disorder and depression) in the vegetarian cohort compared to the carnivore cohorts ( p = 0.036). A similarly sized study, of 15 396 participants, showed that vegetarians in both European and Asian populations had lower positive mental health and more mental health problems ( p < .001; Velten et al., 2018). Lastly, vegetarians were associated with a higher PDS score of 7.4 compared to the control group ( p = 0.042), as well as a lower SF-36 score of 45.6 compared to the control ( p = 0.008) in a study on 1 254 Swiss adults (Schreiner et al., 2019).
Prevalence of mental health disorders
Three studies utilized the diagnosis of a mental health disorder as the outcome measure. A study of 4 181 German adults ranging from ages 18 to 79 found that vegetarians were 77% more likely to suffer from lifetime anxiety disorders than non-vegetarian counterparts (CI95 = 1.12–2.79) and 75% more likely to suffer from unipolar depressive disorders after 1 year (CI95 = 1.03–2.99; Michalak et al., 2012). A study of 9 905 adults in Finland showed an interesting relationship between seasonal affective disorder (SAD) patients and vegetarianism: SAD patients were 3.9 times more likely to be vegetarian ( p = 0.000, CI95 = 1.84–8.45), and vegetarians were 3.9 times more likely to have SAD ( p = 0.000, CI95 = 1.81–8.36; Meesters et al., 2016).
However, the comparison of three dietary patterns (Mediterranean, pro-vegetarian dietary pattern, Spanish government recommendations) of 15 093 participants showed a significant effect on depression: following a vegetarian dietary pattern reduced the risk of depression by 26% (CI95 = 0.61–0.89; Sánchez-Villegas et al., 2015).
Motivators of a vegetarian dietary pattern
Three studies took special consideration of the motivators that led to adopting a vegetarian dietary pattern. Hessler-Kaufmann and colleagues (2020) found a significant relationship effect between 3 groups ( N = 511) and Düsseldorf Orthorexia Scale (DOS) scores when predicting depression scores ( p = 0.01); noting that semi-vegetarians with high DOS score associated with higher depression scores ( p = 0.002) than omnivores or vegetarians. Nonetheless, two studies showed higher rates of depression in vegetarian cohorts due to motivators: the Lavallee et al. (2019) study ( N = 22 417) showed no relationship between vegetarian and control cohorts in the US, Germany, and Russia; but higher prevalence of depression among Chinese vegetarian students (R2 = 0.087; p < 0.001); and the Forestell et al. (2018) cross-sectional study of 6450 participants found vegetarians to be significantly more depressed than omnivores ( p < 0.001), although no significance between the vegetarian and semi-vegetarian cohorts ( p = 0.155).
Discussion
The studies included in this systematic review had mixed conclusions on the effectiveness of a vegetarian diet as an intervention for preventing mental health disorders. Five studies showed a significant ( p < 0.045) protective impact of a vegetarian diet on self-perceived mental health (Beezhold & Johnston, 2012); (Beezhold, Johnston, & Daigle, 2010); (Beezhold, Radnitz, Rinne, & DiMatteo, 2014); (Kahleova, Hrachovinova, Hill, & Pelikanova, 2013); (Hosseinzadeh, et al., 2016); one study showed a significant (CI95 0.61 – 0.89) decrease in the prevalence of mental health disorders (Sánchez-Villegas, et al., 2015); and another study showed the significant (p = 0.002) protective effects due to motivation (Hessler-Kaufmann, et al., 2020). However, five studies showed a significant ( p < 0.046) negative association between a vegetarian diet and self-perceived mental health (Matta, et al., 2018); (Burkert, Muckenhuber, Goßschädl, Rásky, & Freidl, 2014); (Velten, Bieda, Scholten, Wannemüller, & Margraf, 2018); (Schreiner, et al., 2019); two studies showed a significant (CI95 < 1.81) increase in the prevalence of mental health disorders (Michalak, Zhang, & Jacobi, 2012) (Meesters, et al., 2016); and still two others show a negative effect ( p < 0.001) of motivating factors on depression (Lavallee, Zhang, Michelak, Schneider, & Margraf, 2019); (Forestell & Nezlek, 2018).
This review supports the current contrary evidence available in the literature. The most recent study by Dobersek et al. (2020) investigated the association between abstaining from meat or restricting meat consumption and depression and anxiety. The authors similarly presented both positive and negative evidence due to a variety of methodologies used in the studies, as well as limited interpretations and significance (Dobersek, et al., 2020). The temporal association between the onset of depressive symptoms and the adoption of dietary patterns was also addressed, as well as noting that causality could not be determined, as a result of limited study designs (Dobersek, et al., 2020). As a result, the conclusion proposed that restricting meat consumption is not a strategy to improve mental health (Dobersek, et al., 2020).
Potential mechanisms
Psychological disorders may lead to adopting vegetarianism (Forestell & Nezlek, 2018). Thus, it is possible that depressed individuals may try to improve their wellbeing by adopting vegetarian dietary habits (Forestell & Nezlek, 2018); (Michalak, Zhang, & Jacobi, 2012); (Schreiner, et al., 2019).
The reduced amount of arachidonic acid in the diet by restricting meat consumption is able to affect the mood (Beezhold, Johnston, & Daigle, 2010), as well as an increased intake of polyunsaturated fatty acids, such as omega-3 fatty acids (Beezhold & Johnston, 2012) found in many nuts and seeds, affects the mood through the serotonin pathway (Beezhold, Johnston, & Daigle, 2010). In addition, the vegetarian diet alters neurotransmitter synthesis and receptor dynamics, thus increasing voluntary control over food intake (Kahleova et al., 2013). The individual may be satisfied with the type and amount of food consumed, thus indirectly maintaining BMI and reducing the risk of obesity. By reducing the consumption of animal products, especially found in processed food, and increasing the consumption of fruits and vegetables (antioxidant load), the risk of inflammation is reduced and the individual gains the ability to cope with stress and anxiety (Beezhold, et al., 2014; Hosseinzadeh, et al., 2016).
However, not all studies showcased the protective effect of vegetarian diets. Due to nutritional deficiency, including iron, calcium, zinc, vitamin B12, vitamin D, or some omega-3 fatty acids, the risk of mental health disorders is higher among vegetarians (Matta, et al., 2018). Finally, if the motivators to adopt a vegetarian dietary pattern are not strong, there may be dissonance between ideals and behaviour that leads to an increased risk of mental health disorders. Such motivations may include orthorexic tendencies (Hessler-Kaufmann, et al., 2020), or economic reasons (Lavalee et al., 2019).
Strengths and limitations
A strength of this systematic review is that a variety of cultures have been included to improve generalizability. In addition, a variety of dietary patterns were studied to showcase the varying degrees of antidepressive effects; however, this is also a limitation since not all participants entered with the same baseline diet.
Although random grouping ensures validity and generalizability, some of the studies had small sample sizes, which may reduce the generalizability of results. Many study designs did not plan any follow-up beyond two years to explore long term effects. The studies may have also been exposed to selection bias since participants with a higher vegetable intake are often associated with higher socioeconomic status, higher education, household income, and physical activity; as well as social desirability, wherein the participants responded to the surveys and questionnaires to impress the researchers.
Overall, a majority of the studies included had a cross-sectional design; this limits the ability to determine causality – whether the diet type caused the depressive symptoms, or the depressive symptoms influenced the diet choice (Matta, et al., 2018).
Conclusion and Implications
The results of this review have built upon evidence in the literature that investigates the potential of vegetarian diets in mediating the risk of mental health disorders. Nonetheless, the results of this review could direct health promotion and policy changes, particularly regarding the dietary recommendations for individuals at risk for mental health disorders and to address risk factors by adopting coping strategies. This systematic review reflects on and supports the present knowledge in literature which includes contrary evidence. Thus, there still exists a need for future research to ultimately determine the role of a vegetarian dietary pattern in the prevention of mental health disorders.
Figure 1: Flowchart outlining the protocol adopted in this systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Four-Phase Flow Diagram (Moher, Liberati, Tetzlaff, & Altman, 2009).
Records identified through electronic database searching ( n = 118 )
Screening
Included
Eligibility
Identification
Additional records identified through reference lists ( n = 17 )
Records after duplicates removed ( n = 104 )
Articles with titles, abstracts, and keywords screened ( n = 62 )
Records excluded ( n = 42 )
(>10 year publication date, no clearly defined dietary patterns)
Full-text articles assessed for eligibility ( n = 15 )
Full-text articles excluded ( n = 47 )
(>10 year publication date, no clearly defined dietary patterns)
Final literature sample ( n = 15 )
Appendix B
Table 1: Characteristics of the included studies, organized by year
Source |
Duration |
Country |
Total Participants* |
Age (years) |
Dietary Pattern |
Beezhold et al., 2010 |
– |
USA |
138 |
– |
– |
Beezhold et al., 2012 |
2 weeks |
USA |
39 |
– |
Omnivore, pesco-vegetarian, vegetarian |
Michalak et al., 2012 |
– |
Germany |
4 181 |
18 – 79 |
Vegetarian |
Kahleova et al., 2013 |
24 weeks |
USA |
74 |
– |
60% carbohydrates, 15% protein, 25% fat |
Beezhold et al., 2014 |
– |
USA |
620 |
25 – 60 |
Vegan, vegetarian, omnivore |
Burket et al., 2014 |
– |
Austria |
15 474 |
> 15 |
Vegetarian, carnivore rich in fruits and vegetables, carnivore less in fruits and vegetables, carnivores rich in meat |
Hosseinzadeh et al., 2016 |
3 – 4 weeks |
Iran |
3 846 |
20 – 55 |
Lacto-ovo vegetarian, fast-food, traditional, Western |
Sánchez-Villegas et al., 2015 |
– |
Spain |
15 093 |
– |
Mediterranean, pro-vegetarian dietary pattern, AHEI-2010 |
Meesters et al., 2016 |
– |
Finland |
9 905 |
25 – 74 |
|
Forestell et al., 2018 |
– |
USA |
6 450 |
– |
Vegan, lacto-vegetarian, lacto-ovo vegetarian, pesco-vegetarian, semi-vegetarian, occasional omnivore, omnivore |
Matta et al., 2018 |
– |
France |
90 380 |
18 – 69 |
Omnivore, pesco-vegetarian, lacto-ovo vegetarian, vegan |
Velten et al., 2018 |
– |
Germany, China |
15 396 |
15 – 65 |
Vegetarian |
Lavallee et al., 2019 |
– |
Germany, China, Russia, USA |
22 417 |
|
|
Schreiner et al., 2019 |
– |
Switzerland |
1 254 |
– |
– |
Hessler-Kaufmann et al., 2020 |
– |
Germany |
511 |
18 – 84 |
Vegetarian, semi-vegetarian, omnivore |
*Number of participants who completed all trials.
Sims, 2
Table 2: Characteristics of Included Studies
Authors (year) |
Study design |
Main Objective |
Exposure |
Outcomes Measured |
Main Findings |
Rationale / Mechanisms |
Study Limitations and Gaps |
Research Recommend-ations |
Self-perceived health |
||||||||
Beezhold et al., 2010 |
Cross-sectional study |
To determine the difference and association between vegetarian and omnivore dietary patterns on mood |
n-3 fatty acids |
DASS; POMS |
VEG DASS scores lower than OMN ( p < 0.001); VEG POMS scores lower than OMN ( p = 0.007) |
Higher consumption of PUFA, lower consumption of AA |
No blood lipid or inflammatory marker measurements; selection bias; social desirability; not generalizable |
Explore the use of a dietary fat modification intervention to improve mood |
Beezhold et al., 2012 |
Randomized-controlled trial |
To determine the relationship between restricting meat and mood |
Meat intake |
DASS; POMS |
Vegetarian has lower DASS ( p = 0.045) |
Modulation of mood by inflammation and n-3/n-6 FAs |
Small sample; short duration; weight fluctuation |
Large sample; longer duration; manage BMI |
Kahleova et al., 2013 |
Randomized-controlled trial |
To determine the association between a vegetarian diet and psychological traits |
Veg: 60% carbs, 15% protein, 25% fat
Control: 50% carbs, 20% protein, 30% fat |
Quality of life, mood |
VEG decrease in Beck depression score after 24 weeks ( p < 0.001) |
Neurotransmitter synthesis and receptor dynamics, increase in voluntary control over food intake |
Small sample |
Large sample |
Beezhold et al., 2014 |
Retrospective cohort study |
To determine association between mood and lifestyle factors in VG, VEG, OMN |
Plant-based dietary pattern |
Negative measure: symptoms of depression and anxiety stress (DASS-21) |
Age inversely associated with DASS score ( p < 0.05), vegan inversely associated with DASS score ( p < 0.001); significant lower anxiety in male cohorts compared to OMN (VEG: p = 0.022, CI95 = -0.401– -5.140; VG: p = 0.002, CI95 = -1.03– -4.56); significant lower stress scores in VG females compared to OMN ( p = 0.007; CI95 = -0.56– -3.51) |
Animal product, fruit/ vegetable (antioxidant content), processed food intakes; ability to cope with stress/ anxiety helps to maintain plant-based dietary pattern; chronic inflammation |
Self-reporting; selection bias (recruited participants from websites for health-conscious individuals); social desirability |
Further studies on the direct and indirect effects of lifestyle on mood; efficacy of dietary treatment for mood disorders
|
Matta et al., 2018 |
Cross-sectional study |
To determine the relationship between depressive symptoms and vegetarianism |
Dietary pattern, exclusion of food groups |
Odds ratio |
Depressive symptoms were 1.43 times more likely in pesco-vegetarians (CI95 = 1.19–1.72) and 1.36 times in lacto-ovo-vegetarians (CI95 = 1.09–1.70) |
Nutritional deficiency (iron, calcium, zinc, vitamin B12, vitamin D, n-3 fatty acids) |
Self-reporting; inability to state causality; lack of information on nutritional status (caloric intake); confounders |
Further studies should include a larger sample vegan individuals; a longitudinal study to uncover temporal link (depressive symptoms and dietary patterns); remove confounders |
Burket et al., 2014 |
Cross-sectional study |
To determine differences between dietary habits and health-related variables |
Dietary habit |
Self-perceived health, chronic conditions (incl. mental illness) |
Significantly higher prevalence of mental illnesses (anxiety disorder, depression) in VEG compared to OMN ( p = 0.036) |
– |
Self-reporting, inability to state causality; lack of information on nutritional status (macro proportions) |
Further studies should focus on nutrition status |
Velten et al., 2018 |
Cross-sectional; longitudinal study |
To determine the association between lifestyle factors on positive mental health. |
Lifestyle factors (VEG, smoking, alcohol, PA) |
Negative: symptoms of depression and anxiety stress (DASS-21)
Positive measure: P-scale |
Both cohorts had lower positive mental health and more mental health problems ( p < .001) |
Variation of lifestyle factors |
Variation of lifestyle factors; inability to state causality; not generalizable |
Future studies should introduce lifestyle changes individually |
Schreiner et al., 2019 |
Cross-sectional; prospective cohort study |
To determine the association between VEG and gluten-free diets on psychological wellbeing in IBD patients |
IBD VEG |
Post-traumatic stress diagnostic scale (PDS); SF-36 |
VEG had a higher PDS score of 7.4 compared to control ( p = 0.042) and a lower SF-36 score of 45.6 compared to control ( p = 0.008) |
Psychological mechanisms; transitioning to a vegetarian diet related to onset of disorders (mental disorder directly impacts the adoption of plant-based diet or independently) |
Self-reporting, inability to state causality; some biomarkers were not measured; variability of duration participants had been following the diet |
Take lipid measurements, instead of relying on previous records from participant’s physicians |
Hossein-zadeh et al., 2016 |
Cross-sectional study |
To investigate the relationship between dietary pattern and psychological disorder prevalence |
Diet |
Odds ratio |
♀ VEG are 35% less likely to have depression (CI95 = 0.46–0.91); ♀ traditional diet are 42% more likely to have depression (CI95 = 1.01–1.99) and 56% more likely to have anxiety (CI95 = 1.00–2.42);♂ Western diet are 73% more likely to have depression (CI95 = 1.07–2.81) |
Inflammation; oxidative stress |
Self-reporting; inability to state causality; selection bias; not generalizable |
Future studies should investigate specific food or nutrition components |
Prevalence of mental health disorders |
||||||||
Michalak et al., 2012 |
Retrospective cohort study |
To determine association between vegetarian diet and mental disorders in community-based sample |
Dietary pattern |
Prevalence of mental disorders (depressive, anxiety, somatoform, and eating disorders) |
VEG: 1.77 times more likely to suffer from lifetime anxiety disorders than non-veg counterparts (CI95 = 1.12–2.79); 1.75 times more likely to suffer from unipolar depressive disorders after 1 year (CI95 = 1.03–2.99) |
Psychological mechanisms; transitioning to a vegetarian diet related to onset of disorders (mental disorder directly impacts the adoption of plant-based diet or independently) |
Self-reporting; one-item measure for vegetarian diet (no room for diversity of plant-based diets) |
Further studies that make clear definitions of all vegetarian dietary patterns and nutrition status; investigate cross-cultural differences |
Meesters et al., 2016 |
Case-control study |
To determine the association between SAD and vegetarianism |
Vegetarian |
Odds ratio |
SAD patients are 3.9 times more likely to be VEG ( p = 0.000, CI95 = 1.84–8.45); VEG are 3.9 times more likely to have SAD ( p = 0.000, CI95 = 1.81–8.36); Significant results noted in total population and women cohort |
Serotonin pathway affected by animal protein (tryptophan) |
Not a representative SAD sample (generalizability); self-reporting; inconsistent SAD definitions |
Prospective longitudinal study to investigate risk of developing SAD |
Sánchez-Villegas et al., 2015 |
Prospective cohort study |
To compare three dietary patterns with their effect on depression |
Dietary pattern |
Hazard ratio |
Med. 16% lower risk (CI95 = 0.69–1.02); Pro-veg 26% lower risk (CI95 = 0.61–0.89); AHEI-2010 40% lower risk (CI95 = 0.49–0.72) |
|
Self-reported; not representative sample (generalizability); confounding factors |
Future studies should investigate |
Motivators of a vegetarian dietary pattern |
||||||||
Hessler-Kaufmann et al., 2020 |
Retrospective cross-sectional |
To determine the relationship between motivation of diet and depressive symptoms |
Motivation for diet
Düsseldorf Orthorexia Scale (DOS) score |
Depressive symptoms
Patient health questionnaire (PHQ) depression scores |
Significant relationship effect between group and DOS scores when predicting PHQ depression scores ( p = 0.01); semi-veg with high DOS score associated with higher PHQ depression scores (p = 0.002) than OMN or VEG |
Dissonance between ideals and behaviour |
Not representative sample (generalizability); self-reporting |
Further studies on Reason and motivation for dietary patterns |
Lavalee et al., 2019 |
Cross-sectional, longitudinal study |
To determine association between vegetarianism and mental health cross-culturally over time |
Vegetarian |
Negative: symptoms of depression and anxiety stress (DASS-21)
Positive measure: P-scale |
No relationship between VEG and control in US, German, Russian cohorts
Higher prevalence of depression among Chinese VEG students (R2 = 0.087; p < 0.001) |
Motivations for adopting vegetarian diet (economical instead of healthy choice) |
Self-reporting; lack of information on nutritional status (macro proportions); did not use comprehensive mental health measures; SES measures not consistent |
Further studies on the impact of specific dietary intakes on mental health |
Forestell et al., 2018 |
Cross-sectional study |
To determine relationship between vegetarianism and personality in men and women |
Dietary pattern |
|
VEG significantly more depressed than omnivores ( p < 0.001), no significance between VEG cohorts ( p = 0.155) |
– |
Not a representative sample (generalizability); small effect size; inability to state causality |
Investigate reason and motivation for dietary patterns |
Vegan (VG); lacto-ovo vegetarian (VEG); omnivore (OMN); depression and anxiety stress score (DASS); profile of mood states (POMS); seasonal affective disorder (SAD); polyunsaturated fatty acids (PUFA); arachidonic acid (AA); inflammatory bowel disease (IBD); physical activity (PA); fatty acid (FA).
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What does literature reports about anti-inflammatory, anti-oxidant dietary approaches to mitigate fibromyalgia symptoms? Literature Review FDNT 680 – Research Seminar Dr. Anjejo Andrews University April 24, 2020.
Literature Review
What does literature reports about anti-inflammatory, anti-oxidant dietary approaches to mitigate fibromyalgia symptoms?
Background: Fibromyalgia (FM) is defined as a chronic neurological disease that amplifies pain perception throughout the whole body muscles. It is associated with high levels of oxidative stress and with a weak antioxidant capacity causing pro-inflammatory pain, being middle age women are the most affected. Dietary interventions might help in improving mechanisms of redox.
Purpose: To review what literature says about the impact of anti-inflammatory/anti-oxidant dietary approaches on FM symptoms.
Methods: The databases used to find the articles were Ebsco host, PubMed, Deeo Dyve, and Google Scholar from 1993 until 2019, with a total of 10 experimental studies in humans included. The key words used to find them were “fibromyalgia”, “diet”, “nutrition”, “vegan”, “vegetarian”, “plant-based”, “women”, “meat consumption”, “chronic pain”, “elimination diet”, “anti-inflammatory, anti-oxidant dietary approach”.
The target population was adult women diagnosed with FM. Articles from non-peer review journals, systematic or meta-analysis reviews, and with participants with co-morbidities requiring specific nutritional interventions, pregnant women, and breastfeeding women were excluded.
Conclusion: Overall, vegetarian/vegan diets, IGUBAC diets, and Supplementation delivered a significant decrease in FM symptoms, especially somatic pain, while the intervention period last.
Dietary interventions focusing on anti-inflammatory and anti-oxidant rich food such as happens with well-balance vegetarian/vegan diets and other diets that eliminate pro-inflammatory/oxidant substances, may have the potential to ease FM symptoms and to deliver a better quality of life to women suffering from FM.
Introduction
Fibromyalgia (FM) is defined as a chronic neurological disease that amplifies pain perception throughout all body muscles. It mainly involves the central nervous system. People with this condition experience extraordinary pain sensitivity. Other symptoms include chronic fatigue, headaches, weakness, mood changes, anxiety, and problems with memory and concentration. Inability to feel well rested even when sleeping through the night and/or inability to have an uninterrupted sleep; inflexibility (especially in the morning) and feeling of light stings in hands and feet are also present (Mayo Clinic, 2017 & The American College of Rheumatology, 2019). Irritable bowel syndrome (IBS) and Non-Celiac Gluten Sensitivity (NCGS) are conditions that commonly co-exist with FM (Mayo Clinic, 2017 & ACR, 2019.). The etiology of this condition has been difficult to identify and is poorly known. However, suggested possible causes include premature aging of the nervous system (Rusell & Larson, 2009), a defect of the brain’s chemicals (neurotransmitters) unable to inhibit pain perception (Buskila, D., 2009 & Treister, R. et. al., 2009), hormonal imbalances (the National Fibromyalgia Association (NFA), n.d.), and the inability of the body to detoxify itself appropriately (Lamb, et.al., 2011). According to the Centers for Disease and Control and Prevention (CDC, 2017) and to the NFA (n.d.), FM affects between 4 to 5 million of US adults. Risk factors associated with FM involve a traumatic event (physical and/or mental), family history (having a close relative with FM may post a risk 8 times greater than people who don’t have it), virus infections, obesity, lupus, and rheumatoid arthritis (CDC, 2017, ACR, n.d., Arnold et. al. 2004, Firestone, et.al, 2012). FM can affect everyone at any stage of life, but the most prevalence occurs in middle age women (between ages 30 to 40) accounting for about 75% to 90% of all cases (NFA, n.d. & Weir et. al. 2006). FM symptoms are also more prominent or intensified in women (NFA, n.d.).
FM economical burden varies from $100 to $1000 per month, per patient, after insurance covering (NFA, n.d.). The management of FM is multifactorial because no single approach is sufficient. The conventional approach includes painkillers approved by FDA for FM, such as duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica). The non-medicated treatment that has been suggested include aerobic exercise, yoga, Tai Chi Chinese martial arts, stress management with Cognitive behavioral therapy, acupuncture, chiropractic, physical therapy, and massages (Firestone, 2012 & ACR, 2019). The nutritional approach has been lightly studied. Overall, studies have shown that some foods may aggravate FM symptoms, that anti-inflammatory/anti-oxidant rich foods, and nutrient supplementation may have a positive impact on symptoms (Rossi, A. et.al., 2015). Studies have linked FM with high levels of oxidative stress and with a weak antioxidant capacity (Rossi, A. et.al., 2015) Vegetarian/vegan diets have proved to offer great benefits on human health due to its higher intake of anti-inflammatory and anti-oxidant food items (Kim, M.K., et.al. 2012, Le, L.T. & Sabaté, 2014). For that reason, this literature review intends to discuss what studies show about the impact of anti-inflammatory/anti-oxidant dietary approaches, including supplementation, on fibromyalgia symptoms in women. The hypothesis is that anti-inflammatory/anti-oxidant diets such as well-balanced vegetarian and/or vegan diet along with supplementation of nutrients of concerns in FM patients have the potential to improve quality of life and to reduce FM symptoms.
Methodology
Search Strategy
The search was conducted from October 2019 to April of 2020. Selected studies were chosen from the years 1993 to 2019. All studies were retrieved online from the databases Ebsco host, PubMed, Deep Dyve, and Google Scholar using the following key words; “fibromyalgia”, “diet”, “nutrition”, “vegan”, “vegetarian”, “plant-based”, “women”, “meat consumption”, “chronic pain”, “elimination diet”, “anti-inflammatory, anti-oxidant dietary approach”.
Study Selection
The target population was adult women officially diagnosed with Fibromyalgia using The American College of Rheumatology criteria. All the articles were restricted to English language (except for one in Spanish), to be peer-reviewed from scientific journals and to the experimental, quasi-experimental, crossover, clinical trial study design in humans. Systematic or meta-analysis reviews, populations with co-morbidities requiring specific nutritional interventions, pregnant women, and breastfeeding women were excluded.
Data extraction
Titles and abstracts were first identified and revised to determine if they could be included in this review. In the studies, the main exposure searched was diet (especially vegetarian and/or vegan diet). The main outcome searched was fibromyalgia symptoms. The type of diets, the type of intervention, duration of the intervention, age and gender of participants, and country of the study was also extracted directly from the articles.
Flow Chart
Results
Table 1. Characteristics of the included studies.
Source |
Duration (wks/months) |
Country |
*Total participants |
Age (years) |
Diet |
Nutritional Status |
|
Paula Marum, et.al. (2017) |
8 weeks |
Portugal |
31 |
18 – 70 (Mean: 51) |
FODMAP |
- |
|
Martínez-Rodríguez, et. al. (2017) |
4 weeks |
Spain |
21 |
34 ± 3 |
Lacto-vegetarian |
Mean BMI: 23 (normal) |
|
Kaartinen., et. al. (2000) |
3 months |
Finland |
28 |
34 – 62 (Mean: 51) |
Vegan-Raw |
Mean BMI: 28 (overweight) |
|
Lamb, et.al (2011) |
8 weeks |
USA |
8 |
48 – 74 (Mean: 55.6) |
Hypoallergenic, modified diet + supplementation with phytonutrients-rich medical food 2x/d. |
Mean BMI: 32.9 (overweight) Range: 20.4 to 44.8 |
|
Massey, P. (2007) |
8 weeks |
USA |
7 |
38 - 65 |
Modified Myer’s formula - intravenous |
- |
|
Donalson, M. et.al., (2001) |
7 months |
USA |
20 |
45 - 54 |
Hallelujah Diet (mostly raw vegetarian) |
- |
|
Mauro-Martín, I., et. al (2018) |
2 months |
Spain |
31 |
30 - 70 (Mean: 55.87) |
CibusOlivo supplement IGUBAC Diet |
Mean: 26 (overweight) |
|
Towery, P., et. al. (2018) |
8 weeks |
USA |
22 |
19 – 71 (Mean: 48) |
Lacto-ovo-vegetarian diet. |
Mean: 36 (overweight) |
|
Hostmark, A.T., .et.al (1993) |
3 weeks |
Norway |
10 |
Mean: 49.9 |
Vegetarian diet (+fasting 8-10 days) |
- |
|
Mauro-Martín, I., et. al (2019) |
1 month |
Spain |
13 |
30 - 60 |
Turmeric supplement IGUBAC Diet |
Mean: 27 (overweight) |
|
*Number of participants who completed all trials.
A total of ten full text articles were retrieved from online databases and included in this review, all of them had nutritional interventions. Six studies didn’t have a control group. The duration of intervention of the studies was between 3 weeks to 7 months. There are a total of about 273 subjects who participated among all studies from USA (4x), Norway, Spain (3x), Portugal, and Finland. The subjects’ age in the studies fluctuated from 18 to 74 years of age. Most participants were women. The participation of males was limited to two studies with a total 4 males. One study didn’t specify the gender of the subjects. Dietary interventions included in this review were anti-inflammatory in nature. Six studies used vegetarian/vegan diets, three studies focused on IGUBAC diet or FODMAP diet, and one study focused on keeping subjects’ regular diet but supplementing with an antioxidant rich formula via intravenous.
Vegetarian diets
All vegetarian/vegan diet interventions promoted mostly a significant decrease in musculoskeletal pain. As a consequence, participants also improved their quality of life, with some of them reporting significant decrease in fatigue, stiffness and better sleep as well. However, Martínez-Rodríguez, et. al. (2017) reached statistical significance only when vegetarian diet was followed along with core exercise. The control group following a vegetarian diet with no exercise didn’t experience changes in symptoms.
IGUBAC/FODMAP Diet
The use of FODMAP diet by itself reached significant decrease in musculoskeletal pain and gastrointestinal symptoms. IGUBAC Diet intervention mostly showed a non-significant tendency to improve FM symptoms such as pain and fatigue. It reached significant decrease in pain intensity and in their perception of Pain Catastrophizing.
Supplementation
Modified Myer’s-Formula, intravenous nutrient therapy, also promoted a significant decrease in pain and fatigue. Energy level was increased. No dietary intervention (usual diet was not described).
Supplementation with olive oil showed some improvement in Pain Catastrophizing questionnaire and Fatigue Severity Scale, both not significant. Turmeric supplement showed a moderate change for Fatigue Severity Scale. It also showed, statistical significance for pain intensity.
In all studies, FM symptoms do not disappear in its entirely but the mitigation of pain and other symptoms are significant.
Table 2. Summary of Findings per Study
Author s (year) |
Study design |
Main Objective |
Exposure (or independent variable) |
Outcomes Measured |
Main Findings (Include numeric data) |
Rationale (Mechanisms explaining the findings) |
Study Limitations and Gaps |
Research Recommendations |
Paula Marum, et.al. (2017) |
Longi-tudinal study (Pilot Clinical Trial) |
To study the impact of FODMAP diet on FM symptoms and nutritional status.
(8 weeks) |
FODMAP Diet |
FM symptoms |
-Significant (p < 0.01) in all FM symptoms, including GI symptoms (abdominal pain, distention) after 4 weeks. -Somatic pain (p < 0.01). -Muscle Tension (p < 0.01). |
The elimination of poorly absorbed, short chain CHO, fructose, lactose, polyols, fructo-oligosaccharides, galacto-oligosaccharides alleviate GI disorders especially gases and distention. |
-Small sample size. -Short intervention period. -No control group. |
Authors suggested studies to analyze the impact of FODMAP diet over the neuro-enteric axis of FM patients and the cost/benefits of implementing FODMAP diet as part of the FM treatment. |
Martínez-Rodríguez, et. al. (2017) |
RCT |
To analyze the impact of physiotherapy treatment along with a lacto-vegetarian diet over FM pain.
(4 weeks) |
Group A: Lacto-vegetarian diet + core exercise.
Group B: Lacto-vegetarian diet.
Group C: Control
(No supplementat-ion) |
FM symptoms |
Group A: Significant in low back pain. Group B: No effect.
|
Strengthe-ning of the abdominal muscles & lumbar region promoted the of the fat mass & the of the lean mass.
Lacto-vegetarian diet by itself didn’t improve low back pain, but prevent weigh gain. |
-Small sample size. -Short intervention period.
|
Authors suggested studies to analyzed the impact of physiotherapy + vegetarian diets on blood biochemical parameters. |
Kaarti-nen, K. et.al. (2000) |
Experimental (non-randomi-zed control) |
To study the effect of a vegan diet on FM symptoms.
(3 months) |
Vegan - Raw diet.
(Supplement of B12)
Control group: omnivore diet. |
FM symptoms |
in the use of pain-killers (not significant, p = 0.053). Significant in pain (p = 0.005). It disappeared gradually when shifting back to omnivore diet. Significant improvement in sleep’s quality (p=0.0001), morning stiffness (p = 0.0001), general health (p = 0.02), & subjective feelings (p = 0.038). ♯ of tender points non-significant (p = 0.07). Showed only tendency.
|
Weight loss potentially levels of pro-inflamma-tory cytokines & CRP.
The antioxidant intake lead to the decrease in the production of free superoxide radicals, which in turn will interrupt the synthesis of TNF-Alfa & IL-Beta, both involved in inflamma-tory pain.
in antioxidant = in reactive oxygen species (ROS) = improved in mitochondrial functioning = ATP for muscle = pain. (Rossi, A. et.al., 2015). |
-Small sample size. -Short intervention period. -Didn’t offer mechanism-explaining results. -Not blindly randomization.
|
Authors suggested further crossover design studies about veganism over FM symptoms.
|
Lamb, et.al (2011) |
Crossover Trial. |
To assess the effectiveness of a novel lifestyle program on FM clinical symptoms & detoxification.
(8 weeks) |
Program A: Standard American Diet based on USDA rec.
Program B: Hypoallerge-nic, modified elimination diet + supplementa-tion with phytonutrients-rich medical food 2x/d. |
FM clinical symptoms. |
Program B: lower mean on all *questionnaires scores. Statistical significance only for FIQ pain and stiffness scores (p < 0.05).
Had better tolerance to 5 tender points.
Higher mercury excretion (not significant).
Trend of excretion of arsenic (p = 0.056).
Expression of Metallothionein mRNA increased by 54%. |
Program B added a phytoche-mical-rich medical food, which may have provided nutrients that FM patient’s lack. Also, it has ingredients that support hepatic detoxifica-tion against metals.
Increased in Metallothio-nein mRNA expression promoting the binding function of this protein with toxic elements such as mercury, cadmium, lead, arsenic, which in turn ROS. |
-Small sample size. -Short intervention period. -Interindi-vidual differences. -Lower statistical power to detect treatment efficacy. -No washout period between Program A & B. -Program A may have had therapeutic benefits. -No control group. |
Authors suggested further long clinical trials to evaluate intermediate & long-term effects with larger sample size. |
Massey, P. (2007) |
Clinical Trial |
To evaluate the effectiveness of a modified Myer’s formula of intravenous nutrient therapy (IVNT) on the symptoms of FM in therapy-resistant patients.
(8 weeks) |
IVNT Modified Myers’ Formula (Mg, Ca++, Vit.C, Complex B-Vit.). |
FM symptoms |
Pain & fatigue levels decreased (p = 0.005).
Increased in energy level. |
Increased Vit. B complex and Vit. C are involved in the production of neurotransmitters, which can change perception of pain.
Anti-inflamma-tory effect of magnesium. |
-Small sample size. -Short intervention period. -No control group. |
Author suggested further investiga-tion of the IVNT MMF on FM symptoms with larger, randomi-zed, placebo-controlled clinical trials.
|
Donaldson, M.S., et.al. (2001) |
Quasi-experimental |
To evaluate the effect of a vegetarian diet on FM symptoms.
(7 months) |
Halle-lujah Diet |
FM symptoms |
FIQ: after 2 months the score improved 33%. At 7 months: improved by 46%. (p < 0.05).
**QOL and SF-36 questionnaires improved (p < 0.05)
|
Synergistic effect (physiological and psychological factors). |
-Small sample size. -No control group. -Authors mentioned that even though all participants had been diagnosed with FM before, at the moment of the study some of them didn’t meet the dx criteria (didn’t have severe pain). |
Authors suggested further studies with a larger, controlled trial. |
Mauro-Martín, I., et. al (2018) |
RCT |
To evaluate the effect of an olive tree-based dietary supplement and FODMAP diet on FM symptoms.
(2 months) |
Group 1: Control
Group 2: Olive tree-based food supplement.
Group 3: IGUBAC Diet (Inflammatory Gut-Brain Axis Control Diet = low FODMAP diet, gluten-free, low histamine & other amines, preservative free, natural food). |
FM symptoms |
G3 had the greatest positive Δ for Chronic Pain Grade Scale (p = 0.046)
G3: greatest in Pain Catastrophizing questionnaire. G2 followed closely. (Not significant for both)
Not significant for G2 (more pronounce ) & G3 in Fatigue Severity Scale (p > 0.05). |
Phenolic compounds in olive oil have a strong antioxidant activity linked in the protection of lipids, proteins, & DNA from ROS. In turn, oxidative stress . Symptoms will also .
FODMAP GI discomfort. |
-Small sample size. -Short intervention period. -Treatment composed by so many different components |
Authors suggested further research to clarify the role of the different treatment compo-nents. |
Towery, P., et.al. (2018) |
Longitudinal/Quasi-experi-mental. |
To analyze the impact of a plant-based diet on chronic musculoskeletal pain & functionality.
(8 weeks) |
Lacto-ovo-vegetarian diet. |
Chronic pain |
Significant in pain by 3.14 points (p = 0.0001).
Significant improve of 25 points in quality of life (p = 0.0001). |
exposure to pro-inflamma-tory precursors.
Free-radicals are neutralized.
Improve-ment in lipid profile = strengthen vascularization.
Relationship between plant-based diets and mental perceptions of well-being. |
-Small sample size. -Short intervention period. -No control group. -Subjects & Researchers were not blinded. -Self-reported food intake. -Sample of conve-nience (generali-zation may not be warranted). |
Authors suggested further research of the same topic with a control group. |
Hostmark, A.T., et.al. (1993) |
Quasi-Experimental |
To study the effect of a vegetarian diet on plasma fibrinogen. Lipid profile, and serum peroxide concentration in subjects with FM.
(3 weeks) |
Vegetarian diet & fasting.
|
FM symptoms as secondary outcomes. |
Positive effect on pain status (statistical significance was not revealed).
Significant in lipid peroxide formation (p = 0.01) |
intake in antioxidants = oxidative stress (ROS) = in serum peroxides = the oxidation of lipids (lipid oxidation promote inflammatory pain due to direct peripheral sensitization & the release of cytokines) = in pain.
lipid peroxidation also damage to phospho-lipids in cell membrane in the brain = alteration of neurotransmitters systems = depression symptoms.
Cordero, M.D., et.al. (2011). |
-Small sample size. -Short intervention period. -No control group. -Physical activity may have had positive effect. -The type of vegetarian diet wasn’t specified. |
No suggest-ions from authors. |
Mauro-Martín, I., et. al (2019) |
RCT |
To study the effects of a turmeric supplement & IGUBAC Diet on FM symptoms.
(1 month) |
Group 1: Turmeric Supplement + IGUBAC Diet
Group 2: IGUBAC Diet (Control group)
IGUBAC Diet (Inflammatory Gut-Brain Axis Control Diet = low FODMAP diet, gluten-free, low histamine & other amines, preservative free, natural food).
|
FM symptoms |
Patients with Grade III of Chronic Pain (high disability-moderately limiting) improved the Chronic Pain Grade Scale in Group 2.
Moderate Δ in both groups for Fatigue Severity Scale. More pronounce for Group 1 (Not significant).
Statistical significance for pain intensity (p < 0.05)
Significant in Pain Catastrophizing for Group 2 (p = 0.011).
Slight improvement in sleep efficiency for Group 2 (not significant). |
Turmeric is a great source of potent antioxidants such as bisacurone, it has anti-oxidant & anti-inflamma-tory activities.
IGUBAC Diet GI symptoms and pain. |
.-Small sample size. -Short intervention period.
|
Authors suggested further investiga-tions to clarify current results. |
*FIQ = Fibromyalgia Impact Questionnaire, MSQ = Medical Symptom Questionnaire, FibroQuest = FibroQuest Symptoms Survey.
**QOL = Quality of Life Survey, SF – 36 = 36-Item Short Form Health Survey.
Discussion
The results of this literature review shows evidence that anti-inflammatory and anti-oxidant dietary intervention and/or supplementation have the potential to ease FM excruciating symptoms, especially somatic pain. Vegetarian and vegan diets achieved significance on reducing musculoskeletal pain, the most prominent symptom in subjects with FM. Significant improvements in symptoms such as fatigue, inflexibility, and poor sleep were also reported following these diets. Half of these diets were very restrictive, approving only the consumption of raw or mostly raw foods and not allowing any added sugar, refined products, food additives, and caffeinated beverages (Kaartinen, et. al., 2000; Lamb, et.al., 2011; & Donaldson, M.S., et.al., 2001). In addition, Hostmark, A.T., et.al. (1993), did include fasting for 8 – 10 days in his 3 weeks intervention with vegetarian diet. Its main focus was lipids and other biomarkers, but found out that FM pain was decreased in subjects. One of the interventions achieved significance only when core exercise was done along with vegetarian diet (Martínez-Rodríguez, et. al., 2017). But overall, even though vegetarian diets vary per study, they seems to mitigate FM symptoms, especially when are followed focusing of fresh foods, supplementing with phytonutrients, and limiting food additives.
Significant decrease in musculoskeletal pain and gastrointestinal symptoms was also seen following the FODMAP diet by itself. IGUBAC Diet (Inflammatory Gut-Brain Axis Control Diet = low FODMAP diet, gluten-free, low histamine & other amines, preservative free, natural food) intervention, showed a tendency to mitigate symptoms, but didn’t reach statistical significance. Even though they are not a plant-based diet, it limits or discourages the use of dairy and processed meat, high fructose corn syrup and artificial sweeteners, focusing mostly on fresh foods and meats (Mauro-Martín, I., et. al., 2018).
Isolated supplementation with Turmeric and Olive oil had low to moderate effects on FM symptoms when compare with diet intervention. Turmeric along with IGUBAC diet reached statistical significance for pain intensity. The strongest effect seeing in dietary interventions could be explained due to the synergistic work of the different nutrients in a diet when compare with isolated substances (Jacobs, D. R., et.al., 2009).
In the review by da Silva, A. F., et. al. (2017) oxidative stress, the use of antioxidants, body weight, and micronutrient deficiency was addressed. They stated that oxidative stress in patients with FM produces triple the amount of ROS than non-FM patients, exacerbating chronic fatigue. They concluded that a healthy diet among other interventions might represent a decrease in fatigue and/or pain symptoms, improving quality of life. However, they couldn’t establish a solid diet – FM association due to the lack of rigorous studies. According to the findings in this review, it can be agreed that the lack of well-controlled studies on diet (especially on plant based diets) makes the development of nutritional recommendations difficult. Rossi, A., et. al. (2015) discusses in their review, the oxidant – antioxidant imbalance found in people with FM and the improvements seeing in FM symptoms on patients adopting an antioxidant rich diet. It also describes how the elimination of excitotoxin substances such as Monosodium Glutamate (MSG) and aspartame and the micronutrient supplementation (especially magnesium) have the potential to ease FM symptoms. Results in this review agree with those statements. Firestone, K., et. al. (2012) also discusses briefly the possible benefits of vegan diets for been rich in antioxidants and for not including food additives such as MSG and aspartame. In addition, it is mentions that FM patients tends to be low in some micronutrients that have an important role in redox mechanisms and that a whole nutritious diet can diminish FM symptoms. This review agrees on diets rich in antioxidants, with supplementation, and elimination of food additives having a positive effect on FM symptoms. It is important to highlight that Kim, M. K., et. al. (2012) found that a group of people who had followed a vegetarian diet for long time in Korea (mean duration was close to 25 years) had major intake of iron, vit.C, vit. A and other antioxidants than omnivores, and that vegetarians showed a significant lower levels of oxidative stress than omnivores. Beezhold, B., et. al. (2015) discusses in their study that vegans reported less anxiety and stress levels than omnivores possibly due to the higher intake of anti-inflammatory/anti-oxidants substances from nutritious food items such as fruits and veggies. On the contrary, Azad K.A., et. al. (2000) in its RCT of 37 subjects with FM concluded that a vegetarian diet was not the best approach because even when pain had a significant decrease, it had a lower impact when compare to the amitriptyline group (analgesic and sedative drug). However, the dietary intervention had a positive effect on pain.
Several mechanisms have been proposed to explain the beneficial effects of dietary and supplementation approaches focusing on delivering high amounts of anti-oxidant/anti-inflammatory substances on FM symptoms. First, vegetarian/vegan diets tend to promote weight loss. When weight loss is achieve, levels of pro-inflammatory cytokines & CRP has also the potential to decrease (Kaartinen, K. et.al., 2000). Second, the increase in antioxidant intake lead to the decrease in the production of free superoxide radicals, which in turn will interrupt the synthesis of TNF-Alfa & IL-Beta, cytokines involved in inflammatory pain (Kaartinen, K. et.al., 2000). Third, increase intake of antioxidants can decrease the production of reactive oxygen species (ROS), which in turn might improve mitochondrial functioning resulting in more ATP for muscle, decreasing musculoskeletal pain (Rossi, A. et.al., 2015). Also, when a phytochemical-rich medical food that provides nutrients that FM patient’s tend to lack and its ingredients support hepatic detoxification against metals, the expression of Metallothionein mRNA promote the binding function of this protein with toxic elements such as mercury, cadmium, lead, and arsenic, leading to their excretion and as a consequence, decrease in ROS production (Lamb, et.al., 2011). In addition, decrease in lipid peroxidation also decrease damage to phospholipids in cell membrane in the brain, having less alteration of the neurotransmitters systems, ameliorating depression symptoms (Cordero, M.D., et.al., 2011). It has been stated that FM patients tends to be low is some nutrients related to neurological health. The supplementation of intravenous Modified Myers’ Formula promoted an increased in Vit. B complex and Vit. C, both involved in the production of neurotransmitters responsible for changing pain perception (Massey, et. al., 2007). Finally, these diets limit processed foods. Processed foods are an excellent source of excitatory neurotransmitters such as MSG & aspartame. Its elimination from diet have shown the capacity to avoid neurotoxicity and to mitigate FM symptoms (Holton, K.F., et.al., 2012).
Low FODMAP diets have been proposed to treat FM GI symptoms due to the fact that FM and irritable bowel syndrome (IBS) are correlated (Mauro-Martín, I., et. Al., 2018). Paula Marum, et.al. (2017) states that 70% of patients with FM also report IBS symptoms such as abdominal pain and distension. It has been proposed that the release of gases from bacterial fermentation of FODMAP lead to ascending messages that are interpreted as pain and discomfort. However, a FODMAP diet is not for a long-term used because is too restrictive and it is mostly used in two or three phases to identify those foods that cause discomfort (Hill, P., et. al., 2017).
Even when studies have suggested the benefits of dietary interventions to ease FM symptoms, this approach still underestimated and under investigated with no official inclusion in FM treatment by physicians or major advocates. It is also important to take in account that vegetarian/vegan diets may not be easy to follow for many, but if more researches keep promoting its benefits people may be more open to accept them. Griffiths, K., et.al. (2016) reports another beneficial effect that health care providers and FM patients can take in account when thinking of this dietary approaches to mitigate FM symptoms. That is, the protective mechanism over other chronic diseases such as cardiovascular disease, Type 2 diabetes, and cancer, which are pro-inflammatory/oxidant by nature. The chances of getting a better quality of life might increase if dietary approaches that ensure the intake of food items that neutralize free radicals are encourage as part of the multidisciplinary approach to treat FM.
Strengths
This review may be the only one focusing mostly on vegetarian/vegan diets intervention to treat FM symptoms. Even though it should be taken carefully and individualized, results might be generalized to all women with FM that otherwise are not suffering from other serious chronic diseases or allergies.
Limitations
All studies in this review had a very small sample size and a very short intervention period. Many of the studies lack of a control group and more recent studies are needed. There are a few other supplementation that have been used with positive effects that are not included in this review.
Conclusion
Dietary interventions focusing on anti-inflammatory and anti-oxidant rich food such as happens with well-balance vegetarian/vegan diets and other diets that eliminate pro-inflammatory/oxidant substances, may have the potential to ease FM symptoms and to deliver a better quality of life to women suffering from FM. Its effects can even be more pronounce when use along with other medical and non-medical approaches according to individual needs. Long-term RCT studies about the long-term effects of these types of dietary interventions on FM symptoms are deeply needed and encourage to been able to develop an official nutritional intervention.
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Treister, R., Pud, D., Ebstein, R. P., Laiba, E., Gershon, E., Haddad, M., & Eisenberg, E. (2009). Associations
between polymorphisms in dopamine neurotransmitter pathway genes and pain response in healthy humans. Pain, 147(1), 187–193. doi: 10.1016/j.pain.2009.09.001
Articles Identified by title in Ebsco host, Google Scholar & PubMed as possible relevant studies: about 30
Titles and Abstracts reviewed: about 25
Non relevant studies: About 10
Full articles retrieved and assessed for inclusion: About 15
Articles included in this review: 10
2
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A Review On The Effect Of Intermittent Fasting On Weight Loss
Shelly Schick Andrews University
FDNT-680-999 Research Seminar July 1, 2020
Introduction: Epidemiology ● Obesity:
○ BMI =/> 30 & caused by genetic & environmental factors and behaviors like a poor diet & sedentary lifestyle
○ Leads to: HTN, Dyslipidemia, CVD, T2DM, Stroke, Sleep Apnea, Depression, Cancer, etc. (CDC, 2020)
○ Costs billions of $$ in medical expenses (CDC, 2020)
○ 2017-2018: 42.4% of adults in the US were obese (CDC, 2020)
Introduction ● Intermittent Fasting (IF):
○ Ramadan, Muslims fast between sunrise and sunset for religious purposes, rather than weight loss
○ Various versions: ■ Fasting from 6pm-10am and
feasting from 10am-6pm ■ Fast for 2 days/week and eat
regularly for the other 5 days ■ “Fast” = 25% of energy needs
or low calories (i.e. 500 calories)
Introduction: Aim of Review
To conduct a literature review looking at the relationship/effectiveness of IF on body weight (with a specific focus on weight loss) to see if IF can help
those who are obese lose weight
Methodology: Literature Search ● EBSCO, Google Scholar, and PubMed
○ Keywords: “intermittent fasting” “weight” “weight loss” “humans or people” and “BMI”
○ Peer-reviewed & within the past 15 years (from 2005-2020).
○ Inclusion criteria: (1) An experimental study design, (2) A study population of adults, (3) An exposure of intermittent fasting, and (4) An outcome of body weight.
○ Exclusion criteria: (1) Any study that was conducted on animals or (2) any study that was conducted more than 15 years ago (before 2005)
Methodology: Data Extraction ● 10 experimental studies (9 RCTs & 1 quasi-experimental) ● Many of the studies looked at other outcomes, like
changes in waist circumference, insulin sensitivity, blood pressure, & lipid levels (specifically, HDL cholesterol, LDL cholesterol, & triglycerides) ○ Only information pertaining to body weight was
included in the analysis ○ Information taken from the studies:
■ Main objective ■ Exposure/intervention ■ Main results/findings and conclusions ■ Study limitations
Results ● 10 experimental studies
○ 9 randomized control trials ○ 1 quasi-experimental
● Intervention time periods: 6 weeks to 6 months
● Sample size of the study population: 15 to 162 participants
● 9/10 studies included study population of participants who were obese ○ 1 study didn’t have any
comorbidities in its study population (Heilbronn et al., 2005)
Results Author (year)
Main Objective Exposure/Outcome Measured
Type of Analysis (α & p-value)
Bhutani (2013)
To investigate whether alternate day fasting (ADF) with exercise has a greater effect on body composition compared to ADF or exercise alone
ADF plus exercise vs. exercise alone vs. ADF alone / Body weight
One‐way ANOVA at baseline; repeated‐measures ANOVA for within‐group differences; Intention‐to‐treat analysis (α: 0.05; p: <0.05)
Bowen (2018)
To compare an energy restriction with ADF to a high-protein, meal replacement program with daily energy restriction (DER) on weight loss
High-protein, meal replacement program with DER vs. energy restriction with ADF / Body weight
Mixed effects linear models (α: 0.05; p: <0.05)
Byrne (2017)
To determine whether intermittent energy restriction (IER) had a greater impact on weight loss efficiency in comparison to continuous energy restriction (CER)
IER vs. CER / Weight loss efficiency
Mixed model repeated measures analyses (α: 0.05; p: <0.05)
Catenacci (2016)
To compare the effects of ADF versus a moderate daily caloric restriction (CR) on weight status
Zero-calorie ADF vs. calorie restriction (-400 kcal/day) / Body weight
Linear mixed‐effects model; Independent‐samples t ‐tests (α: 0.05; p: <0.05)
Eshghinia (2013)
To evaluate the effects of a modified ADF on body weight in obese women
Alternate-day fasting diet / Body weight
Paired T-test (α: 0.05; p: <0.05)
Results Author (year) Main Objective Exposure/Outcome Measured Type of Analysis (α & p-value)
Harvie (2011) To compare the effectiveness & practicality of IER vs. CER on weight loss
IER vs. CER / Weight loss Paired t-tests at baseline & LOCF analysis at 6 months (α: 0.05; p: <0.05)
Heilbronn (2005) To examine if ADF is a practical method of dietary restriction for weight loss in non-obese individuals
ADF / Body weight One- & two-factor repeated-measures analysis of variance (α: 0.05; p: <0.05)
Hoddy (2014) To compare the effects of ADF with three meal times on body weight
ADF with three meal times / Body weight
One way ANOVA, Tukey's post hoc test, & a paired t‐test (α: 0.05; p: <0.05)
Keogh (2014) To investigate the effect of IER versus CER on weight loss
IER vs. CER / Body weight Independent samples t-test at baseline; repeated-measures ANOVA (α: 0.05; p: <0.05)
Trepanowski (2017) To compare the effects of ADF vs. a DER on weight loss
ADF vs. DER / Weight loss Independent-samples t test; a linear mixed model (α: 0.05; p: <0.05)
Results Author Main Finding(s) Conclusion(s) Study Limitations
Bhutani (2013)
Body weight was reduced in all of the intervention groups after 12 weeks (P < 0.05). Body weight decreased by 6 ± 4 kg, 3 ± 1 kg, and 1 ± 0 kg in the ADF plus exercise, ADF, and exercise groups, respectively
ADF plus exercise produces greater amount of weight loss compared to ADF or exercise alone
Short intervention time frame (12 weeks); used BIA to measure fat mass & fat free mass instead of dual‐energy X‐ray absorptiometry (DXA); participants were only from the University of Illinois, Chicago campus (cannot generalized results); flawed randomization procedure
Bowen (2018)
There was a statistically significant decrease in body weight over time (p < 0.001); At week 16 of the intervention, weight decreased by 10.7 ± 0.5 kg & −11.2 ± 0.6 kg in the ADF + DER group and the DER group, respectively (no significant difference between groups)
Both a high-protein, meal replacement program with DER & a energy restriction with ADF support weight loss
No biological data at 6 months; no long-term follow up; small number of male participants; no measurement for energy expenditure & physical activity monitoring
Byrne (2017)
The IER group lost more weight compared to the CER group (14.1±5.6 vs 9.1±2.9 kg; P<0.001); Both groups regained weight after the 6-month follow-up (IER: 3.5±5.9 vs. CER: 5.9±4.7 kg; P=0.24)
IER prodcued a higher amount of weight and fat loss compared to CER
Attrition in study population; small weight loss during baseline period; no measurements for body composition or resting energy expenditure during energy balance blocks in the IER group
Catenacci (2016)
At week 8, the ADF group had a greater energy deficient of 376 kcal/day compared to the CR group; however, no significant changes in weight were seen between the two groups (mean ±SE; ADF -8.2 ± 0.9 kg, CR -7.1 ± 1.0 kg). Finally, after week 24 of unsupervised follow-up, no significant differences in weight regain were seen
ADF & CR produced similar amount of weight loss after the 8 weeks
Pilot study; small sample size; randomization was arranged by sex; small male percentage; no measurements on physical activity; results cannot be generalized
Eshghinia (2013) ADF significantly reduced body weight from 84.3 ± 11.44 kg
to 78.3 ± 10.18 kg (P < 0.001) Short-term ADF is an effective intervention for weight loss
No control groups; small sample size; short intervention time frame (<8 weeks)
Results Author (year)
Main Finding(s) Conclusion(s) Study Limitations
Harvie (2011) IER & CER are equally effective (but not significantly different) for weight loss. The average weight change was -6.4 (-7.9 to -4.8) kg for IER and -5.6 (-6.9 to -4.4) kg for CER (P=0.4)
IER & CER are effective ways to lose weight; IER could be used as an alternative to CER for weight loss
Did not assess long term adherence to IER
Heilbronn (2005)
Participants significantly reduced their initial body weight by 2.5 ± 0.5% (P < 0.001)
ADF is a practical method of dietary restriction for weight loss
Small sample size (16), short intervention time frame (22 days)
Hoddy (2014) Body weight (P < 0.001) reduction included: ADF‐Lunch: 3.5 ± 0.4 kg, ADF‐Dinner 4.1 ± 0.5 kg, ADF‐Small Meal 4.0 ± 0.5 kg, but there were no significant differences between groups
Consuming the fast day meal at D, L, or SM all produce similar weight loss results
No “breakfast” group; adherence to fasting was self-reported; no control group
Keogh (2014) Weight decreased significantly with time (P < 0.001). There was no significant difference in regard to weight loss between CER and IER after 8 weeks (-3.2 ± 2.1 kg for CER and -2.0 ± 1.9 kg for IER; P = 0.06) or after 12 months (-4.2 ± 5.6 kg for CER and -2.1 ± 3.8 kg for IER; P = 0.19); Weight loss between weeks 8-52 was -0.7 ± 49 kg for CER and -1± 1.1 kg for IER; P = 0.6
Intermittent dieting is as effective as a continuous caloric restriction over a 8 week time frame, as well as for weight loss maintenance at 1 year
60% of participants dropped out (limited power to the study); protocol in the study is different than for IF & ADF
Trepanowski (2017)
At 6 months, the average weight loss between the two groups (ADF vs. DER) was not significantly different (–6.8% [–9.1% to –4.5%] vs. –6.8% [–9.1% to –4.6%], respectively). These same findings were seen after 12 months as well (–6.0% [–8.5% to –3.6%] vs. –5.3% [–7.6% to –3.0%], respectively). No significant weight changes were seen in the control group. Overall, the participants in the ADF group consumed more calories than prescribed on fasting days, however they consumed less calories than prescribed on feasting days. Participants in the DER group met their prescribed caloric intake goals.
ADF did not produce a greater weight loss compared to DER
Short maintenance phase (6 weeks); control group did not receive food/counseling; high dropout rate; limited generalizability; study population was metabolically healthy obese individuals
Results Author (year) Demographics of the study population (n= number of participants)
Bhutani (2013) n= 64; Comorbidities in study population: obesity; Average age (years): 44.5 (range: 25-65); % male: 3.6; % female: 96.4
Bowen (2018) n= 162; Comorbidities in study population: obesity; Average age (years): 40 (range: 25-60); % male: 19; % female: 81
Byrne (2017) n= 51; Comorbidities in study population: obesity; Average age (years): 40 (range: 25-54); % male: 100; % female: 0
Catenacci (2016) n= 26; Comorbidities in study population: obesity; Average age (years): 41.1 (range: 18-55); % male: 24; % female: 76
Eshghinia (2013) n= 15; Comorbidities in study population: obesity; Average age (years): 33.5 (range: 20-45); % male: 0; % female: 100
Harvie (2011) n= 107; Comorbidities in study population: obesity; Average age (years): 40 (range: 30-45); % male: 0; % female: 100
Heilbronn (2005) n= 16; Comorbidities in study population: none; Average age (years): 32 (range: 23-53); % male: 50; % female: 50
Hoddy (2014) n= 74; Comorbidities in study population: obesity; Average age (years): 45 (range: 25-65); % male: 15; % female: 85
Keogh (2014) n= 36; Comorbidities in study population: obesity; Average age (years): 60.2; % male: 0; % female: 100
Trepanowski (2017)
n= 100; Comorbidities in study population: obesity; Average age (years): 44 (range:18-65); % male: 14; % female: 86
Results ● All 10 studies found that following an IF
diet protocol lead to a reduction in weight; the weight loss for IF ranged from 4.4 pounds to 31.0 pounds
● More research needs to be conducted before recommending IF as a means to lose weight since long-term studies on IF have yet to be conducted, although the research does not present any harm in metabolic function in the short-term
Discussion: Overall Findings ● 10/10 studies found weight reduction when following a
IF diet protocol (but varied from article to article) ○ Differences may be due to the differences in study
durations and/or the differences in IF diet protocol. ■ Some had 2-3 fasting days/week where
participants consumed 25-30% of their daily energy needs (Bhutani, 2013, Eshghinia, 2013, Heilbronn, 2005, Hoddy, 2014, and Trepanowski, 2017)
■ Another study had participants fast for 1 week (-1,314.5 calories/day) followed by a regular week (Keogh, 2014)
Discussion: Overall Findings ● Most of the studies did not find any significant
differences in weight loss between IF and continuous energy restriction (CER) ○ Both found to be effective strategies for
weight loss within the obese population
● Heilbronn et. al (2005) noticed that participants’ hunger levels did not adapt to ADF, which may hinder the sustainability of the diet ○ People could add a small meal on the fasting
day to help make this diet more feasible over a long period of time
Discussion: Mechanisms ● Participants were not able to
consume enough calories on days they were eating to maintain their body weight, leading to weight loss
● Breaking fasting periods up with energy balance could decrease compensatory metabolic responses, which may improve the efficiency of weight loss (Byrne et al., 2017)
Discussion: Strengths & Limitations ● Strengths:
○ Experimental design (9/10 RCTs) ■ High internal validity &
reliability ○ All studies conducted within past
15 years ● Limitations:
○ 8/10 had small sample sizes (100 or less)
○ 6/10 had short interventions (3 months or less)
○ 3/10 studies the generalizability of the findings are limited
Discussion: Other Research ● Narrative review with 6 studies looked at
the effects of short-term IF found that IF is equivalent to CER in regard to weight loss in overweight & obese individuals and does not show any evidence of harmful effects (Harvie and Howell, 2017)
● A systematic review/meta-analysis of 6 studies with interventions =/> 6 months also found that there was no significant difference between IF & CER on weight loss (Headland, Clifton, Carter, & Keogh, 2016)
Conclusion ● ADF/IF is a safe & effective approach for short-term weight
reduction in obese ○ Even a 5-10% weight loss has been shown to have
various cardiometabolic improvements, like improved lipid levels, blood pressure, and glucose control and can help reduce healthcare costs (Ryan & Yockey, 2017)
● ADF/IF does not seem to have any adverse side effects in short-term
● Future research: ○ Larger & longer study duration (> 1 year) ○ Overweight/healthy BMI individuals with lipid/glucose
abnormalities, HTN, and/or high body fat percentage
References Bhutani, S., Klempel, M. C., Kroeger, C. M., Trepanowski, J. F., & Varady, K. A. (2013). Alternate day fasting and endurance exercise
combine to reduce body weight and favorably alter plasma lipids in obese humans. Obesity (Silver Spring, Md.), 21(7), 1370–1379. https://doi.org/10.1002/oby.20353
Bowen J, Brindal E, James-Martin G, Noakes M. (2018). Randomized trial of a high protein, partial meal replacement program with or without alternate day fasting: similar effects on weight loss, retention status, nutritional, metabolic, and behavioral outcomes. Nutrients, 10(9). https://doi.org/10.3390/nu10091145
Byrne, N. M., Sainsbury, A., King, N. A., Hills, A. P., & Wood, R. E. (2017). Intermittent energy restriction improves weight loss efficiency in obese men: The MATADOR study. International Journal of Obesity, 42(2), 129-138. doi:10.1038/ijo.2017.206
Catenacci, V. A., Pan, Z., Ostendorf, D., Brannon, S., Gozansky, W. S., Mattson, M. P., Martin, B., MacLean, P. S., Melanson, E. L., & Troy Donahoo, W. (2016). A randomized pilot study comparing zero-calorie alternate-day fasting to daily caloric restriction in adults with obesity. Obesity (Silver Spring, Md.), 24(9), 1874–1883. https://doi.org/10.1002/oby.21581
Centers of Disease Control and Prevention. (2020, April 10). Adult Overweight and Obesity. Retrieved May 28, 2020, from https://www.cdc.gov/obesity/adult/index.html
Eshghinia, S., & Mohammadzadeh, F. (2013). The effects of modified alternate-day fasting diet on weight loss and CAD risk factors in overweight and obese women. Journal of diabetes and metabolic disorders, 12(1), 4. https://doi.org/10.1186/2251-6581-12-4
Harvie M. & Howell A. (2017). Potential Benefits and Harms of Intermittent Energy Restriction and Intermittent Fasting Amongst Obese, Overweight and Normal Weight Subjects—A Narrative Review of Human and Animal Evidence. Behav. Sci., 7(1), 4. https://doi.org/10.3390/bs7010004
Harvie, M. N., Pegington, M., Mattson, M. P., Frystyk, J., Dillon, B., Evans, G., Cuzick, J., Jebb, S. A., Martin, B., Cutler, R. G., Son, T. G., Maudsley, S., Carlson, O. D., Egan, J. M., Flyvbjerg, A., & Howell, A. (2011). The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. International journal of obesity (2005), 35(5), 714–727. https://doi.org/10.1038/ijo.2010.171
References (con’t) Headland M., Clifton P.M., Carter S., & Keogh J.B. (2016). Weight-Loss Outcomes: A Systematic Review and Meta-Analysis of
Intermittent Energy Restriction Trials Lasting a Minimum of 6 Months. Nutrients, 8(6), 354. https://doi.org/10.3390/nu8060354 Heilbronn, L. K., Smith, S. R., Martin, C. K., Anton, S. D., & Ravussin, E. (2005). Alternate-day fasting in nonobese subjects: effects on
body weight, body composition, and energy metabolism. The American Journal of Clinical Nutrition, 81(1), 69–73. https://doi.org/10.1093/ajcn/81.1.69
Hoddy, K. K., Kroeger, C. M., Trepanowski, J. F., Barnosky, A., Bhutani, S., & Varady, K. A. (2014). Meal timing during alternate day fasting: Impact on body weight and cardiovascular disease risk in obese adults. Obesity (Silver Spring, Md.), 22(12), 2524–2531. https://doi.org/10.1002/oby.20909
Keogh, J. B., Pedersen, E., Petersen, K. S., & Clifton, P. M. (2014). Effects of intermittent compared to continuous energy restriction on short-term weight loss and long-term weight loss maintenance. Clinical obesity, 4(3), 150–156. https://doi.org/10.1111/cob.12052
Ryan, D. H., & Yockey, S. R. (2017). Weight Loss and Improvement in Comorbidity: Differences at 5%, 10%, 15%, and Over. Current obesity reports, 6(2), 187–194. https://doi.org/10.1007/s13679-017-0262-y
Trepanowski, J. F., Kroeger, C. M., Barnosky, A., Klempel, M. C., Bhutani, S., Hoddy, K. K., . . . Varady, K. A. (2017). Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults. JAMA Internal Medicine, 177(7), 930. doi:10.1001/jamainternmed.2017.0936
Shelly Schick
A Review On The Effect Of Intermittent Fasting On Weight Loss
Andrews University
FDNT-680-999 Research Seminar
Summer 2020
Abstract
Obesity is a prominent disease in the United States, affecting millions of Americans and
costing billions of dollars in healthcare each year. Healthcare professionals recommend a
lifestyle change, including a healthy diet with calorie restriction along with daily physical
activity in order to promote weight loss. A relatively new approach to weight loss is intermittent
fasting, in which an individual goes a period of time without consuming calories. This literature
review was conducted via the databases EBSCO, Google Scholar, and PubMed and contains 10
experimental studies which looked at the relationship between intermittent fasting and body
weight. All 10 studies found that intermittent fasting led to weight loss, which ranged from 4.4
pounds to 31.0 pounds. Overall, intermittent fasting has been shown to be a safe and effective
way to lose weight, however long-term effects remain unknown.
Introduction
Obesity is a major health problem within the United States and leads to many different
chronic diseases and health conditions, like Hypertension, Dyslipidemia, Cardiovascular
Disease, Type 2 Diabetes Mellitus, Stroke, Sleep Apnea, Depression, and certain types of
cancers. This causes billions of dollars in medical expenses every year (Centers of Disease
Control and Prevention, 2020). Obesity is caused by genetic and environmental factors and
behaviors, like a poor diet and sedentary lifestyle. According to the Centers of Disease Control
and Prevention (CDC), from 2017-2018, 42.4% of adults in the United States were obese. A
person who has a body mass index (BMI) greater than or equal to 30.0 is considered obese
(Centers of Disease Control and Prevention, 2020).
Recently, Intermittent Fasting (IF) has become a popular method for people to try to lose
weight. However, IF it has been around for centuries; during Ramadan, Muslims fast between
sunrise and sunset, although they fast for religious purposes, rather than weight loss. There are
different versions of IF. One type is where a person fasts for a specific time frame (for example,
from 6:00 pm to 10:00 am) and then is allowed to eat for the remainder of the day (from 10:00
am to 6 pm). Another popular type is to fast for two days of the week and then eat normally the
other five days of the week. The fast can be defined as consuming no calories or consuming a
very low amount of calories (for example, 500 calories per day). With the recent increase in
popularity of IF, there have been many novel studies looking at IF and its benefits; the purpose
of this literature review was to conduct a literature review looking at the
relationship/effectiveness of IF on body weight (with a specific focus on weight loss) to see if IF
can help those who are obese lose weight.
Methodology
Literature Search
A literature review was conducted via the databases EBSCO, Google Scholar, and
PubMed by using the keywords: “intermittent fasting” “weight” “weight loss” “humans or
people” and “BMI.” Furthermore, the results were specified to be peer-reviewed and within the
past 15 years (from 2005-2020). The keyword “humans OR people” was used because only
studies conducted on humans were included in the review (as opposed to animals). After
reviewing the abstract of potential articles, the full-length text was reviewed to confirm inclusion
criteria of: (1) An experimental study design, (2) A study population of adults, (3) An exposure
of intermittent fasting, and (4) An outcome of body weight. Any study that was conducted on
animals, or any study that was conducted more than 15 years ago (before 2005) was excluded
from this analysis.
Data extraction
10 experimental studies (nine randomized control trials and one quasi-experimental) were
included in the final analysis, all of which investigated the association between IF on body
weight within the adult population. The 10 sources included in this review were: Bhutani,
Klempel, Kroeger, Trepanowski, & Varady (2013), Bowen, Brindal, James-Martin, & Noakes
(2018), Byrne, Sainsbury, King, Hills, & Wood (2017), Catenacci et al. (2016), Eshghinia &
Mohammadzadeh (2013), Harvie et al. (2011), Heilbronn, Smith, Martin, Anton, & Ravussin
(2005), Hoddy et al. (2014), Keogh, Pedersen, Petersen, & Clifton (2014), and Trepanowski et
al. (2017). Many of the studies looked at other outcomes, like changes in waist circumference,
insulin sensitivity, blood pressure, and lipid levels (specifically, HDL cholesterol, LDL
cholesterol, and triglycerides), however only information pertaining to body weight was included
in this analysis. The specific information taken from these studies included the main objective of
each study, the type exposure/intervention used in each study, the main results/findings and
conclusions (specifically findings related to body weight), as well as study limitations.
Results
This literature review included 10 experimental studies. Table 1.1 shows the study
design, main objective, type of exposure used and outcome measured within all of the articles
reviewed. Altogether, the intervention time periods ranged from six weeks to six months. Each
study had its own definition for what a “fasting” day looked like; one study defined its fasting
day by not consuming any calories, while most studies defined fasting days by allowing
participants to eat a certain percentage of their calorie needs (for example, 25% of their daily
calorie/energy needs).
Table 1.2 explains the main finding(s), conclusion(s), and the limitations of the studies
reviewed. All of the studies found that following an IF diet protocol caused a reduction in
weight; the weight loss for IF ranged from 4.4 pounds to 31.0 pounds.
Table 1.3 displays the demographics of the study population, as well as any comorbidities
in the study population. The sample size of the study population ranged from 15 to 162
participants. Nine out of the 10 studies included study population of participants who were obese
and one study did not have any comorbidities in its study population (Heilbronn et al., 2005).
In general, it is evident that more research needs to be conducted before recommending
IF as a means to lose weight since long-term studies on IF have yet to be conducted, although the
research does not present any harm in metabolic function in the short-term.
Discussion
Overall, most of the studies did not find any significant differences in weight loss
between IF and continuous energy restriction (CER)— both were found to be effective strategies
for weight loss within the obese population. However, there needs to be longer and larger studies
looking at the long-term effects of IF. For example, Heilbronn and colleagues (2005) noticed that
participants’ hunger levels did not adapt to alternate day fasting (ADF), which may hinder the
sustainability of the diet. The researchers suggest that people could add a small meal on the
fasting day to help make this diet more feasible over a long period of time.
All of the studies investigated in this literature review found changes in weight,
specifically weight reduction, when following a IF diet protocol. However, the amount of weight
loss varied from article to article. These differences in amount of weight loss between the studies
may be due to the differences in study durations and/or the differences in IF diet protocol. For
example, some studies had two or three fasting days each week where participants consumed
25-30% of their daily energy needs (Bhutani, 2013, Eshghinia, 2013, Heilbronn, 2005, Hoddy,
2014, and Trepanowski, 2017), while another study had participants fast for one week (-1,314.5
calories per day) followed by a regular week (Keogh, 2014).
Several other peer-reviewed articles have found similar findings seen in this literature
review. For example, in a narrative review conducted by Harvie and Howell (2017) included six
studies looking at the effects of short-term IF. The researchers found that IF is equivalent to CER
in regard to weight loss in overweight and obese individuals and does not show any evidence of
harmful effects. Furthermore, a systematic review and meta-analysis of nine studies with
interventions equal to or longer than six months also found that there was no significant
difference between IF and CER on weight loss (Headland, Clifton, Carter, & Keogh, 2016).
Mechanisms
The likely mechanism explaining the results found in this literature review suggests that
participants were not able to consume enough calories on days they were eating (as opposed to
fasting) to maintain their body weight, leading to weight loss. Furthermore, Byrne and colleagues
(2017) suggest that breaking fasting periods up with energy balance could decrease
compensatory metabolic responses, which may improve the efficiency of weight loss.
Strengths and Limitations
Like all studies, there were various strengths and limitations regarding the studies
reviewed. In regard to strengths, all of the studies reviewed were an experimental design, with
nine out of the 10 being randomized control trials (the gold standard for a research design); this
is a major strength regarding this literature review because experimental designs have high
internal validity and reliability. Furthermore, all of the studies reviewed were conducted within
the past 15 years, which means that the findings are from the most up-to-date data within the
field.
However, there were also various limitations that need to be addressed. First off, many of
the studies had a sample size of 100 or less (Bhutani et al. (2013), Byrne et al. (2017), Catenacci
et al. (2016), Eshghinia & Mohammadzadeh (2013), Heilbronn et al. (2005), Hoddy et al. (2014),
Keogh et al. (2014), and Trepanowski et al. (2017). Additionally some studies had short
intervention time frames of equal to or less than three months (Bhutani et al. (2013), Catenacci et
al. (2016), Eshghinia & Mohammadzadeh (2013), Heilbronn et al. (2005), Hoddy et al. (2014),
and Keogh et al. (2014)). Finally, in some of the studies, the generalizability of the findings were
limited (Bhutani et al. (2013), Catenacci et al. (2016), and Trepanowski et al. (2017)).
Conclusion
In conclusion, this review shows support that IF can aid in short-term weight loss,
especially in those who are obese. There seems to be no short-term adverse side effects
connected with IF/ADF. Researchers concluded that ADF can be as safe and effective as CER in
regard to losing weight; even a 5-10% weight loss has been shown to have various
cardiometabolic improvements, like improved lipid levels, blood pressure, and glucose control
and can help reduce healthcare costs (Ryan & Yockey, 2017).
Since many of the studies have short intervention time frames (less than one year), the
long-term health effects and effectiveness in weight loss/maintenance regarding IF remains
unknown. Future research studies looking at the association of IF and weight loss should have
longer durations (greater than one year) and larger sample sizes (greater than 100 participants) to
assess sustainability, as well as the long-term effects of IF. Additionally, there is limited
evidence looking at the impact of IF on weight loss in overweight individuals since most of the
studies conducted look at obese individuals. Future research should include a study population
with overweight individuals and/or individuals with a healthy BMI with other health
abnormalities (for example, a high body fat percentage, hypertension, abnormal glucose and/or
lipid panel levels) to assess if IF helps improve these cardiometabolic risk factors.
References
Bhutani, S., Klempel, M. C., Kroeger, C. M., Trepanowski, J. F., & Varady, K. A. (2013).
Alternate day fasting and endurance exercise combine to reduce body weight and
favorably alter plasma lipids in obese humans. Obesity (Silver Spring, Md.), 21(7),
1370–1379. https://doi.org/10.1002/oby.20353
Bowen J, Brindal E, James-Martin G, Noakes M. (2018). Randomized trial of a high protein,
partial meal replacement program with or without alternate day fasting: similar effects on
weight loss, retention status, nutritional, metabolic, and behavioral outcomes. Nutrients,
10(9). https://doi.org/10.3390/nu10091145
Byrne, N. M., Sainsbury, A., King, N. A., Hills, A. P., & Wood, R. E. (2017). Intermittent
energy restriction improves weight loss efficiency in obese men: The MATADOR study.
International Journal of Obesity, 42(2), 129-138. doi:10.1038/ijo.2017.206
Catenacci, V. A., Pan, Z., Ostendorf, D., Brannon, S., Gozansky, W. S., Mattson, M. P., Martin,
B., MacLean, P. S., Melanson, E. L., & Troy Donahoo, W. (2016). A randomized pilot
study comparing zero-calorie alternate-day fasting to daily caloric restriction in adults
with obesity. Obesity (Silver Spring, Md.), 24(9), 1874–1883.
https://doi.org/10.1002/oby.21581
Centers of Disease Control and Prevention. (2020, April 10). Adult Overweight and Obesity.
Retrieved May 28, 2020, from https://www.cdc.gov/obesity/adult/index.html
Eshghinia, S., & Mohammadzadeh, F. (2013). The effects of modified alternate-day fasting diet
on weight loss and CAD risk factors in overweight and obese women. Journal of diabetes
and metabolic disorders, 12(1), 4. https://doi.org/10.1186/2251-6581-12-4
Harvie M. & Howell A. (2017). Potential Benefits and Harms of Intermittent Energy Restriction
and Intermittent Fasting Amongst Obese, Overweight and Normal Weight Subjects—A
Narrative Review of Human and Animal Evidence. Behav. Sci., 7(1), 4.
https://doi.org/10.3390/bs7010004
Harvie, M. N., Pegington, M., Mattson, M. P., Frystyk, J., Dillon, B., Evans, G., Cuzick, J., Jebb,
S. A., Martin, B., Cutler, R. G., Son, T. G., Maudsley, S., Carlson, O. D., Egan, J. M.,
Flyvbjerg, A., & Howell, A. (2011). The effects of intermittent or continuous energy
restriction on weight loss and metabolic disease risk markers: a randomized trial in young
overweight women. International journal of obesity (2005), 35(5), 714–727.
https://doi.org/10.1038/ijo.2010.171
Headland M., Clifton P.M., Carter S., & Keogh J.B. (2016). Weight-Loss Outcomes: A
Systematic Review and Meta-Analysis of Intermittent Energy Restriction Trials Lasting a
Minimum of 6 Months. Nutrients, 8(6), 354. https://doi.org/10.3390/nu8060354
Heilbronn, L. K., Smith, S. R., Martin, C. K., Anton, S. D., & Ravussin, E. (2005). Alternate-day
fasting in nonobese subjects: effects on body weight, body composition, and energy
metabolism. The American Journal of Clinical Nutrition, 81(1), 69–73.
https://doi.org/10.1093/ajcn/81.1.69
Hoddy, K. K., Kroeger, C. M., Trepanowski, J. F., Barnosky, A., Bhutani, S., & Varady, K. A.
(2014). Meal timing during alternate day fasting: Impact on body weight and
cardiovascular disease risk in obese adults. Obesity (Silver Spring, Md.), 22(12),
2524–2531. https://doi.org/10.1002/oby.20909
Keogh, J. B., Pedersen, E., Petersen, K. S., & Clifton, P. M. (2014). Effects of intermittent
compared to continuous energy restriction on short-term weight loss and long-term
weight loss maintenance. Clinical obesity, 4(3), 150–156.
https://doi.org/10.1111/cob.12052
Ryan, D. H., & Yockey, S. R. (2017). Weight Loss and Improvement in Comorbidity:
Differences at 5%, 10%, 15%, and Over. Current obesity reports, 6(2), 187–194.
https://doi.org/10.1007/s13679-017-0262-y
Trepanowski, J. F., Kroeger, C. M., Barnosky, A., Klempel, M. C., Bhutani, S., Hoddy, K. K., . .
. Varady, K. A. (2017). Effect of alternate-day fasting on weight loss, weight
maintenance, and cardioprotection among metabolically healthy obese adults. JAMA
Internal Medicine, 177(7), 930. doi:10.1001/jamainternmed.2017.0936
Appendices Table 1.1
Author (year)
Study Design
Main Objective Exposure Outcome Measured
Type of Analysis (α & p-value)
Bhutani (2013)
Randomized Control Trial
To investigate whether ADF with exercise has a greater effect on body composition compared to ADF or exercise alone
ADF plus exercise vs. exercise alone vs. ADF alone
Body weight
One-way ANOVA at baseline; repeated-measures ANOVA for within-group differences; Intention-to-treat analysis (α: 0.05; p: <0.05)
Bowen (2018)
Randomized Control Trial
To compare an energy restriction with ADF to a high-protein, meal replacement program with daily energy restriction (DER) on weight loss
High-protein, meal replacement program with DER vs. energy restriction with ADF
Body weight
Mixed effects linear models (α: 0.05; p: <0.05)
Byrne (2017)
Randomized Control Trial
To determine whether intermittent energy restriction (IER) had a greater impact on weight loss efficiency in comparison to continuous energy restriction (CER)
IER vs. CER Weight loss efficiency
Mixed model repeated measures analyses (α: 0.05; p: <0.05)
Catenacci (2016)
Randomized Control Trial
To compare the effects of ADF versus a moderate daily caloric restriction (CR) on weight status
Zero-calorie ADF vs. calorie restriction (-400 kcal/day)
Body weight
Linear mixed-effects model; Independent-sampl es t -tests (α: 0.05; p: <0.05)
Eshghinia (2013)
Quasi- experimenta l
To evaluate the effects of a modified ADF on body weight in obese women
Alternate-day fasting diet
Body weight
Paired T-test (α: 0.05; p: <0.05)
Harvie (2011)
Randomized Control Trial
To compare the effectiveness & practicality of IER vs. CER on weight loss
IER vs. CER Weight loss
Paired t-tests at baseline & LOCF analysis at 6
months (α: 0.05; p: <0.05)
Heilbronn (2005)
Randomized Control Trial
To examine if ADF is a practical method of dietary restriction for weight loss in non-obese individuals
ADF Body weight
One- & two-factor repeated-measures analysis of variance (α: 0.05; p: <0.05)
Hoddy (2014)
Randomized Control Trial
To compare the effects of ADF with three meal times on body weight
ADF with three meal times
Body weight
One way ANOVA, Tukey's post hoc test, & a paired t-test (α: 0.05; p: <0.05)
Keogh (2014)
Randomized Control Trial
To investigate the effect of IER versus CER on weight loss
IER vs. CER Body weight
Independent samples t-test at baseline; repeated-measures ANOVA (α: 0.05; p: <0.05)
Trepanowski (2017)
Randomized Control Trial
To compare the effects of ADF vs. a DER on weight loss
ADF vs. DER Weight loss
Independent-sampl es t test; a linear mixed model (α: 0.05; p: <0.05)
Table 1.2
Author (year)
Main Finding(s) Conclusion(s) Study Limitations
Bhutani (2013)
Body weight was reduced in all of the intervention groups after 12 weeks (P < 0.05). Body weight decreased by 6 ± 4 kg, 3 ± 1 kg, and 1 ± 0 kg in the ADF plus exercise, ADF, and exercise groups, respectively
ADF plus exercise produces greater amount of weight loss compared to ADF or exercise alone
Short intervention time frame (12 weeks); used BIA to measure fat mass & fat free mass instead of dual-energy X-ray absorptiometry (DXA); participants were only from the University of Illinois, Chicago campus (cannot generalized results); flawed randomization procedure
Bowen (2018)
There was a statistically significant decrease in body weight over time (p < 0.001); At week 16 of the intervention, weight decreased by 10.7 ± 0.5 kg & −11.2 ± 0.6 kg in the ADF + DER group and the DER group, respectively (no significant difference between groups)
Both a high-protein, meal replacement program with DER & a energy restriction with ADF support weight loss
No biological data at 6 months; no long-term follow up; small number of male participants; no measurement for energy expenditure & physical activity monitoring
Byrne (2017) The IER group lost more weight compared to the CER group (14.1±5.6 vs 9.1±2.9 kg; P<0.001); Both groups regained weight after the 6-month follow-up (IER: 3.5±5.9 vs. CER: 5.9±4.7 kg; P=0.24)
IER prodcued a higher amount of weight and fat loss.
Attrition in study population; small weight loss during baseline period; no measurements for body composition or resting energy expenditure during energy balance blocks in the IER group
Catenacci (2016)
At week 8, the ADF group had a greater energy deficient of 376 kcal/day compared to the CR group; however, no significant changes in weight were seen between the two groups (mean ±SE; ADF -8.2 ± 0.9 kg, CR -7.1 ± 1.0 kg). Finally, after week 24 of unsupervised follow-up, no significant differences in weight regain were seen
ADF & CR produced similar amount of weight loss after the 8 weeks
Pilot study; small sample size; randomization was arranged by sex; small male percentage; no measurements on physical activity; results cannot be generalized
Eshghinia (2013)
ADF significantly reduced body weight from 84.3 ± 11.44 kg to 78.3 ± 10.18 kg (P < 0.001)
Short-term ADF is an effective intervention for weight loss & reducing CAD risk in obese individuals
No control groups; small sample size; short intervention time frame (<8 weeks)
Harvie (2011)
IER & CER are equally effective (but not significantly different) for weight loss. The average weight change was -6.4 (-7.9 to -4.8) kg for IER and -5.6 (-6.9 to -4.4) kg for CER (P=0.4)
IER & CER are both effective ways to lose weight and produce similar results; IER could be used as an alternative to CER for weight & disease risk reduction
Did not assess long-term adherence to IER
Heilbronn (2005)
Participants significantly reduced their initial body weight by 2.5 ± 0.5% (P < 0.001)
ADF is a practical method of dietary restriction for weight loss in non-obese individuals
Small sample size (16), short intervention time frame (22 days)
Hoddy (2014)
Body weight (P < 0.001) reduction included: ADF-Lunch: 3.5 ± 0.4 kg, ADF-Dinner 4.1 ± 0.5 kg, ADF-Small Meal 4.0 ± 0.5 kg, but there were no significant differences between groups
Consuming the fast day meal at dinner, lunch, or small meals all produce similar weight loss results, as well as cardio-protective benefits; the flexibility to choose the time of the fast day meal could increase tolerability & sustainability for adherence to ADF
No “breakfast” group to look at effects of consuming the fast day meal between 6:00-8:00am.; only 80% of data for participants’ activity in intervention group were collected because of malfunctioning activity monitors; adherence to fasting was self-reported; no control group
Keogh (2014)
Weight decreased significantly with time (P < 0.001). There was no significant difference in regard to weight loss between CER and IER after 8 weeks (-3.2 ± 2.1 kg for CER and -2.0 ± 1.9 kg for IER; P = 0.06) or after 12 months (-4.2 ± 5.6 kg for CER and -2.1 ± 3.8 kg for IER; P = 0.19); Weight loss between weeks 8-52 was -0.7 ± 49 kg for CER and -1± 1.1 kg for IER; P = 0.6
Intermittent dieting is as effective as a continuous caloric restriction over a 8 week time frame, as well as for weight loss maintenance at 1 year
60% of participants dropped out (limited power to the study); protocol in the study is different than for IF & ADF
Trepanowski (2017)
At 6 months, the average weight loss between the two groups (ADF vs. DER) was not significantly different (–6.8% [–9.1% to –4.5%] vs. –6.8% [–9.1% to –4.6%], respectively). These same findings were seen after 12 months as well (–6.0% [–8.5% to –3.6%] vs. –5.3% [–7.6% to –3.0%], respectively). No significant weight changes were seen in the control group. Overall, the participants in the ADF group consumed more calories than prescribed on fasting days, however they consumed less calories than prescribed on feasting days. Participants in the DER group met their prescribed caloric intake goals.
ADF did not produce a greater weight loss compared to DER
Short maintenance phase (6 weeks); control group did not receive food or counseling and received less attention; high dropout rate (this decreased the power); generalizability of the study is limited; study population was metabolically healthy obese individuals (improvements might have been greater in metabolically unhealthy individuals)
Table 1.3
Author (year) Demographics of the study population (n= number of participants)
Bhutani (2013) n= 64; Comorbidities in study population: obesity Average age (years): 44.5 (range: 25-65) % male: 3.6; % female: 96.4
Bowen (2018) n= 162; Comorbidities in study population: obesity Average age (years): 40 (range: 25-60) % male: 19; % female: 81
Byrne (2017) n= 51; Comorbidities in study population: obesity Average age (years): 40 (range: 25-54) % male: 100; % female: 0
Catenacci (2016) n= 26; Comorbidities in study population: obesity Average age (years): 41.1 (range: 18-55) % male: 24; % female: 76
Eshghinia (2013) n= 15; Comorbidities in study population: obesity Average age (years): 33.5 (range: 20-45) % male: 0; % female: 100
Harvie (2011) n= 107; Comorbidities in study population: obesity Average age (years): 40 (range: 30-45) % male: 0; % female: 100
Heilbronn (2005) n= 16; Comorbidities in study population: none Average age (years): 32 (range: 23-53) % male: 50; % female: 50
Hoddy (2014) n= 74; Comorbidities in study population: obesity Average age (years): 45 (range: 25-65) % male: 15; % female: 85
Keogh (2014) n= 36; Comorbidities in study population: obesity Average age (years): 60.2 % male: 0; % female: 100
Trepanowski (2017) n= 100; Comorbidities in study population: obesity Average age (years): 44 (range:18-65) % male: 14; % female: 86
SySllyalblaubsus FDNT680
Page 1
Dr. Dixon Anjejo
FDNT 680-999: Research Seminar
Spring 2020
FDNT 680-999: Research Seminar
Spring 2025
Dr. Dixon Anjejo Assistant: Eugenie Mukamunana
FDNT680 Syllabus
Page 2
Spring 2025
FDNT 680: RESEARCH SEMINAR (1 Credit Hour)
Course Descriptions
The Research Seminar allows MPH students to prepare and present scientific information on
nutrition, wellness, health promotion, and health education to MPH/MS students and/or public
health professionals.
Instructor Contact
Professor: Dixon Anjejo, MPH, DrPH
Assistant: Eugenie Mukamunana
Office: Marsh Hall 313
Office Hours: Wednesdays & Thursdays 12 pm – 2 pm
EST Email: [email protected]
Office Phone: 269-471-3386
Interactive Online Format
This course follows an interactive online format delivered online through Learning Hub
https://learninghub.andrews.edu/. You are expected to log in regularly during the course to
participate in the online discussions, post research documents, and communicate with classmates
and the instructor. The technical requirements include weekly access to an internet connection
(DSL, LAN, or cable connection desirable). Please plan accordingly. Your username and
password are your Andrews’ username and password. You must activate your username and
password to access Learning Hub:
https://vault.andrews.edu/vault/pages/activation/information.jsp.
Username and password
assistance
[email protected] (269) 471-6016
Bookstore http://bookstore.mbsdirect.net/andrews.htm
Library – Silas Marques,
Off-campus Services
Librarian
https://www.andrews.edu/library/offcamp.html 269-471-6263
Technical assistance with
Learning Hub
[email protected] (269) 471-3960
Exam requests and
proctoring assistance
[email protected] (269) 471-6566
FDNT680 Syllabus
Page 3
Course Methods and Delivery Methods of Instruction
Methods of instruction include assigned readings from articles in peer-reviewed journals related
to the students’ Interactive Learning Experience (ILE), the course material and selected videos, as
well as feedback from peers and instructor. This course is delivered online through Learning Hub
at http://learninghub.andrews.edu. Your username and password are your Andrews’ username and
password. You need to activate your username and password to access LearningHub. Please do
this online here: https://vault.andrews.edu/vault/pages/activation/information.jsp if you haven’t
already. (269) 471- 6016 or email [email protected] if you need assistance. If you need
technical assistance at any time during the course or to report a problem with Learning Hub,
please email [email protected] or call 269-471-3960.
Part 1: Course Objectives & Schedule
FDNT 680 Research Seminar meets the following requirements:
Course Competencies for CEPH Accreditation
The course reinforces the following foundational and concentration competencies to meet the
CEPH requirements:
1. Review literature of evidence-based education initiatives designed to address diet and
lifestyle issues focusing on preventing chronic diseases and health promotion by applying
knowledge acquired from courses emphasizing vegetarian nutrition and physical activities.
2. Review the literature on a wellness program for a specific population to decrease the
prevalence and incidence of chronic disease related to inactivity using relevant
evidence-based recommendations on physical activity.
3. Review the literature on a health and wellness education initiative/program to educate
and motivate people about health.
4. Review literature on developing and evaluating research (methods) designs using
public health methodology, biostatistics, and/or epidemiology to address research
questions in public health.
5. Systematically and critically evaluate peer-reviewed research articles on nutritional
wellness, physical activities, and general lifestyle.
6. Apply epidemiological methods to the breadth of settings and situations in public
health practice
7. Select quantitative and qualitative data collection methods appropriate for a given
public health context
8. Analyze quantitative and qualitative data using biostatistics, informatics, computer-
based programming and software as appropriate
FDNT680 Syllabus
Page 4
9. Interpret results of data analysis for public health research, policy or practice
10. Select communication strategies for different audiences and sectors
11. Communicate audience-appropriate public health content, both in writing and
through oral presentation
Course Learning Outcomes (Objectives) (LO) from Andrews University:
1. Learn how to search scientific data using different library databases.
2. Learn how to select and gather relevant and sound scientific data.
3. Critically analyze and evaluate scientific literature.
4. Summarize and interpret relevant scientific literature.
5. Create a formal scientific PowerPoint presentation.
6. Present scientific information for graduate level and professional audiences.
7. Enhance verbal and written communication skills.
8. Lead a research discussion using data-backed evidence to defend own conclusions.
FDNT680 Syllabus
Page 5
Course Schedule
Week Activity Assignment CC LO
Week 1
Choose your research topic. This topic may be
something you choose to explore further in your
ILE or other culminating research activity. Discuss
your topic with the course instructor. The instructor
must approve the topic before you post.
Post your
research topic.
1, 2
1,2
Week 2
Search scientific databases (Pub Med, Science
Direct, EBSCO, Google Scholar, etc.). Create an
annotated bibliography that includes at least 12
articles relevant to your topic. Ideally, those
papers should be the backbone for the literature
review section of your Interactive Learning
Experience (ILE) or Research Project.
Post an annotated
bibliography with
at least 12
relevant articles
to your topic.
1,2, 3
1,2
Week 3-5
Critically and systematically review the 12
selected articles from week 2. Please remember
how you did your review in Research Methods
and other courses like Current Issues in
Nutrition.
Submit
your
reviews.
1, 2
3
Week 6 Read the 12 selected articles. Write a (200-250
words) abstract of your reviews.
Post your revised
title and the
abstract.
1, 2 3
Week 7
Create and prepare the PowerPoint slides for your
oral presentation of the reviews. You may consult
with your instructor for further guidance.
Present your
research via
Zoom
conference.
8,
9,
10
5,6,7,8
Week 8
Oral presentations.
Present your
research via
Zoom conference.
Upload the
research
presentation
slides and the
research paper
after revising
based on instructor
feedback.
8, 9, 10
5, 6,7,8
FDNT680 Syllabus
Page 6
KEY: CC – Concentration Competency
LO – Course Learning Outcome
Part 2: Course Requirements
Topic Selection: 5%
Bibliography: 10%
Critical and Systematic of Literature 35%
Students are required to prepare a focused literature review paper and a PowerPoint presentation.
Then, write a short abstract summarizing the presentation. See the rubrics for the evaluation in
the syllabus appendix. In addition, the student will research and critically review the scientific
literature to prepare a 30-minute PowerPoint culminating presentation summarizing a selected
topic of nutrition and wellness, highlighting the most salient finding of their research, and
critically analyzing the literature used for the research presentation. In addition, each student will
prepare a 4-6 research paper summarizing the key research topic and critically analyzing the data
of the research topic articles.
The research topic must be approved in advance by the instructor early in the course. NOTE: To
expedite the completion of the ILE, each student can research the literature relevant to their ILE
project. The research seminar can help students meet the course requirements and, at the same
time, can be used to gather background information relevant to the ILE.
The content of the literature review paper:
1) Title.
2) Abstract.
3) Literature review—focused systematic and critical review
4) Summary of results.
5) Discussion
6) Conclusion
7) Recommendations
Timely Submission of Assignments: 5%
The assignments must be submitted before or on the due date. Students who submit past the due date
will lose points.
FDNT680 Syllabus
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PowerPoint Presentation-Instructor Evaluation 45%
The PowerPoint presentations follow a research conference format. The abstracts will be printed
and circulated to all participants in the presentation. The instructor will announce the conference
time after discussing it in class. Each student will consult with the instructor at least once to review
their presentation before presenting. As the rubric indicates, faculty will react to several aspects of
each presentation. This is an interactive presentation, and the presenters will have the opportunity
to answer questions about their research and to receive feedback from students and faculty. This
culminating presentation will enhance the presentation skills of each participant. The culminating
presentation will target graduate public health students and health professionals, not lay audiences.
Therefore, we expect the student to demonstrate an in-depth understanding of the topic presented.
The presentation should provide the following:
• a clear overview of the topic
• a solid and relevant background about the topic being presented and key findings of
the papers reviewed in the selected research area
• methodological issues that might explain discrepancies between similar studies
• gaps in knowledge
• Recommendations for future research in the topic of study
Students must consult with the course instructor before their oral
presentations.
FDNT680 Syllabus
Page 8
Credit Hour and Commitment
This course is offered for 1 credit; therefore, it is expected that you will spend averagely 22 hours
per week during the 8-week duration of this class. There are no quizzes or exams for this course.
MS students will take an additional credit of Research Seminar the following semester. The
additional credit will focus on clinical aspects.
Part 4: Grading Policy
Key Assignments and Evaluations
Percent
%
Description
5% Topic of the Review
10% Annotated Bibliography
35% Critical and systematic review of Literature - This literature review can be
used in the student’s ILE research project.
Peer Evaluation - Average of all the peer evaluations for each presentation
45% PowerPoint Presentation - Instructor Evaluation - Course instructor
evaluation
4% Timely submission of assignments
1% Course Evaluation
100% Total Percent Possible
Letter Grade Assignment
Letter Grade Percentage
A 94-100%
A- 90-93%
B+ 88-89%
B 83-87%
B- 80-82%
C+ 78-79%
C 73-77%
C- 70-72%
D 60-69%
F 0-59%
FDNT680 Syllabus
Page 9
Completing Assignments
All assignments for this course will be submitted electronically through Learning Hub unless
otherwise instructed.
Part 5: Course Policies
Late Work
Each student is expected to turn in all the assignments promptly. The deadline for submissions
and reviews is Sunday at midnight the following week. If I need to modify those deadlines, I will
notify the students.
Withdrawal and Incomplete Policies
The current withdrawal policy can be found online at
http://www.andrews.edu/distance/students/withdrawal.html. The incomplete policy is found online
at http://www.andrews.edu/weblmsc/moodle/public/incompletes.html.
ACADEMIC INTEGRITY:
“Andrews University, as a Seventh-day Adventist institution, expects students to demonstrate the
ability to think clearly and exhibit personal moral integrity in every sphere of life. Honesty in all
academic matters is a vital component of personal integrity. Breaches in academic integrity
principles are taken seriously by the University. Acts of academic dishonesty, as described in the
University Bulletin, are subject to incremental disciplinary penalties with redemptive intent. Such
acts are tracked in the office of the Provost. Repeated and/or serious offenses will be referred to
the Committee on Academic Integrity for further recommendations on penalties.”
ARTIFICIAL INTELLIGENCE (AI) USE POLICY
This policy applies to generative AI tools like ChatGPT, Elicit, etc. Suppose you include material generated
by an AI program in your work; it must be cited as you would with any other reference material,
considering the reference quality, which might be subpar. No more than 25% of an assignment should
consist of AI-created content. For guidance on proper APA formatting for these citations, please refer to the
article in the link below How to cite ChatGPT
In this course my policy will be that any student who:
(a) submits work done by another student as their own
(b) engages in or contributes to plagiarism
(c) engages in or contributes to cheating on a test or assignment
(d) deliberately misleads the instructor through falsehood (i.e. lying)
(e) falsifies data etc.
The student may receive a grade of zero for that assignment. Depending on the severity of the
offense, and at the discretion of the instructor, further disciplinary measures may be pursued at the
college level. Repeat offenses may result in a zero for the course. Please note again that all
FDNT680 Syllabus
Page 10
instances of academic honesty must and will be reported to the office of the Provost, where a
record will be kept on file. As noted above, the University uses these records to track repeat
offenders
FDNT680 Syllabus
Page 11
In order to protect academic integrity the following policies will be followed:
(a) A student may be given an oral examination on any assignment at any time.
(b) All electronic equipment must be turned off and placed out of sight during tests. The
presence of active electronic equipment may be considered as an attempt to engage in
cheating. (c) The provision of materials used in plagiarism or cheating will be
considered as serious an offense as the plagiarism or cheating itself.
Plagiarism is defined as:
(a) The use of works produced by another without indicating that a source is being copied
and without citation
(b) The use of ideas produced by another without citation
(c) The use of a structure for making an argument or describing a finding without citation
(d) Any of the above, no matter what the type of material that is used – drawings,
written text, and spoken presentations, may all be plagiarism
EMAIL ETIQUETEE
• Answer ASAP – within 24 to 48 hours. A month in email feels like 20 years. A day feels
like a week. Not returning emails or phone calls is communicating that you view the caller
or sender as unimportant. Be brief in your communication – Most people don’t
thoroughly read anything much longer than a memo.
• Don’t forget punctuation, capitalization, and spelling – How many emails have you
received with poor spelling or grammar? How many have you sent with poor spelling and
grammar? It sends what communication theorists call a meta-message or “message around
a message.” The meta message is that you don’t care enough to proofread. Use the spell-
check feature.
• Respond to the sender’s question when returning the email - Isn’t it frustrating when
you purposefully ask a question via email only to ignore it? You then have to resubmit
the question in the next email. Use a greeting and a salutation – They are friendlier.
Every e-mail sounds better with a “Dear Bill” and a “Thanks, Sue.” The greeting and the
closing set an important tone for your message.
• Email is a written work – There is a finality to an email message. Never use email to
send sensitive information.
USING TECHNOLOGY:
Many assignments in this class will require you to complete assignments on computers or the
internet. If you submit an assignment electronically, be sure to keep a backup copy. At a
minimum, this should be an electronic copy; however, you may find it to your advantage to print
a copy for your records.
EMERGENCY PROTOCOLS
FDNT680 Syllabus
Page 12
Andrews University takes the safety of its student seriously. Signs identifying emergency protocol
are posted throughout buildings. Instructors will provide guidance and direction to students in the
classroom in the event of an emergency affecting that specific location. It is important that you
follow these instructions and stay with your instructor during any evacuation or sheltering
emergency.
DISABILITY:
Andrews University accepts and appreciates diversity in its students, including students with
disabilities. Accordingly, students with documented disabilities are encouraged to inform the
University of their disability and enter into a dialogue regarding ways in which the University
might reasonably accommodate them. If you qualify for the accommodations under the Americans
with Disabilities Act, please see the instructor as soon as possible for referral and assistance in
arranging such accommodations.
Academic Accommodations
Students who require accommodations may request an academic adjustment as follows:
1. Read the Andrews University Disability Accommodation information at
https://www.andrews.edu/services/sscenter/disability/
2. Download and fill in the disability form at
http://www.andrews.edu/services/sscenter/disability/accommodationsreqform.pdf .
Preferably type answers. To save a digital copy, 1) print to file and save or 2) print and
scan. Email the completed form and disability documentation (if any) to
[email protected] or fax it to 269471-8407.
3. Email [email protected] to inform the School of Distance Education that a
disability has been reported to Student Success.
4. Please note that you cannot revise a paper you have not written. If you fail to turn in an
assigned essay, you cannot submit a revision of that paper. You are encouraged to revise
any paper with which you are not satisfied. Unfortunately, you can only revise your
essays. You cannot revise discussion board postings, journal entries, midterm exam, or
final exam.
Commit to Integrity
As a student in this course (and at this university) you are expected to maintain high degrees of
professionalism, commitment to active learning and participation in this class and also integrity in
your behavior in and out of the classroom.
Commit to Excellence
You deserve a standing ovation based on your decision to enroll in, and effectively complete this
course.
FDNT680 Syllabus
Page 13
Along with your pledge of “commitment to Integrity” you are expected to adhere to a
“Commitment to excellence.” Andrews University has established high academic standards that
will truly enhance your writing and communication skills across the disciplines and in diverse
milieu with many discourse communities in the workplace.
Honesty
Using the work of another student or allowing work to be used by another student jeopardizes not
only the teacher-student relationship but also the student’s academic standing. Lessons may be
discussed with other students, tutors may help to guide a student’s work, and textbooks,
encyclopedias and other resource materials may be used for additional assistance, but the actual
response must be the student’s own work. A student who gives information to another student to
be used in a dishonest way is equally guilty of dishonesty.
“Andrews University, as a Seventh-day Adventist institution, expects students to demonstrate the
ability to think clearly and exhibit personal moral integrity in every sphere of life. Honesty in all
academic matters is a vital component of personal integrity. Breaches in academic integrity
principles are taken seriously by the University. Acts of academic dishonesty as described in the
University Bulletin are subject to incremental disciplinary penalties with redemptive intent. Such
acts are tracked in the office of the Provost. Repeated and/or serious offenses will be referred to
the Committee on Academic Integrity for further recommendations on penalties.”
In this course my policy will be that any student who:
(a) submits work done by another student as their own
(b) engages in or contributes to plagiarism
(c) engages in or contributes to cheating on a test or assignment
(d) deliberately misleads the instructor through falsehood (i.e., lying) (e)
falsifies that may receive a grade of zero for that assignment.
Depending on the severity of the offense and at the instructor's discretion, further disciplinary
measures may be pursued at the college level. Repeat offenses may result in a zero for the course.
Please note again that all instances of academic honesty must and will be reported to the office of
the Provost, where a record will be kept on file. As noted above, the University uses these records
to track repeat offenders.
In order to protect academic integrity, the following policies will be followed:
(a) A student may be given an oral examination on any assignment at any time.
(b) All electronic equipment must be turned off and placed out of sight during tests. The presence
of active electronic equipment may be considered as an attempt to engage in cheating.
(c) The provision of materials used in plagiarism or cheating will be considered as serious an
offense as the plagiarism or cheating itself.
FDNT680 Syllabus
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Any violation of this policy will be taken before the Higher Education Academic and Curriculum
Committee for appropriate punitive action.
Copyright © 2024 by Andrews University. Update the year if necessary and this should always be
at the bottom of the last page. All rights reserved. No part of these course materials may be
reproduced, stored in a retrieval system, or transmitted by any form or by any means-electronic,
mechanical, photocopying, recording, or otherwise except as may be expressly permitted by the
applicable copyright statutes or in writing by Andrews University.
FDNT680 Syllabus
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Appendix 1
15 POINTS TITLE OR TOPIC
Perfect Title with EDP: 15
points
Title with 2 of the required
contents: 10 points
Title with the one required
content: 5 points
FDNT680 Syllabus
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Appendix 2
30 POINTS ANNOTADATED BIBLIOGRAPHY RUBRIC
Illegible or inaccurate annotations score a 0
Rubric
Categories:
30 points
Thorough &
Insightful: 27
points
Acceptable &
Literal: 21 points
Attempted &
Gaps: 15 points
Partial &
Incomplete: 9
points
Confused &
Inaccurate: 3
points
Number of
Annotations:
10 points
Ample margin
Notes: 9 points
Sufficient margin
notes: 7 points
Some margin
notes: 5 points
Few margin notes:
3 points
Very few
margin notes; 1
point
Quality of
Annotations:
10 points
Insightful margin
notes with many
connections made
beyond the text;
outstanding effort:
9 points
Literal margin
notes show
understanding of
the text; sufficient
effort: 7 points
Some margin
notes show
confusion: some
effort: 5 points
Many margin
notes show
confusion: little
effort: 3 points
Most margin
notes show
confusion or
inaccurate;
very little
effort: 1 point
Quality of
Writing: 10
points
Very neat writing;
very easy to read:
9 points
Neat writing
readable: 7 points
Attempted to
write neatly, some
areas require
effort to read: 5
points
Struggled to write
neatly; many areas
require effort to
read: 3 points
Really
Struggled to
write neatly;
most areas are
difficult to
read: 1 point
30 27 21 15 9 3
FDNT680 Syllabus
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Appendix 3
Systematic and Review Literature: 100 points
Criterion Excellent: (100) Good: (90) Satisfactory: (80) Needs Improvement
(70)
Unsatisfactory:
(50)
Research
Quality and
Relevance
Sources are scholarly,
credible, and highly
relevant to the topic; a
variety of perspectives
are well-integrated.
Sources are credible
and mostly relevant;
minor gaps in
coverage, but overall
sufficient.
Sources are somewhat
relevant but lack
depth or variety;
several sources lack
credibility.
Sources are minimally
relevant or mostly not
credible; coverage of
topic is lacking.
Sources are
irrelevant, outdated,
or lacking
credibility; topic is
insufficiently
addressed.
Depth of
Analysis and
Synthesis
Demonstrates in-depth
analysis and synthesis of
research; integrates
multiple perspectives
seamlessly.
Shows good synthesis
and some analysis;
integrates different
perspectives, but some
may lack depth.
Basic synthesis with
limited analysis;
perspectives are
presented without
strong integration.
Minimal synthesis or
analysis; perspectives are
mostly summarized
rather than analyzed.
Lacks synthesis and
analysis;
perspectives are
presented without
critical insight.
Clarity and
Organization
Literature review is
well-organized, flows
logically, and uses clear,
professional language;
follows assignment
format.
Organization is
generally clear and
logical; minor issues
with flow or clarity;
mostly follows
assignment format.
Organization is
adequate but lacks
cohesion in some
areas; language and
structure require
improvement.
Organization is unclear or
illogical; language and
structure are inconsistent
or difficult to follow.
Disorganized and
difficult to
understand; lacks
adherence to
assignment format.
Referencing
and Citation
References and citations
are accurate and
complete, following the
required citation style
consistently.
References and
citations are mostly
accurate, with few
minor errors; generally
follows the required
style.
Several references or
citations contain
errors; style is
inconsistent in places.
Significant errors in
referencing and citation;
does not consistently
follow required style.
Referencing is
inaccurate or
missing; lacks
adherence to
required citation
style.
Argument
Structure
and
Coherence
Presents a clear,
coherent argument
throughout; supports
claims with relevant
evidence and logical
progression.
Presents a generally
coherent argument;
supports claims well
but may lack depth in
some areas.
Argument is mostly
clear, though parts
lack coherence or
sufficient support.
Argument is unclear or
inconsistent; lacks logical
progression and sufficient
supporting evidence.
No clear argument
is presented; lacks
coherence and
necessary support
for claims.
FDNT680 Syllabus
Page 18
Appendix 4
Evaluation of Oral Presentation
Criteria Excellent Very Good Good Poor
Content
Opening
Opening
captivates the
audience with
interest and/or
intrigue. 10 points
Interesting
opening; engages
audience. 8 points
Opening is
minimally
engaging. 6 points
Opening is not
engaging. 4 points
Organization
Information/ideas
are presented in a
consistently
logical sequence.
Transition/conne
ctions are
eloquent. A
strong sense of
wholeness is
conveyed.
Conclusion
leaves the
audience with a
strong sense of
closure. 10
points
Important ideas
and information
are identified for
the audience.
Information/ideas
are presented in a
logical sequence
with few lapses.
Transitions and
connections are
made. Closing
effectively
summarizes the
presentation. 8
points
Irrelevant,
unnecessary
information
detracts. Big
ideas are not
specifically
identified. There
are significant
lapses in the
order of ideas.
Transitions are
inconsistent and
weak or missing.
Closing
demonstrates an
attempt to
summarize. 6
points
No clear
organization.
Ideas do not
connect with one
another. There are
no clear
transitions.
No closing is
evident. 4 points
FDNT680 Syllabus
Page 19
Presentation
Speech
Commands
audience politely
using eye contact,
making sure the
audience is ready.
Can be heard by
all members of
the audience
without
assistance. Uses
visual aid as a
guide or outline
for speaking.
Consistently
maintains eye
contact. 20 points
Makes sure the
audience is ready
before starting.
May need
reminders from the
audience to speak
up; generally,
consistently
maintains eye
contact and
minimizes reliance
on notes. 15 points
Makes occasional
eye contact, makes
few attempts to
command the
audience; may
start speaking
before an audience
is ready. Needs
reminders from
the audience to
speak up. Mostly
reads from notes.
10 points
The audience
hears with great
difficulty. Reads
notes and seldom
establishes eye
contact. 5 points
FDNT680 Syllabus
Page 20
Visual Aid
Visual aid
readable and
attractive from all
parts of the room.
Graphic is clear
and professional
looking,
enhancing the
message. 10
points.
Visual aid
readable from all
parts of the room.
Graphic is neat.
Appropriate
subject chosen to
depict message. 8
points
Visual aid is not
completely
accessible to all
audience
members.
Graphic may be
messy. Visual may
not be most
appropriate to
support
presentation. 6
points
Visual aid is
indecipherable.
The graphic
detracts from
the message.
Messy or
inappropriate
visual. 4 points
Content
The content of the
presentation
reflects extensive
research and is
based on strong
scientific
evidence. 40
points
The content of the
presentation
reflects some
supportive
research. 30 points
The content of the
presentation
reflects limited
research to
support it. 20
points
The content of the
presentation
reflects limited
research. 10 points
Time Frame
The presentation
falls within the
required time
frame.
The presentation
falls within the
required time
frame.
Presentation is
less than the
minimum time.
Presentation is
more than the
maximum time.
Total Points /100 points

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