S Wilson‐Barnes, L. P Gymnopoulos, K Dimitropoulos, V Solachidis, K Rouskas, D Russell, Y Oikonomidis, S Hadjidimitriou, J María Botana, B Brkic, E Mantovani, S Gravina, G Telo, E Lalama, R Buys, M Hassapidou, S Balula Dias, A Batista, L Perone, S Bryant, S Maas, S Cobello, P Bacelar, S. A Lanham‐New, K Hart (2021)PeRsOnalised nutriTion for hEalthy livINg: The PROTEIN project, In: Nutrition bulletin46(1)pp. 77-87
Personalised nutrition is a novel public health strategy aiming to promote positive diet and lifestyle changes. Tailored dietary and physical activity advice may be more appropriate than a generalised ‘one‐size‐fits‐all’ approach as it is more biologically relevant to the individual. Information and computing technology, smartphones and mobile applications have become an integral part of modern life and thereby present the opportunity for novel methods to encourage individuals to lead a healthier lifestyle. This article introduces the European Union‐funded PROTEIN project (PeRsOnalised nutriTion for hEalthy livINg) consortium and introduces the associated work packages. The primary objective of the PROTEIN project is to produce a novel adaptable mobile application suite based on sound nutrition and physical activity advice from experts in their field, accessible to all population groups, with differing health outcomes, whose behaviour can be tracked with a variety of sensors and health hazard perception. The mobile application ‘ecosystem’ that will be developed by the consortium includes a platform, mobile suite, cloud services, artificial intelligence advisor, game suite, modelling of expert’s knowledge, users’ behaviour data collection, data analysis and a dashboard for healthcare professionals. It is proposed that users will find the provision of personalised nutrition advice and real‐time data capture through a smartphone application useful, and importantly, will be encouraged by this to make positive health behaviour changes.
Background: Processed foods are typically praised/revered for their convenience, palatability, and novelty; however, their healthfulness has increasingly come under scrutiny. Classification systems that categorise foods according to their “level of processing” have been used to predict diet quality and health outcomes and inform dietary guidelines and product development. However, the classification criteria used are ambiguous, inconsistent and often give less weight to existing scientific evidence on nutrition and food processing effects; critical analysis of these criteria creates conflict amongst researchers.
Scope and approach: We examine the underlying basis of food classification systems and provide a critical analysis of their purpose, scientific basis, and distinguishing features by thematic analysis of the category definitions.
Key findings and conclusions: These classification systems were mostly created to study the relationship between industrial products and health. There is no consensus on what factors determine the level of food processing. We identified four defining themes underlying the classification systems: 1. Extent of change (from natural state); 2. Nature of change (properties, adding ingredients); 3. Place of processing (where/by whom); and 4. Purpose of processing (why, essential/cosmetic). The classification systems embody socio-cultural elements and subjective terms, including home cooking and naturalness. Hence, “processing” is a chaotic conception, not only concerned with technical processes. Most classification systems do not include quantitative measures but, instead, imply correlation between “processing” and nutrition. The concept of “whole food” and the role of the food matrix in relation to healthy diets needs further clarification; the risk assessment/management of food additives also needs debate.
There is an urgent need to better understand the problem of vitamin D deficiency, and its health effects, in population groups of different ethnicity. The principal aim of this project was to examine vitamin D status, sunlight exposure, and health outcomes in UK dwelling South Asian and Caucasian women. A cohort of 80 postmenopausal and 32 premenopausal South Asian and Caucasian women were assessed for vitamin D status (serum 25-hydroxyvitamin D; 25(OH)D), musculoskeletal health, light exposure and sleep-wake cycles. In postmenopausal women, South Asians had a significantly lower vitamin D concentration than Caucasians (p=0.002), with 83% of Asians vs. 24% of Caucasians below 50nmol/l for 25(OH)D. Despite adaptations in tibial bone structure of the South Asians to improve bone strength, their bones were weaker by 38% compared with Caucasians (p<0.001). Stand-to-walk time (Asian mean (±SD) time 8.1 s ± 1.8 vs. Caucasian mean (±SD) time 6.9 s ± 1.4); p=0.002) and grip strength (Asian strength=70% of Caucasian strength, p<0.001) were worse in the South Asians. For both premenopausal and postmenopausal women, Caucasians showed a significantly higher actigraphic sleep efficiency (p<0.001) and lower sleep fragmentation (p=0.002) than Asians. There was a higher outdoor light exposure (over 1000 lux) in premenopausal and postmenopausal Caucasians than in same-age Asians (p=0.052). Qualitative analysis of interview data suggested that religious and cultural influences on family, work and community life may partly explain the reduced sunlight exposure in South Asian women, which contributes to vitamin D deficiency. The implications of this work are that older South Asian women are in need of intervention to improve vitamin D status. There is also some evidence for poorer musculoskeletal health, lower light exposure and poorer sleep in this group. The qualitative research included in the current study offers future intervention options to improve the health of UK dwelling South Asian women.
There is a lack of research into 25-hydroxyvitamin D (25(OH)D) status, light exposure and sleep patterns in South Asian populations. In addition, results of research studies are conflicting as to whether there is an association between 25(OH)D status and sleep quality.
We investigated 25(OH)D status, self-reported and actigraphic sleep quality in n = 35 UK dwelling postmenopausal women (n = 13 South Asians, n = 22 Caucasians), who kept daily sleep diaries and wore wrist-worn actiwatch (AWL-L) devices for 14 days. A subset of n = 27 women (n = 11 South Asian and n = 16 Caucasian) also wore a neck-worn AWL-L device to measure their light exposure.
For 25(OH)D concentration, South Asians had a median ± IQR of 43.8 ± 28.2 nmol/L, which was significantly lower than Caucasians (68.7 ± 37.4 nmol/L)(P = 0.001). Similarly, there was a higher sleep fragmentation in the South Asians (mean ± SD 36.9 ± 8.9) compared with the Caucasians (24.7 ± 7.1)(P = 0.002). Non-parametric circadian rhythm analysis of rest/activity patterns showed a higher night-time activity (L5) (22.6 ± 14.0 vs. 10.5 ± 4.4; P = 0.0008) and lower relative amplitude (0.85 ± 0.07 vs. 0.94 ± 0.02; P ˂ 0.0001) in the South Asian compared with the Caucasian women. More South Asians (50%) met the criteria for sleep disorders (PSQI score ˃5) than did Caucasians (27%) (P = 0.001, Fishers Exact Test). However, there was no association between 25(OH)D concentration and any sleep parameter measured (P ˃ 0.05) in either ethnic group. South Asians spent significantly less time in illuminance levels over 200 lx (P = 0.009) than did Caucasians.
Overall, our results show that postmenopausal South Asian women have lower 25(OH)D concentration than Caucasian women. They also have higher sleep fragmentation, as well as a lower light exposure across the day. This may have detrimental implications for their general health and further research into sleep quality and light exposure in the South Asian ethnic group is warranted.
Vitamin D deficiency is a major public health concern in the UK. As the natural sources of vitamin D in the UK are limited, supplementation or food fortification are possible strategies for achieving the dietary recommendations of 10 μg/d that will be introduced in 2016 for the whole population. However, there is controversy as to whether vitamin D2 and vitamin D3 are equally effective at raising vitamin D status (25OHD concentration). The primary and secondary aims of this PhD project were: to investigate the effects of both these forms of vitamin D independently on vitamin D status, markers of bone and cardiovascular health, and gene expression; as well as to examine whether common genetic variants affect response to either form of vitamin D. A cohort of 90 South Asian and 245 Caucasian women were recruited onto a randomised-controlled trial; the D2-D3 Study. Participants were given either 15 µg/d of vitamin D2, 15 µg/d of vitamin D3 or placebo, in fortified foods, for 12 weeks. At baseline, serum total 25OHD concentrations were significantly lower in the South Asian women (27.6 nmol/L) than the Caucasian women (60.3 nmol/L). In both the South Asian and Caucasian women, 25OHD concentrations significantly decreased in the placebo intervention (-5% and -15% respectively, p<0.001), and significantly increased in both the vitamin D2 (112% and 39% respectively, p<0.001) and the vitamin D3 interventions (243% and 72% respectively, p<0.001), with significantly greater increases seen in the vitamin D3 intervention (p<0.001). In the vitamin D3 groups, parathyroid hormone (PTH) concentrations decreased in the South Asian women (p<0.001), who had higher baseline concentrations, and were maintained in the Caucasian women, who had healthy baseline PTH concentrations. This effect was not seen with vitamin D2 fortification. Over the 12 weeks, there were no clinically relevant changes in blood lipid concentrations in response to either vitamin D2 or D3, in the South Asian and Caucasian women. Interestingly, whole blood transcriptome analysis indicated that the vitamin D2 and D3 interventions triggered a difference in expression of entirely different genes, and predicted therefore a difference in the activity of the respective metabolic and cellular pathways. The associations between genetic polymorphisms and change in 25OHD concentration in response to vitamin D also appear to differ depending on the form of vitamin D taken, although baseline 25OHD concentration may be a confounder. The implications of this work, as the largest RCT conducted to date and showing conclusively that vitamin D3 is more effective than vitamin D2 at raising total 25OHD concentration and achieving or maintaining a healthy PTH concentration, are important: in the clinical setting vitamin D3 may be preferable in the treatment of vitamin D deficiency. The novel findings that vitamin D2 and vitamin D3 lead to different metabolic/cellular responses requires further research to determine whether the response to vitamin D2 is due to a decrease in 25OHD3 concentration (observed in this study following vitamin D2 treatment) or whether it is in response to the increase in 25OHD2 concentration.
End stage renal disease (ESRD) is associated with several physiological and metabolic changes which together cause poor health and impair patients’ quality of life. Anaemia is one of the most common metabolic consequences of renal failure and is highly prevalent among ESRD patients. Renal anaemia has a significant negative impact not only on patients’ health outcomes but also poses a heavy economic burden on the health system due to the high cost of treatment. Interactions between nutrition, anaemia status or/and response to anaemia therapies have been suggested. This programme of work aimed to investigate anaemia and nutritional status (including body composition) among haemodialysis (HD) patients and to study how nutrition status and body composition modify patients’ anaemia status and their response to the hormone erythropoietin (EPO). The first two sections of this project were cross-sectional studies conducted to characterise the health status of patients. Firstly, health outcomes were compared between the UK (n = 101) and Tanzanian (n = 96) HD patients after which a more in depth study was conducted in Tanzania only (n = 77). These are presented in chapter 2 and 3 respectively. Both studies showed that Tanzanian HD patients had increased risk of low haemoglobin (Hb) levels, inadequate nutrition and inflammation. The findings showed that body fat and muscle mass were significantly and positively associated with Hb and EPO response. These investigations were then extended to the UK via recruitment and assessment of a cohort of UK adults HD patients on EPO treatment (n = 41). The UK study was conducted longitudinally and included additional markers of anaemia and nutritional status to further assess the relationship previously observed and in an attempt to uncover the mechanisms involved. The findings showed that longitudinally, body fat, significantly and positively influenced Hb concentration independent of EPO type and gender. Equally, there was a positive association between leptin hormone and Hb concentrations, suggesting a potential link and possible mechanism for the observed association between body fat and Hb levels. Finally, building on this work, an exercise intervention of low intensity (walking + intradialytic resistance training) was adopted and conducted as a randomized controlled pilot and feasibility study. The aims were to investigate if such an intervention was feasible and acceptable to patients and staff and capable of inducing favourable changes in patients’ body composition (body fat and muscle), and if so, how any such changes would modify patients response to EPO and their Hb status. The eight week study was unable to achieve significant changes in body composition or iron markers. However, there was a slight improvement in exercise performance and lower body strength assessed through the sit to stand test. To our knowledge, the low intensity exercise protocol used, combining walking + intradialytic resistance training, has not been previously tested in the dialysis setting and offers an acceptable intervention for further research. This programme of work has demonstrated that good nutrition helps improve the EPO response and Hb levels of HD patients. A flexible and low intensity exercise programme involving walking and intradialytic resistance training is feasible and practical in the presence of a physiotherapist. However eight weeks of low intensity exercise is not sufficient to induce changes in body composition or EPO response in HD patients but may help improve their physical functioning and so warrants further investigation as a more cost effective alternative to cycle-based interventions.
Eating rate (ER) is part of the microstructure of meal ingestion and has been of increasing scientific interest due to manipulations being implicated in energy intake, appetite control and mindfulness. The current thesis aims to develop and test the slow eating rate (SER) protocol for use in overweight-free living adults and to investigate the protocol’s effects on body weight, hormones, metabolites and mindfulness.
The developmental part spanned over 5 studies. Studies A and B the SER was refined and finalised through volunteer feedback and in Study C successfully transformed into a 2-minute, online-friendly video which was then incorporated into an online (website and application) weight loss tool. In Study D software (AlexNet) which could identify chewing rate through ER video play back was developed. In Study E, the Mindful Eating Questionnaire -under development (MEQ-UD) was not found as a valid proxy for measuring ER.
The final study was a 10-week parallel, open label randomised controlled trial (control group: n = 7 intervention: n = 8) testing the SER protocol in a 6-week community intervention. Significant changes in body composition were seen in the intervention group, with reductions in weight (p= 0.006), BMI (p=0.006), body fat % (p= 0.026) and visceral fat (p= 0.007) and a trend towards a reduced energy intake (p=0.086) as compared to stable anthropometrics in the control group (n=7).The SER protocol resulted in significantly increased mindful eating in the intervention group. The online monitoring (web and app) proved effective, with duration of intervention (days), total online session duration (minutes) and average online session duration/visit (mins) shown to be the most influential parameters correlated with BMI change. Combined, these data provide novel insights into the effects of a SER protocol in controlled environments and the community. Replication and evaluation in larger and diverse population groups is warranted.
BACKGROUND: The number of children being diagnosed with type 1 diabetes mellitus (T1DM) is on the rise and has more than doubled in the past 10 years in Bahrain. Some studies have linked low vitamin D levels with an increased risk of diabetes. There are concerns regarding the variations in circulating 25(OH)D levels measured by different laboratories and by using different analytical techniques. OBJECTIVE: The aim of this study was to evaluate the vitamin D levels of newly diagnosed children with T1DM using the "gold standard method" with high-pressure liquid chromatography-tandem mass spectrometry methods compared to the chemiluminescence micro-particle immunoassay (CMIA) used in a hospital laboratory. SUBJECTS: Eighteen children, aged 6-12 years, who received a confirmed diagnosis of T1DM in 2014 were chosen as subjects. METHODS: Serum vitamin D levels were assessed in a hospital, while an extra aliquot of blood collected during routine blood collection after acquiring informed written consents from the subjects, and sent to Princess Al-Jawhara Center for Molecular Medicine and Inherited Disorders to be analyzed by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). RESULTS: The mean age of the study group was 9±2 years. The mean total of 25(OH)D levels (D3 and D2) assessed by UPLC-MS/MS was 49.7±18.8, whereas the mean total of 25(OH)D levels obtained from the CMIA assay was 44.60±13.20. The difference in classification between the two methods was found to be statistically significant (P=0.004). A Bland-Altman plot showed a poor level of agreement between the two assay methods. The CMIA overestimated insufficient values and underestimated deficiency, when compared to UPLC-MS/MS. CONCLUSION: There was a statistically significant difference between the two assay methods with CMIA overestimating vitamin D insufficiency. Clinicians should be prudent in their assessment of a single vitamin D reading, when the gold standard method is not available or feasible.
PS Gibson, S Lang, M Gilbert, D Kamat, S Bansal, ME Ford-Adams, AP Desai, A Dhawan, E Fitzpatrick, JB Moore, KH Hart (2015)Assessment of Diet and Physical Activity in Paediatric Non-Alcoholic Fatty Liver Disease Patients: A United Kingdom Case Control Study, In: NUTRIENTS7(12)pp. 9721-9733
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children, with prevalence rising alongside childhood obesity rates. This study aimed to characterise the habitual diet and activity behaviours of children with NAFLD compared to obese children without liver disease in the United Kingdom (UK). Twenty-four biopsy-proven paediatric NAFLD cases and eight obese controls without biochemical or radiological evidence of NAFLD completed a 24-h dietary recall, a Physical Activity Questionnaire (PAQ), a Dutch Eating Behavior Questionnaire (DEBQ) and a 7-day food and activity diary (FAD), in conjunction with wearing a pedometer. Groups were well matched for age and gender. Obese children had higher BMI z-scores (p = 0.006) and BMI centiles (p = 0.002) than participants with NAFLD. After adjusting for multiple hypotheses testing and controlling for differences in BMI, no differences in macro- or micronutrient intake were observed as assessed using either 24-h recall or 7-day FAD (p > 0.001). Under-reporting was prevalent (NAFLD 75%, Obese Control 87%: p = 0.15). Restrained eating behaviours were significantly higher in the NAFLD group (p = 0.005), who also recorded more steps per day than the obese controls (p = 0.01). In conclusion, this is the first study to assess dietary and activity patterns in a UK paediatric NAFLD population. Only a minority of cases and controls were meeting current dietary and physical activity recommendations. Our findings do not support development of specific dietary/ physical activity guidelines for children with NAFLD; promoting adherence with current general paediatric recommendations for health should remain the focus of clinical management.
Laura Tripkovic, LR Wilson, Kathryn Hart, Sigurd Johnsen, Simon de Lusignan, CP Smith, G Bucca, S Penson, G Chope, Ruan Elliott, E Hypponen, J L Berry, Susan Lanham-New (2017)Daily supplementation with 15 mg vitamin D2 compared with vitamin D3 to increase wintertime 25-hydroxyvitamin D status in healthy South Asian and white European women: a 12-wk randomized, placebo-controlled food-fortification trial, In: American Journal of Clinical Nutrition106(2)pp. 481-490
American Society for Nutrition
Background: There are conflicting views in the literature as to whether vitamin D2 and vitamin D3 are equally effective in increasing and maintaining serum concentrations of 25-hydroxyvitamin D [25(OH)D], particularly at lower doses of vitamin D. Objective: We aimed to investigate whether vitamin D2 or vitamin D3 fortified in juice or food, at a relatively low dose of 15 μg/d, was effective in increasing serum total 25(OH)D and to compare their respective efficacy in South Asian and white European women over the winter months within the setting of a large randomized controlled trial. Design: A randomized, double-blind, placebo-controlled food-fortification trial was conducted in healthy South Asian and white European women aged 20–64 y (n = 335; Surrey, United Kingdom) who consumed placebo, juice supplemented with 15 μg vitamin D2, biscuit supplemented with 15 μg vitamin D2, juice supplemented with 15 μg vitamin D3, or biscuit supplemented with 15 μg vitamin D3 daily for 12 wk. Serum 25(OH)D was measured by liquid chromatography–tandem mass spectrometry at baseline and at weeks 6 and 12 of the study. Results: Postintervention in the 2 ethnic groups combined, both the vitamin D3 biscuit and the vitamin D3 juice groups showed a significantly greater absolute incremental change (Δ) in total 25(OH)D when compared with the vitamin D2 biscuit group [Δ (95% CI): 15.3 nmol/L (7.4, 23.3 nmol/L) (P < 0.0003) and 16.0 nmol/L (8.0, 23.9 nmol/L) ( P < 0.0001)], the vitamin D2 juice group [Δ (95% CI): 16.3 nmol/L (8.4, 24.2 nmol/L) (P < 0.0001) and 16.9 nmol/L (9.0, 24.8 nmol/L) (P < 0.0001)], and the placebo group [Δ (95% CI): 42.3 nmol/L (34.4, 50.2 nmol/L) (P < 0.0001) and 42.9 nmol/L (35.0, 50.8 nmol/L) (P < 0.0002)]. Conclusions: With the use of a daily dose of vitamin D relevant to public health recommendations (15 μg) and in vehicles relevant to food-fortification strategies, vitamin D3 was more effective than vitamin D2 in increasing serum 25(OH)D in the wintertime. Vitamin D3 may therefore be a preferential form to optimize vitamin D status within the general population. This trial was registered at www.controlled-trials.com as ISRCTN23421591.
LR Wilson, L Tripkovic, K Hart, R Elliott, CP Smith, G Bucca, S Penson, G Chope, E Hypponen, J Berry, S Lanham-New (2014)IS VITAMIN D3 MORE EFFECTIVE THAN VITAMIN D2 IN RAISING 25OHD STATUS IN WOMEN WITH OSTEOPOROSIS AND OSTEOPENIA?, In: OSTEOPOROSIS INTERNATIONAL25pp. S687-S687
Polycystic Ovary Syndrome (PCOS), the most common endocrine condition in women, is often anecdotally associated with binge eating behaviours and food cravings; however there is a paucity of research. This study aimed to report the prevalence of binge eating and food cravings and their relation to obesity risk in women with PCOS. Participants completed an online survey including the Bulimia Investigatory Test, Edinburgh, Food Cravings-Trait Questionnaire and the Three Factor Eating Questionnaire revised-18. The study included obese (n = 340), overweight (n = 70) and lean (n = 45) women with PCOS and lean healthy women (n = 40). Sixty percent of obese women with PCOS were categorised with binge-eating behaviour, with 39% presenting with clinically significant behaviour. Obese women with PCOS presented with high mean food cravings-trait scores (131.6 ± 28.9) that were significantly greater compared with lean (114.0 ± 34.9) and overweight women with PCOS (120.1 ± 29.5; p < 0.001). Multiple regression exploring relations between eating styles and adiposity explained 59% of the variance in binge eating symptom scores in women with PCOS (F = 173.8; p < 0.001, n = 463): significant predictors were food cravings total score (beta = 0.52; p < 0.001), emotional eating score (beta = 0.16; p < 0.001), BMI (beta = 0.13; p < 0.001) and uncontrolled eating score (beta = 0.10; p < 0.01). Compared with lean healthy women, lean women with PCOS exhibited significantly higher binge eating symptom scores (10.9 ± 7.8 versus 7.4 ± 6.0; p < 0.05), though similar total food craving scores (114.0 ± 34.9 versus 105.6 ± 26.6: NS). This study is the largest, to date, to robustly report that a high proportion of women with PCOS exhibit binge eating behaviours. We recommend screening women with PCOS for binge eating behaviours to help inform the choice of weight management approach for this clinical population.
Use of substances including alcohol, tobacco and drugs is common in people of reproductive age, can lead to dependence and is a major global health concern. Despite targeted public health policies and campaigns, population surveys (National Institute on Drug Abuse (NIH) 2020; European Drug Report 2019) continue to highlight widespread use of substances, often in combination, which have substantial negative implications for health in general and the potential to harm future generations (Stephenson et al. 2018). Healthcare professionals need to be aware of the complex psychological, physiological and social factors that may be linked to substance use and be prepared to offer counselling and referral for specialist services. Pregnancy, however, can be a ‘window of opportunity’ and a motivating factor for women and their partners to change their behaviour and minimise risk with help to quit or cut down on substance use (Solomon and Quinn 2004). Preconception care offers the opportunity to further reduce risk by helping to modify consumption prior to pregnancy.
The role of vitamin D in supporting the growth and maintenance of the skeleton is robust; with recent research also suggesting a beneficial link between vitamin D and other nonskeletal health outcomes, including immune function, cardiovascular health and cancer. Despite this, vitamin D deficiency remains a global public health issue, with a renewed focus in the UK following the publication of Public Health England’s new Dietary Vitamin D Requirements. Natural sources of vitamin D (dietary and UVB exposure) are limited, and thus mechanisms are needed to allow individuals to achieve the new dietary recommendations. Mandatory or voluntary vitamin D food fortification may be one of the mechanisms to increase dietary vitamin D intakes and subsequently improve vitamin D status. However, for the food industry and public to make informed decisions, clarity is needed as to whether vitamins D2 and D3 are equally effective at raising total 25-hydroxyvitamin D (25(OH)D) concentrations as the evidence thus far is inconsistent. This review summarises the evidence to date behind the comparative efficacy of vitamins D2 and D3 at raising 25(OH)D concentrations, and the potential role of vitamin D food fortification as a public health policy to support attainment of dietary recommendations in the UK. The comparative efficacy of vitamins D2 and D3 has been investigated in several intervention trials, with most indicating that vitamin D3 is more effective at raising 25(OH)D concentrations. However, flaws in study designs (predominantly under powering) mean there remains a need for a large, robust randomised-controlled trial to provide conclusive evidence, which the future publication of the D2–D3 Study should provide (BBSRC DRINC funded: BB/ I006192/1). This review also highlights outstanding questions and gaps in the research that need to be addressed to ensure the most efficacious and safe vitamin D food fortification practices are put in place. This further research, alongside cost, availability and ethical considerations (vitamin D3 is not suitable for vegans), will be instrumental in supporting government, decision-makers, industry and consumers in making informed choices about potential future vitamin D policy and practice.
This study aimed to compare the use of the bioelectrical impedance device (BIA) seca® mBCA 515 using dual X-ray absorptiometry (DXA) as a reference method, for body composition assessment in adults across the spectrum of body mass indices. It explores the utility of simple anthropometric measures (the waist height ratio (WHtR) and waist circumference (WC)) for the assessment of obesity. In the morning after an overnight fast (10 h), 30 participants underwent a body composition DXA (GE iDXA) scan, BIA (seca 515), and anthropometric measures. Compared to the DXA reference measure, the BIA underestimated fat mass (FM) by 0.32 kg (limits of agreement
L Tripkovic, H Lambert, K Hart, CP Smith, G Bucca, S Penson, G Chope, E Hyppönen, J Berry, R Vieth, S Lanham-New (2012)Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis., In: Am J Clin Nutr95(6)pp. 1357-1364
American Society for Nutrition
Currently, there is a lack of clarity in the literature as to whether there is a definitive difference between the effects of vitamins D(2) and D(3) in the raising of serum 25-hydroxyvitamin D [25(OH)D].
There is some evidence that South Asian women may have an increased risk of osteoporosis compared with Caucasian women, although whether South Asians are at increased risk of fracture is not clear. It is unknown whether older South Asian women differ from Caucasian women in bone geometry. This is the first study, to the authors' knowledge, to use peripheral Quantitative Computed Tomography (pQCT) to measure radial and tibial bone geometry in postmenopausal South Asian women. In comparison to Caucasian women, Asian women had smaller bone size at the 4% (-18% p<0.001) and 66% radius (-15% p=0.04) as well as increased total density at the 4% (+13% p=0.01) radius. For the tibia, they had a smaller bone size at the 4% (-16% p=0.005) and 14% (-38% p=0.002) sites. Also, Asians had increased cortical thickness (-17% p=0.04) at the 38% tibia, (in proportion to bone size (-30% p=0.003)). Furthermore, at the 4% and 14% tibia there were increased total densities (+12% to +29% p<0.01) and at the 14% tibia there was increased cortical density (+5% p=0.005) in Asians. These differences at the 14% and 38% (but not 4%) remained statistically significant after adjustment for Body Mass Index (BMI). These adaptations are similar to those seen previously in Chinese women. Asian women had reduced strength at the radius and tibia, evidenced by the 20-40% reduction in both polar Strength Strain Index (SSIp) and fracture load (under bending). Overall, the smaller bone size in South Asians is likely to be detrimental to bone strength, despite some adaptations in tibial cortical thickness and tibial and radial density which may partially compensate for this.
BACKGROUND: Renal diets are arguably the most restrictive for any patient group, and many of the restrictions contradict current recommendations for healthy eating. OBJECTIVES. This study aims to explore the knowledge and beliefs of chronic kidney disease (CKD) patients about the role of diet in their disease presentation and management. METHODS: Focus groups (FG) with nephrology and dialysis patients informed the development of a questionnaire. Patient experiences and knowledge of diet-disease links and their education needs were explored. RESULTS: Renal diets were not always perceived as compatible with other dietary advice, and often difficult to integrate with family and social occasions. Eighty percent respondents said they would like to receive dietary advice as soon as they know they have renal damage. Renal dietitians were identified as the most reliable and trustworthy source of dietary information, followed by renal specialist doctors. CONCLUSION: Early dietetic intervention would be welcomed by patients, with group work and 'expert patient' assistance offering one means of delivering this service in a patient-centred way.
OBJECTIVES: The aim of the study was to evaluate efficacy of nutrition and physical activity interventions in the clinical management of paediatric nonalcoholic fatty liver disease. The prevalence of paediatric nonalcoholic fatty liver disease continues to rise alongside childhood obesity. Weight loss through lifestyle modification is currently first-line treatment, although supplementation of specific dietary components may be beneficial. METHODS: Medline, CINAHL, EMBASE, Scopus, and Cochrane Libraries were systematically searched to identify randomized controlled trials assessing nutritional and physical activity interventions. Primary outcome measures were changes to liver biomarkers assessed by imaging, histology, or serum liver function tests. Study quality was evaluated using the American Dietetic Association Quality Criteria Checklist. RESULTS: Fifteen articles met eligibility criteria investigating nutritional supplementation (vitamin E [n = 6], probiotics [n = 2], omega-3 fatty acids [n = 5]), dietary modification (low glycaemic load [n = 1] and reducing fructose intake [n = 1]). No randomized controlled trials examining physical activity interventions were identified. Vitamin E was ineffective at improving alanine transaminase levels, whereas omega-3 fatty acids decreased hepatic fat content. Probiotics gave mixed results, whereas reduced fructose consumption did not improve primary outcome measures. A low glycaemic load diet and a low-fat diet appeared equally effective in decreasing hepatic fat content and transaminases. Most studies were deemed neutral as assessed by the American Dietetic Association Quality Criteria Checklist. CONCLUSIONS: The limited evidence base inhibits the prescription of specific dietary and/or lifestyle strategies for clinical practice. General healthy eating and physical activity guidelines, promoting weight loss, should remain first-line treatment until high-quality evidence emerges that support specific interventions that offer additional clinical benefit.
Background: Vitamin D deficiency has been associated with non-alcoholic fatty liver disease (NAFLD). However, the role of polymorphisms determining vitamin D status remains unknown. Objectives: To determine in UK children with biopsy-proven NAFLD: (i) vitamin D status throughout a 12-month period; (ii) interactions between key vitamin D-related genetic variants (NADSYN1/DHCR7, VDR, GC, CYP2R1) and disease severity. Methods: In 103 pediatric patients with NAFLD, serum 25-hydroxyvitamin D (25OHD) levels and genotypes were determined contemporaneously to liver biopsy and examined in relation to NAFLD activity score and fibrosis stage. Results: Only 19.2% of children had adequate vitamin D status; most had mean 25OHD levels considered deficient (<25nmol/l, 25.5%) or insufficient (<50nmol/l, 55.3%). Patients had significantly lower 25OHD levels in winter months (95%CI: 22.7-31.2nmol/l) when compared to spring (30.5-42.1nmol/l; P=0.0089), summer (36.3-47.2nmol/l; P<0.0001) and autumn (34.2-47.5nmol/l; P=0.0003). Polymorphisms in the NADSYN1/DHCR7 (rs3829251, rs12785878), and VDR (rs2228570) genes were independently associated with increased steatosis; while a GC variant (rs4588) was associated with increased inflammation in liver biopsies. Conclusions: Children with NAFLD in the UK have particularly low winter vitamin D status; with vitamin D insufficiency prevalent throughout the year. Polymorphisms in the vitamin D metabolic pathway are associated with histological severity of pediatric NAFLD.
Vitamin D is a unique nutrient. Firstly, it acts as a pro-hormone and secondly, the requirement for vitamin D can be met by both endogenous synthesis from sunlight and by dietary sources. This complicates the determination of dietary requirements for vitamin D, which along with the definition of optimal vitamin D status, have been highly controversial and much debated over recent years. Adolescents are a population group at high risk of low vitamin D status, which is concerning given the important role of vitamin D, and calcium, in promoting normal bone mineralisation and attainment of peak bone mass during this rapid growth phase. Dietary vitamin D recommendations are important from a public health perspective in helping to avoid deficiency and optimise vitamin D status for health. However limited experimental data from winter-based dose-response randomised trials in adolescents has hindered the development of evidence-based dietary requirements for vitamin D in this population group. This review will highlight how specifically designed randomised trials and the approach adopted for estimating such requirements can lead to improved recommendations. Such data indicates that vitamin D intakes of between 10 and ~30 µg/day may be required to avoid deficiency and ensure adequacy in adolescents, considerably greater than the current recommendations of 10-15 µg/day. Finally this review will consider the implications of this on public health policy, in terms of future refinements of vitamin D requirement recommendations and prioritisation of public health strategies to help prevent vitamin D deficiency
HM Macdonald, A Mavroeidi, WD Fraser, AL Darling, AJ Black, L Aucott, F O'Neill, K Hart, JL Berry, SA Lanham-New, DM Reid (2011)Sunlight and dietary contributions to the seasonal vitamin D status of cohorts of healthy postmenopausal women living at northerly latitudes: a major cause for concern?, In: Osteoporos Int22(9)pp. 2461-2472
We assessed sunlight and dietary contributions to vitamin D status in British postmenopausal women. Our true longitudinal 25-hydroxyvitamin D (25(OH)D) measurements varied seasonally, being lower in the north compared to the south and lower in Asian women. Sunlight exposure in summer and spring provided 80% total annual intake of vitamin D.
Background: Epidemiological studies have supported inverse associations between low serum 25-hydroxyvitamin D [25(OH)D] and cardiometabolic risk markers, but few randomized trials have investigated the effect of vitamin D supplementation on these markers in adolescents.
Objective: The objective of this study was to investigate the effect of winter-time cholecalciferol (vitamin D3) supplementation on cardiometabolic risk markers in white, healthy 14-18 year-old adolescents in the UK (51°N) as part of the ODIN Project.
Methods: In a dose-response trial, 110 adolescents (15.9±1.4 years; 43% male; 81% normal weight) were randomly assigned to receive 0, 10 or 20 μg/day vitamin D3 for 20 weeks (October-March). Cardiometabolic risk markers including BMI-for-age z-score (BMIz), waist circumference, systolic and diastolic blood pressure, fasting plasma triglycerides, cholesterol (total, HDL, LDL and total:HDL) and glucose were measured at baseline and endpoint as secondary outcomes, together with serum 25(OH)D. Intervention effects were evaluated in linear regression models as between-group differences at endpoint, adjusted for the baseline value of the outcome variable and additionally for age, sex, Tanner stage, BMIz and baseline serum 25(OH)D.
Results: Mean±SD baseline serum 25(OH)D was 49.1±12.3 nmol/L and differed between groups at endpoint with concentrations of 30.7±8.6, 56.6±12.4 and 63.9±10.6 nmol/L in the 0, 10 and 20 μg/day groups respectively (P≤0.001). Vitamin D3 supplementation had no effect on any of the cardiometabolic risk markers (all P>0.05), except for lower HDL (-0.12 mmol/L, 95% CI -0.21, 0.04, P=0.003) and total cholesterol (-0.21 mmol/L, 95% CI -0.42, 0.00, P=0.05) in the 20 compared to the 10 μg/day group, which disappeared in the fully adjusted analysis (P=0.27 and P=0.30 respectively).
Conclusions: Supplementation with vitamin D3 at 10 and 20 μg/25 day, which increased serum 25(OH)D concentrations during the winter-time, had no effect on markers of cardiometabolic risk in healthy 14-18 year-old adolescents. This trial was registered at clinicaltrials.gov as NCT02150122.
Vitamin D is essential for bone development during adolescence and low vitamin D status during this critical period of growth may impact bone mineralization, potentially reducing peak bone mass and consequently increasing the risk of osteoporosis in adulthood. Therefore, the high prevalence of vitamin D inadequacy and deficiency in adolescent populations is of great concern. However, there is currently a lack of consensus on the 25-hydroxyvitamin D [25(OH)D] concentration, the widely accepted biomarker of vitamin D status, that defines adequacy, and the vitamin D intake requirements to maintain various 25(OH)D thresholds are not well established. While the current intake recommendations of 10–15 μg/day may be sufficient to prevent vitamin D deficiency (25(OH)D < 25–30 nmol/l), greater intakes may be needed to achieve the higher threshold levels proposed to represent adequacy (25(OH)D > 50 nmol/l). This review will address these concerns and consider if the current dietary recommendations for vitamin D in adolescents are sufficient.
PS Gibson, E Fitzpatrick, A Quaglia, A Dhawan, H Wu, K Hart, S Lanham-New, JB Moore (2014)Association of NADSYN1, DHCR7, GC and VDR Genotypes With Steatosis And Liver Inflammation in UK Paediatric Non-Alcoholic Fatty Liver Disease Patients, In: HEPATOLOGY60pp. 967A-967A
This is the first 1-year longitudinal study which assesses vitamin D deficiency in young UK-dwelling South Asian women. The findings are that vitamin D deficiency is extremely common in this group of women and that it persists all year around, representing a significant public health concern. Introduction: There is a lack of longitudinal data assessing seasonal variation in vitamin D status in young South Asian women living in northern latitudes. Studies of postmenopausal South Asian women suggest a lack of seasonal change in 25-hydroxy vitamin D [25(OH)D], although it is unclear whether this is prevalent among premenopausal South Asians. We aimed to evaluate, longitudinally, seasonal changes in 25(OH)D and prevalence of vitamin D deficiency in young UK-dwelling South Asian women as compared with Caucasians. We also aimed to establish the relative contributions of dietary vitamin D and sun exposure in explaining serum 25(OH)D. Methods: This is a 1-year prospective cohort study assessing South Asian (n = 35) and Caucasian (n = 105) premenopausal women living in Surrey, UK (51 N), aged 20-55 years. The main outcome measured was serum 25(OH)D concentration. Secondary outcomes were serum parathyroid hormone, self-reported dietary vitamin D intake and UVB exposure by personal dosimetry. Results: Serum 25(OH)D <25 nmol/L was highly prevalent in South Asians in the winter (81 %) and autumn (79.2 %). Deficient status (below 50 nmol/L) was common in Caucasian women. Multi-level modelling suggested that, in comparison to sun exposure (1.59, 95 %CI = 0.83-2.35), dietary intake of vitamin D had no impact on 25(OH)D levels (-0.08, 95 %CI = -1.39 to 1.23). Conclusions: Year-round vitamin D deficiency was extremely common in South Asian women. These findings pose great health threats regarding the adverse effects of vitamin D deficiency in pregnancy and warrant urgent vitamin D public health policy and action. © 2012 International Osteoporosis Foundation and National Osteoporosis Foundation.
L Wilson, K Hart, R Elliott, CP Smith, G Bucca, S Penson, G Chope, E Hypponen, J Berry, S Lanham-New, L Tripkovic (2015)The D2-D3 Study: comparing the efficacy of 15 mu g/d vitamin D2 vs. D3 in raising vitamin D status in both South Asian and Caucasian women, and the ethical implications of placebo treatment, In: PROCEEDINGS OF THE NUTRITION SOCIETY74(OCE1)pp. E116-E116
CAMBRIDGE UNIV PRESS
HM Macdonald, A Mavroeidi, WD Fraser, AL Darling, AJ Black, L Aucott, F O'Neill, K Hart, JL Berry, SA Lanham-New, DM Reid (2011)Erratum to: Sunlight and dietary contributions to the seasonal vitamin D status of cohorts of healthy postmenopausal women living at northerly latitudes: a major cause for concern?, In: Osteoporos Int L Tripkovic, L Wilson, K Hart, R Elliott, CP Smith, G Bucca, S Penson, G Chope, E Hypponen, J Berry, S Lanham-New (2015)The D2-D3 Study: a randomised, double-blind, placebo-controlled food-fortification trial in women, comparing the efficacy of 15ug/d vitamin D2 vs vitamin D3 in raising serum 25OHD levels, In: PROCEEDINGS OF THE NUTRITION SOCIETY74(OCE1)pp. E16-E16
CAMBRIDGE UNIV PRESS
KH Hart (2007)Malabsorption, In: Manual of dietetic practicepp. 455-460
Objectives: Hyperhomocysteinemia in Alzheimer’s disease (AD) is widely reported and appears to worsen as the disease progresses. While active dietary intervention with vitamins B12 and folate decreases homocysteine blood levels, with promising clinical outcomes in Mild Cognitive Impairment (MCI), this so far has not been replicated in established AD populations. The aim of the study is to explore the relationship between hyperhomocystenemia and relevant vitamins as the disease progresses. Methods: In this longitudinal cohort study, 38 participants with mild to moderate AD were followed for an average period of 13 months. Plasma folate, vitamin B12 and homocysteine concentrations were measured at baseline and at follow-up. Dietary intake of B vitamins was also measured. Spearman’s correlations were conducted by homocysteine and B vitamin status. Results: As expected, cognitive status significantly declined over the follow-up period and this was paralleled by a significant increase in homocysteine concentrations (p=0.006). However, during this follow-up period there was no significant decline in neither dietary intake, nor the corresponding blood concentrations of vitamin B12/folate, with both remaining within normal values. Changes in blood concentrations of B vitamins were not associated with changes in homocysteine levels (p>0.05). Conclusion: In this study, the increase in homocysteine observed in AD patients as the disease progresses cannot be solely explained by dietary and blood levels of folate and vitamin B12. Other dietary and non-dietary factors may contribute to hyperhomocysteinemia and its toxic effect in AD, which needs to be explored to optimise timely intervention strategies.
KH Hart (2007)Dietary Fibre, In: Manual of dietetic practice(2.5)pp. 180-186
OA Hakim, A Darling, S Starkey, M Wong, F Shojaee-Moradie, K Hart, L Morgan, J Berry, A Umpleby, B Griffin, S Lanham-New (2010)POOR BONE HEALTH AND INCREASED CARDIOVASCULAR DISEASE RISK: EVIDENCE OF A LINK IN THE D-FINES STUDY POPULATION, In: OSTEOPOROSIS INTERNATIONAL21pp. 96-97 SA Lanham-New, H Lambert, L Tripkovic, CP Smith, G Bucca, K Hart, S Penson, G Chope, E Hyppoenen, JL Berry, R Vieth (2011)Vitamin D-2 v. vitamin D-3 supplementation in raising 25OHD status: preliminary findings of a meta-analysis, In: PROCEEDINGS OF THE NUTRITION SOCIETY70(OCE3)pp. E94-E94
CAMBRIDGE UNIV PRESS
The effects of urban living on health are becoming increasingly important, due to an increasing global population residing in urban areas. Concomitantly, due to immigration, there is a growing number of ethnic minority individuals (African, Asian or Middle Eastern descent) living in westernised Higher Latitude Countries (HLC) (e.g. Europe, Canada, New Zealand). Of concern is the fact that there is already a clear vitamin D deficiency epidemic in HLC, a problem which is likely to grow as the ethnic minority population in these countries increases. This is because 25-hydroxyvitamin D (25(OH)D) status of ethnic groups is significantly lower compared to native populations.
Environmental factors contribute to a high prevalence of vitamin D deficiency in HLC, particularly during the winter months when there is no sunlight of appropriate wavelength for vitamin D synthesis via the skin. Also, climatic factors such as cloud cover may reduce vitamin D status even in the summer. This may be further worsened by factors related to urban living, including air pollution, which reduces UVB exposure to the skin, and less occupational sun exposure (may vary by individual HLC). Tall building height may reduce sun exposure by making areas more shaded. In addition, there are ethnicity-specific factors which further worsen vitamin D status in HLC urban dwellers, such as low dietary intake of vitamin D from foods, lower production of vitamin D in the skin due to increased melanin and reduced skin exposure to UVB due to cultural dress style and sun avoidance.
A multidisciplinary approach applying knowledge from engineering, skin photobiology, nutrition, town planning and social science is required to prevent vitamin D deficiency in urban areas. Such an approach could include reduction of air pollution, modification of sun exposure advice to emphasise spending time each day in non-shaded urban areas (e.g. parks, away from tall buildings), and advice to ethnic minority groups to increase sun exposure, take vitamin D supplements and/or increase consumption of vitamin D rich foods in a way that is safe and culturally acceptable. This review hopes to stimulate further research to assess the impact of high latitude, urban environment and ethnicity on the risk of vitamin D deficiency.
There is still limited data on the association between 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), and bone health in healthy younger adults, particularly in Latin America. This cross-sectional analysis aimed to investigate the associations of 25(OH)D and plasma PTH concentrations with bone parameters, and potential confounders, in women living in a high (England) or low (Brazil) latitude country. Bone was assessed by either peripheral quantitative computed tomography (pQCT) (England) or dual-energy x-ray absorptiometry (DXA) scan (Brazil), serum 25(OH)D concentrations by high performance liquid chromatography tandem mass spectrometry (HPLC-MS) and PTH by the chemiluminescent method. In participants living in England, total volumetric bone mineral density (vBMD) was significantly higher in women <29 years compared to ≥30 years, and total and cortical vBMD values at the 66% site were negatively correlated with weight and body mass index (BMI). In participants living in Brazil, age was positively correlated with bone mineral density (BMD) at the femur and bone mineral content (BMC), and weight, BMI, and body fat were correlated with BMD (lumbar spine and femur) and BMC. PTH concentrations were negatively correlated with 25(OH)D concentrations, and the prevalence of secondary hyperparathyroidism was 28.6% (n = 14) in participants with concentrations <25 nmol/L and 12.2% (n = 41) with concentrations between 25 and 49.9 nmol/L, compared to 6.3% (n = 79) in those with concentrations ≥50 nmol/L. In conclusion, weight and BMI were significantly correlated with bone parameters in both groups and age was significantly correlated with BMD at the femoral neck for women living in Brazil only. Although 25(OH)D concentrations were not correlated to bone parameters at any sites, in either country, PTH concentrations showed a significant correlation with total vBMD at the 66% site for women living in England. Secondary hyperparathyroidism was more common amongst those with deficient and insufficient vitamin D status.
Andrea Darling, Kath Hart, MA Gibbs, Susan Lanham-New, F Gossiel, R Eastell, T Kantermann, K Horton, Sigurd Johnsen, JL Berry, DJ Skene, R Vieth (2014)Greater seasonal cycling of 25-hydroxyvitamin D is associated with increased parathyroid hormone and bone resorption, In: Osteoporosis International25(3)pp. 933-941
This analysis assessed whether seasonal change in 25-hydroxyvitamin D concentration was associated with bone resorption, as evidenced by serum parathyroid hormone and C-terminal telopeptide concentrations. The main finding was that increased seasonal fluctuation in 25-hydroxyvitamin D was associated with increased levels of parathyroid hormone and C-terminal telopeptide. Introduction: It is established that adequate 25-hydroxyvitamin D (25(OH)D, vitamin D) concentration is required for healthy bone mineralisation. It is unknown whether seasonal fluctuations in 25(OH)D also impact on bone health. If large seasonal fluctuations in 25(OH)D were associated with increased bone resorption, this would suggest a detriment to bone health. Therefore, this analysis assessed whether there is an association between seasonal variation in 25(OH)D and bone resorption. Methods: The participants were (n = 279) Caucasian and (n = 88) South Asian women (mean (±SD); age 48.2 years (14.4)) who participated in the longitudinal Diet, Food Intake, Nutrition and Exposure to the Sun in Southern England study (2006-2007). The main outcomes were serum 25(OH)D, serum parathyroid hormone (sPTH) and serum C-terminal telopeptide of collagen (sCTX), sampled once per season for each participant. Results: Non-linear mixed modelling showed the (amplitude/mesor) ratio for seasonal change in log 25(OH)D to be predictive of log sPTH (estimate = 0.057, 95 % CI (0.051, 0.063), p < 0.0001). Therefore, individuals with a higher seasonal change in log 25(OH)D, adjusted for overall log 25(OH)D concentration, showed increased levels of log sPTH. There was a corresponding significant ability to predict the range of seasonal change in log 25(OH)D through the level of sCTX. Here, the corresponding parameter statistics were estimate = 0.528, 95 % CI (0.418, 0.638) and p ≤ 0.0001. Conclusions: These findings suggest a possible detriment to bone health via increased levels of sPTH and sCTX in individuals with a larger seasonal change in 25(OH)D concentration. Further larger cohort studies are required to further investigate these preliminary findings. © 2013 International Osteoporosis Foundation and National Osteoporosis Foundation.
Optimal vitamin D status has commonly been deﬁned as the level of 25-hydroxyvitamin D (25(OH)D) at which parathyroid hormone (PTH) concentrations would be maximally suppressed, represented by an observed minimum plateau. Previous ﬁndings indicate a large variation in this plateau, with values ranging from <30 nmol/L up to 100 nmol/L. This disparity in values might be explained by diﬀerences in study design and methodology, ethnicity, age, gender and latitude. This study aimed to investigate the concentration of 25(OH)D at which PTH concentrations were suppressed in Brazilian women living in opposite latitudes (high vs. low: i.e., UK and Brazil), during wintertime. Using data from the D-SOL study (Interaction between Vitamin D Supplementation and Sunlight Exposure in Women Living in Opposite Latitudes), the association between 25(OH)D status and PTH levels were examined in 135 Brazilian women (56 living in England and 79 living in Brazil, aged 20–59 years old). Mean PTH concentrations for Brazilian women with vitamin D deﬁciency (<25 nmol/L) were signiﬁcantly higher compared to those with vitamin D insuﬃciency (25–49.9 nmol/L) (p < 0.01), vitamin D adequacy (50–74.9 nmol/L) (p < 0.01) and those with optimal vitamin D status (>75 nmol/L) (p < 0.001). Regression modelling was used to investigate the relationship between serum 25(OH)D and PTH for the sample as a whole and for each group separately. A cubic model was statistically signiﬁcant for the total sample (p < 0.001), whereas a linear model presented the best ﬁt for Brazilian women living in England (p = 0.04) and there were no statistically signiﬁcant models ﬁtted for Brazilian women living in Brazil. The cubic model suggests that 25(OH)D concentrations above 70–80 nmol/L are optimal to suppress the parathyroid gland in Brazilian women. These ﬁndings contribute to a better understanding of the relationship between 25(OH)D and PTH in populations living in a low latitude location and are of great relevance for discussions regarding the estimation of optimal cut-oﬀs for vitamin D levels in the Brazilian population as well as for other low latitude locations.
OA Hakim, F Shojaee-Moradie, K Hart, JL Berry, R Eastell, F Gossiel, R Hannon, AM Umpleby, BA Griffin, SA Lanham-New (2011)Vitamin D deficiency, poor bone health and the risk of CVD in Caucasian and South Asian women: analysis from the D-FINES study, In: PROCEEDINGS OF THE NUTRITION SOCIETY70(OCE3)pp. E100-E100
CAMBRIDGE UNIV PRESS
Half of all bariatric surgical procedures are in women of childbearing age but it remains unclear whether surgery is suitable for women who subsequently conceive: specifically the relative risks and benefits of potential nutrient deficiencies versus weight reduction. We will present data collected from Clinical Practice Research Databases on the maternal and fetal outcomes of pregnancies complicated either by obesity or previous bariatric surgery (BS). Two groups, matched to obese controls for BMI pre-BS and post-BS (at the time of ante-natal booking) will be compared. In this way, the effect of BS on pregnancy outcomes may be examined, independent of its effect on weight. A sub-group of women with antecedent Type 2 diabetes (T2DM) will allow for investigation of the additional impact and persistence of this co-morbidity. This builds upon pilot data collected from a retrospective cohort of women (18-45years) undergoing laparoscopic roux-en-Y (RYGB) surgery over a 24-month period (n=218). After exclusions and loss to follow up, data from 111 patients were analysed; 81 (73%) had conceived prior to RYGB, 20 (18%) became pregnant post RYGB and a further 22 patients (20%) were trying to conceive at the time of data collection. Three women had T2DM which resolved post BS. A suggestion of greater miscarriage risk prior to surgery in this sub-group will be confirmed as more women are recruited. Pregnancy is a frequent desire/occurrence after BS. This database study will advance understanding of the maternal and fetal outcomes of such pregnancies and inform antenatal care.
© 2015, Bahrain Medical Bulletin. All Rights Reserved.Background: The prevalence of diabetes in the Middle East is amongst the highest worldwide; Bahrain ranks amongst the top 10 countries. In particular, increasing number of children are being diagnosed with type 1 diabetes mellitus (T1DM) posing a significant public health concern. Objective: To evaluate the magnitude of type 1 diabetes in Bahrain. Design: A Case-Control Retrospective Study. Setting: Pediatric Diabetes and Endocrine Clinic and Local Health Centers (LHC). Method: Fifty-nine cases and 53 controls were included in the study. Data from the Diabetes Registry were recorded for subjects meeting the inclusion criteria and questionnaire was administered to healthy controls. Chi Square or Student’s t-test was used as appropriate. Logistic regression analysis was used to evaluate independent predictors of T1DM. Result: Fifty-nine children aged 6-12 years diagnosed with T1DM in the years 2009 and 2010 were compared to 53 healthy controls. Children with T1DM were more likely to have suffered from a pre-diabetes illness such as tonsillitis 32 (54.2%) compared to controls 3 (5.7%), and have undergone a surgery prior to diagnosis 14 (23.7%), and to have mothers with T2DM or family history of GDM. No significant difference in infant-feeding practices was observed between children with type 1 diabetes and the healthy controls. Conclusion: Children with T1DM were more likely to have suffered from other infectious illnesses before the diagnosis was established. Whilst unable to fully investigate any potential genetic differences between cases and controls, this study provides support for the theoretical role of infections as a trigger for T1DM.
Half of all bariatric surgical procedures are in women of childbearing age. Surgery may improve fertility yet exacerbate nutritional deficiencies, that may be disadvantageous to the fetus. A frequently encountered subgroup of obese women have type 2 diabetes. The health risks, to both mother and child, of diabetes in pregnancy are well described including 4.7× risk of stillbirth and 2× risk of congenital abnormality. What is not clear is whether bariatric surgery mitigates or complicates the health consequences of women with obesity and diabetes in pregnancy. In addition the influence of the type of surgery, the optimal interval between surgery and conception and evidence based preconception recommendations are unknown. This study complements wider research aiming to inform optimal management of this patient population. Obese diabetic women require clear guidance regarding pregnancy planning after surgery. This study will develop an understanding of the barriers and facilitators (psychological, behavioural, attitudinal and nutritional) to achieving effective pre-pregnancy health and care in women with type 2 diabetes who have undergone metabolic surgery. Currently women's perception of fertility issues and risks after bariatric surgery is unknown and thus a qualitative interpretive paradigm was chosen. Interviews with the target population will explore decision-making processes; experience regarding metabolic surgery and perceived pregnancy risk. Interviews with a broad range of health professionals involved in bariatric care will include rationale for selected surgical procedure and post surgery referral processes e.g. contraceptive care. This will advance understanding of how to provide targeted support and monitoring.
Andrea Darling, Kathryn Hart, F Gossiel, F Robertson, Julie Hunt, TR Hill, Sigurd Johnsen, JL Berry, R Eastell, R Vieth, Susan Lanham-New (2017)Higher bone resorption excretion in South Asian women vs White Caucasians and increased bone loss with higher seasonal cycling of vitamin D: results from the D-FINES cohort study, In: Bone98pp. 47-53
Few data exist on bone turnover in South Asian women and it is not well elucidated as to whether Western dwelling South Asian women have different bone resorption levels to that of women from European ethnic backgrounds. This study assessed bone resorption levels in UK dwelling South Asian and Caucasian women as well as evaluating whether seasonal variation in 25-hydroxyvitamin D [25(OH)D] is associated with bone resorption in either ethnic group. Data for seasonal measures of urinary N-telopeptide of collagen (uNTX) and serum 25(OH)D were analysed from n=373 women (four groups; South Asian postmenopausal n=44, South Asian premenopausal n=50, Caucasian postmenopausal n=144, Caucasian premenopausal n =135) (mean (± SD) age 48 (14) years; age range 18-79 years) who participated in the longitudinal D-FINES (Diet, Food Intake, Nutrition and Exposure to the Sun in Southern England) cohort study (2006-2007). A mixed between-within subjects ANOVA (n=192) showed a between subjects effect of the four groups (P<0.001) on uNTX concentration, but no significant main effect of season (P=0.163). Bonferroni adjusted Post hoc tests (P≤0.008) suggested that there was no significant difference between the postmenopausal Asian and premenopausal Asian groups. Season specific age-matched-pairs analyses showed that in winter (P=0.04) and spring (P=0.007), premenopausal Asian women had a 16 to 20 nmol BCE/mmol Cr higher uNTX than premenopausal Caucasian women. The (amplitude/mesor) ratio (i.e. seasonal change) for 25(OH)D was predictive of uNTX, with estimate(SD)=0.213 (0.015) and 95% CI (0.182, 0.245; P<0.001) in a non-linear mixed model (n=154). This showed that individuals with a higher seasonal change in 25(OH)D, adjusted for overall 25(OH)D concentration, showed increased levels of uNTX. Although the effect size was smaller than for the amplitude/mesor ratio, the mesor for 25(OH)D concentration was also predictive of uNTX, with estimate(SD)= -0.035 (0.004), and 95% CI (-0.043, -0.028); P<0.001). This study demonstrates higher levels of uNTX in premenopausal South Asian women than would be expected for their age, being greater than same-age Caucasian women, and similar to postmenopausal Asian women. This highlights potentially higher than expected bone resorption levels in premenopausal South Asian women which, if not offset by concurrent increased bone formation, may have future clinical and public health implications which warrant further investigation. Individuals with a larger seasonal change in 25(OH)D concentration showed an increased bone resorption, an association which was larger than that of the 25(OH)D yearly average, suggesting it may be as important clinically to ensure a stable and steady 25(OH)D concentration, as well as one that is high enough to be optimal for bone health.
Taryn Smith, Laura Tripkovic, CT Damsgaard,, C Mølgaard, C Ritz, Saskia Wilson-Barnes, KG Dowling, A Hennessy, KD Cashman, M Kiely, Susan Lanham-New, Kathryn Hart (2016)Estimation of the dietary requirement for vitamin D in adolescents aged 14-18 years: a dose-response, double-blind, randomized placebo-controlled trial, In: The American Journal of Clinical Nutrition104(5)138065pp. 1301-1309
American Society for Nutrition
Background Adolescents are a population group at high risk of low vitamin D status, yet the evidence base for establishing dietary vitamin D requirements to ensure adequacy remains weak. Objective To establish the distribution of vitamin D intakes required to maintain serum 25- hydroxyvitamin D [25(OH)D] concentrations above proposed cut-offs (25, 30, 40 and 50 nmol/L) during the winter-time in white males and females (14-18 years) in the UK (51o 9 N). Design In a dose-response trial, 110 adolescents (age 15.9 ± 1.4 years; 43% male) were randomizedto receive daily 0, 10 or 20 µg vitamin D3 supplements for 20 weeks during the winter-time. A non-linear regression model was fit to the total vitamin D intake (diet plus supplemental) and post-intervention serum 25(OH)D concentrations, and regression predicted values were used to estimate the vitamin D intakes required to maintain serum 25(OH)D concentrations above specific cut-offs. Results Mean (± SD) serum 25(OH)D concentrations increased from 49.2 ± 12.0 to 56.6 ± 12.4 nmol/L and from 51.7 ± 13.4 to 63.9 ± 10.6 nmol/L in the 10 and 20 µg/day groups respectively, and decreased in the placebo group from 46.8 ± 11.4 to 30.7 ± 8.6 nmol/L (all p ≤ 0.001). Vitamin D intakes required to maintain post-intervention 25(OH)D concentrations > 25 and > 30 nmol/L in 97.5% of adolescents were estimated as 10.1 and 13.1 µg/day respectively, and 6.6 µg/day to maintain 50% of adolescents > 40 nmol/L. As the response of 25(OH)D plateaued at 46 nmol/L, there is uncertainty in estimating the vitamin D intake required to maintain 25(OH)D > 50 nmol/L in 97.5% of adolescents, but it did exceed 30 µg/day Conclusions Vitamin D intakes of between 10 and ~30 µg/day are required by white adolescents during the winter-time in order to maintain serum 25(OH)D concentrations > 25 – 50 nmol/L, depending on the serum 25(OH)D threshold chosen.
Clinical psychology trainees and dietetic students came together to learn from and with each other. This article reports some of the experiences of those involved.
O Hakim, F Shojaee-Moradie, K Hart, J Berry, R Eastell, F Gossiel, R Hannon, M Umpleby, B Griffin, S Lanham-New (2011)Evidence of a link between poor bone health, low vitamin D status and CVD risk in caucasian and asian women, In: BONE48pp. S197-S198 L Tripkovic, LR Wilson, K Hart, R Elliott, CP Smith, G Bucca, S Penson, G Chope, E Hypponen, J Berry, S Lanham-New (2014)DAILY SUPPLEMENTATION WITH VITAMIN D3 IS COMPREHENSIVELY MORE EFFECTIVE THAN VITAMIN D2 IN RAISING 25OHD STATUS AND CONCOMITANTLY REDUCING PARATHYROID HORMONE LEVELS: IMPLICATIONS FOR BONE HEALTH, In: OSTEOPOROSIS INTERNATIONAL25pp. S665-S665
This study aimed to establish prevalence of malnutrition in older adult care home residents and investigate whether a nutritional screening and intervention program could improve nutritional and clinical outcomes. A community-based cohort study was conducted in five Newcastle care homes. 205 participants entered; 175 were followed up. Residents already taking oral nutritional supplements (ONS) were excluded from interventions. Those with Malnutrition Universal Screening Tool (MUST) score of 1 received dietetic advice and ≥2 received dietetic advice and were prescribed ONS (220 ml, 1.5 kcal/ml) twice daily for 12 weeks. Body mass index (BMI), MUST, mini nutritional assessment score (MNA)®, mid upper arm muscle circumference (MAMC), and Geriatric Depression Scale (GDS) were recorded at baseline and 12 weeks. Malnutrition prevalence was 36.6% ± 6.6 (95% CI). A higher MUST was associated with greater mortality (p = 0.004). Type of intervention received was significantly associated with change in MUST score (p < 0.001); dietetic advice resulting in the greatest improvement. There were no significant changes in BMI (p = 0.445), MAMC (p = 0.256), or GDS (p = 0.385) following the interventions. Dietitian advice may slow the progression of nutritional decline. In this study oral nutritional supplements over a 3-month period did not significantly improve nutritional status in malnourished care home residents.
O Hakim, S Lanham-New, F Shojaee-Moradie, L Morgan, A Umpleby, B Griffin, J Berry, R Eastell, F Gossiel, R Hannon, K Hart (2010)POORER LIPID PROFILE ARE ASSOCIATED WITH INCREASED BONE RESORPTION AND PARATHYROID HORMONE: PRELIMINARY RESULTS OF THE D-FINES STUDY, In: OSTEOPOROSIS INTERNATIONAL21(Suppl)pp. S506-S507
It is known that skin pigmentation reduces the penetration of ultraviolet radiation (UVR) and thus photosynthesis of 25-hydroxvitamin D (25(OH)D). However ethnic differences in 25(OH)D production remain to be elucidated.The aim of this study was to investigate differences in vitamin D production between UK South Asian and Caucasian postmenopausal women, in response to a defined and controlled exposure to UVR.Seventeen women; 9 white Caucasian (skin phototype II and III), 8 South Asian women (skin phototype IV and V) participated in the study, acting as their own controls. Three blood samples were taken for the measurement of vitamin D status during the run in period (9 days, no sunbed exposure) after which, all subjects underwent an identical UVR exposure protocol irrespective of skin colour (9 days, 3 sun bed sessions, 6, 8 and 8minutes respectively with approximately 80% body surface exposed). Skin tone was measured four times during the study.Despite consistently lower 25(OH)D levels in South Asian women, they were shown to synthesise vitamin D as efficiently as Caucasians when exposed to the same dose of UVR. Interestingly, the baseline level of vitamin D rather than ethnicity and skin tone influenced the amount of vitamin D synthesised.This study have found no ethnic differences in the synthesis of 25(OH)D, possibly due to the baseline differences in 25(OH)D concentration or due to the small population size used in this study. Applying mixed linear model, findings indicated no effect of ethnicity and skin tone on the production of vitamin D; baseline level and length of exposure were the critical factors. To confirm that ethnicity and skin tone has no effect on 25(OH)D production, a larger sample size study is required that considers other ethnic groups with highly pigmented skin. Initial vitamin D status influences the amount of UVB needed to reach equal serum concentrations.
This is the first 1-year longitudinal study which assesses vitamin D deficiency in young UK-dwelling South Asian women. The findings are that vitamin D deficiency is extremely common in this group of women and that it persists all year around, representing a significant public health concern. Introduction There is a lack of longitudinal data assessing seasonal variation in vitamin D status in young South Asian women living in northern latitudes. Studies of postmenopausal South Asian women suggest a lack of seasonal change in 25-hydroxy vitamin D [25(OH)D], although it is unclear whether this is prevalent among premenopausal South Asians. We aimed to evaluate, longitudinally, seasonal changes in 25(OH)D and prevalence of vitamin D deficiency in young UK-dwelling South Asian women as compared with Caucasians. We also aimed to establish the relative contributions of dietary vitamin D and sun exposure in explaining serum 25(OH)D. Methods This is a 1-year prospective cohort study assessing South Asian (n = 35) and Caucasian (n = 105) premenopausal women living in Surrey, UK (51° N), aged 20–55 years. The main outcome measured was serum 25(OH)D concentration. Secondary outcomes were serum parathyroid hormone, self-reported dietary vitamin D intake and UVB exposure by personal dosimetry. Results Serum 25(OH)D <25 nmol/L was highly prevalent in South Asians in the winter (81 %) and autumn (79.2 %). Deficient status (below 50 nmol/L) was common in Caucasian women. Multi-level modelling suggested that, in comparison to sun exposure (1.59, 95 %CI = 0.83–2.35), dietary intake of vitamin D had no impact on 25(OH)D levels (−0.08, 95 %CI = −1.39 to 1.23). Conclusions Year-round vitamin D deficiency was extremely common in South Asian women. These findings pose great health threats regarding the adverse effects of vitamin D deficiency in pregnancy and warrant urgent vitamin D public health policy and action.
Background: Low serum 25-hydroxyvitamin D [25(OH)D] has been associated with unfavorable cardiometabolic risk profiles in many observational studies in children, but very few randomized controlled trials have investigated this. Objective: We explored the effect of winter-time cholecalciferol (vitamin D3) supplementation on cardiometabolic risk markers in young, white, 4- to 8-y-old healthy Danish children (55°N) as part of the pan-European ODIN project. Methods: In the ODIN Junior double-blind, placebo-controlled, dose-response trial, 119 children (mean ± SD age: 6.7 ± 1.5 y; 36% male; 82% normal weight) were randomly allocated to 0, 10 or 20 μg/d of vitamin D3 for 20 wk (October–March). Cardiometabolic risk markers including BMI-for-age z score (BMIz), waist circumference, systolic and diastolic blood pressure, serum triglycerides and cholesterol (total, LDL, HDL, and total:HDL), plasma glucose and insulin, and whole-blood glycated hemoglobin were measured at baseline and endpoint as secondary outcomes together with serum 25(OH)D. Intervention effects were evaluated in linear regression models as between-group differences at endpoint adjusted for baseline value of the outcome, and additionally for age, sex, baseline serum 25(OH)D, BMIz, time since breakfast, and breakfast content. Results: Mean ± SD serum 25(OH)D was 56.7 ± 12.3 nmol/L at baseline and differed between groups at endpoint with concentrations of 31.1 ± 7.5, 61.8 ± 10.6, and 75.8 ± 11.5 nmol/L in the 0-, 10-, and 20 μg/d groups, respectively (P < 0.0001). Vitamin D3 supplementation had no effect on any of the cardiometabolic risk markers in analyses adjusted for baseline value of the outcome (all P ≥ 0.05), and additional covariate adjustment did not change the results notably. Conclusions: Preventing the winter decline in serum 25(OH)D with daily vitamin D3 supplementation of 10 or 20 μg had no cardiometabolic effects in healthy 4- to 8-y-old Danish children. This trial was registered at www.clinicaltrials.gov as NCT02145195.
It has been hypothesised that the U shaped association between 25(OH)D and some health outcomes may be due to large seasonal fluctuations of 25(OH)D1. It is unknown whether such fluctuation of 25(OH)D (‘cycling’) influences bone health. This is an important issue, because if ‘cycling’ is detrimental for bone, then winter only rather than year round vitamin D supplementation may be useful for bone health to ‘blunt’ the rhythm. In the D-FINES study, n = 373 women (South Asian/Caucasian) had repeated measurements in four seasons for serum 25(OH)D and PTH, as well as a DXA scan in autumn and spring. Serum C-telopeptide (sCTX) was also measured in a random subset (n = 66). Cosinor regression analysis was used to identify individuals showing a significant rhythm (p < 0.10) (‘cyclers’) and those not showing a significant seasonal rhythm (‘non-cyclers’). Potential differences in bone indices between the two groups were assessed within ethnicity. Dependent variables analysed were absolute values for autumn femoral neck and lumbar spine BMD, BMC and bone area, and absolute sCTX and sPTH in each season. Also, change in sCTX and sPTH from summer to winter and change in DXA bone indices from autumn to spring were analysed. ANCOVA was run, adjusting for summer and winter 25(OH)D status, age, socioeconomic status, physical activity, and dietary calcium. BMI was also controlled for in the analysis due to its negative correlation with seasonal change in 25(OH)D. There was no statistically significant difference (p>0.05) between ‘cyclers’ and ‘non-cyclers’ for any of the bone indices in either ethnic group. However, there were trends for a higher CTX and PTH in ‘cyclers’ versus ‘non-cyclers’ in both ethnic groups in every season, but no differences for BMD or BMC (Figs. 1–4). This suggests tentatively that ‘cycling’ could be associated with changes in bone metabolism but may not translate into structural changes. In summary, there is no clear evidence here to suggest that ‘cycling’ is detrimental to bone health, although there are trends in PTH and CTX that warrant further investigation with a larger sample.
Previous research has suggested a role for vitamin D in non-alcoholic fatty liver disease (NAFLD) pathogenesis. Several observational studies have observed low vitamin D status (25OHD) with poorer histological findings. The principal aims of this study were to assess diet and lifestyle, 25OHD status, gene variants in vitamin D metabolism in UK children, and separately examine the effect of vitamin D in an in vitro NAFLD model. Dietary results from the case control study (n=32) indicated vitamin D intakes of paediatric patient with biopsy-proven NAFLD and ultrasound-cleared obese patients were 1.7μg/day and 3.5μg/day, respectively, well below the new UK recommendation. Children failed to meet current UK government recommendations for physical activity. In our UK paediatric biopsy-proven NAFLD cohort (n=103), the majority of patients presented with deficient (<25nmol/L, 25.5%) or insufficient (<50nmol/L, 80.8%) mean serum 25OHD levels. Furthermore, patients had significantly lower 25OHD levels during winter months in comparison to summer (p=0.0001) and autumn (p=0.0026), while 25OHD levels were non-significantly lower in NASH compared to non-NASH patients (p=0.0576). We observed that single nucleotide polymorphisms (SNPs) involved in vitamin D metabolism were associated with poorer liver histology grading; specifically, three SNPs were associated with increased steatosis and one with increased inflammation score in Caucasian patients. Finally, LX-2 cells, an immortalised human hepatic stellate cell line, demonstrated significantly reduced cell proliferation (p=0.0005) with increasing doses of 1α,25(OH)2D3 after 10 days of incubation in clonogenic assays. In conclusion, we found that NAFLD children have extremely low levels of 25OHD throughout the year, with little dietary contribution. In addition, several vitamin D related SNPs were associated with poorer histological findings. These novel data suggest an important role for vitamin D in the pathogenesis and progression of NAFLD in a paediatric population.
Background: The prevalence of diabetes in the Middle East is amongst the highest worldwide, Bahrain ranks amongst the top 10 countries. In particular, increasing number of children are being diagnosed with type 1 diabetes mellitus (T1DM) posing a significant public health concern. Objective: The aim of this thesis was to characterize the population by exploring lifestyle, dietary and health risk factors associated with pediatric T1DM and to undertake a local needs assessment to inform the development of management strategies. Methodology: An observational case-control study of children with T1DM and healthy controls (n=59 and 53; mean age 9.66±1.72 and 9.02±1.88 years respectively) was conducted to ascertain baseline characteristics of children with T1DM as compared to healthy children with a subsequent more detailed prospective investigation (n=20) of the T1DM population, which included a focus on vitamin D intake and status. A systematic review of the effectiveness of interventions that seek to improve the management of children and adolescents with T1DM and a qualitative study using focus groups with service-users and healthcare workers were undertaken to inform the development of a specific educational package targeting the needs of Bahraini children with diabetes and their families. The findings of all phases were amalgamated to inform the design of an education package and associated feasibility study. Results: Children with T1DM appeared to be more likely to have suffered from an illness before diagnosis of T1DM than their healthy counterparts. Dietary inadequacies were common in Bahraini children irrespective of diabetes diagnosis, particularly excessive sodium intakes, whilst children with T1DM consumed significantly more calories than controls and more protein relative to their RDA. Serum vitamin D as measured by CLIA assay method (standard practice) and by UPLC/MSMS (gold standard) classified 72% and 50% respectively of the children as having suboptimal vitamin D levels. It appears that dietary intake, sunlight exposure and physical activity may to some extent impact the vitamin D status of children with T1DM. The systematic review identified facilitators of successful interventions aimed at children and adolescents with T1DM such as theoretical based interventions. It also highlighted barriers to the real-life integration of such interventions. These factors and the themes identified by the focus groups such as a need to focus on adolescents prior to transitioning were incorporated into the educational package. Conclusion: Children with diabetes do appear to differ from age matched controls with respect to health factors and socio-demographic characteristics. Larger confirmatory studies are urgently needed. The feasibility and acceptability testing of the proposed educational package is currently ongoing with a planned pilot test of the program within the coming year.
ABSTRACT Malnutrition in older adults: A comparative study of factors affecting malnutrition across care settings in the UK and Malaysia. Malnutrition is a serious and common problem in older adults. This study aimed to determine and compare the nutritional status and factors affecting malnutrition in older adults in different care settings in the UK and Malaysia, in order to inform the development of setting and country-appropriate recommendations to reduce the prevalence and impact of malnutrition. An observational study was conducted in the UK and Malaysia involving 151 older adults aged 75 years and over in free-living, care home and hospital Data was collected using the Mini Nutritional Assessment (MNA), the Satisfaction with Food-related Life (SWFL) questionnaire, and 3-day 24hr recalls. Attitudes of 41 staff towards the nutritional care of older patients, the food access experience of 150 patients and a menu audit of 155 lunch time meals served, consumed and wasted were assessed in an additional study in hospital. Dietary data were analysed using Dietplan 6 and all data were analysed using SPSS (v16). Prevalence of malnutrition was higher among Malaysian older adults in all care settings, over their UK counterparts, while older patients in hospitals had the highest prevalence of malnutrition than other care settings in both countries. Although hospital food contained adequate levels of energy and protein, protein consumption was inadequate in the UK hospital setting, suggesting that it is the intake of hospitalised patients rather than the provision that is problematic. However energy consumption was inadequate in all care settings in both countries, suggesting that older adults are not eating enough to meet their estimated needs and the risk of malnutrition is widespread in older adults. This research has identified that the satisfaction with food-related life is the strongest unique indicator of malnutrition in this group and may present a simple early warning measure of malnutrition risk in older adults.
Vitamin D deficiency and inadequacy are worldwide public health concerns and occur across all age, sex and ethnic groups, with significant implications for human health. Adolescents are a population group at high risk of low vitamin D status, yet the evidence base for establishing vitamin D requirements remains weak. The primary aim of this Thesis was to estimate the dietary vitamin D intakes required to maintain serum 25-hydroxyvitamin D [25(OH)D] concentrations above specific cut-off thresholds (25, 30, 40 and 50 nmol/l) during the winter-time in white Caucasian adolescents residing in the UK (51°N). Secondary aims were to: 1) investigate vitamin D status in relation to musculoskeletal and cardiometabolic health outcomes and; 2) explore familial associations in vitamin D status, dietary intakes and musculoskeletal health in mother-child pairs. This was achieved via a dose-response trial in 110 adolescents (14-18 years), who were randomly allocated to receive 0 (placebo), 10 or 20 μg vitamin D3 daily for 20 weeks during the winter-time. A final aim of this Thesis was to assess the vitamin D status and prevalence of vitamin D deficiency in a small study of African Caribbean and South Asian adolescent and young adult females (16-25 years) in comparison to their white Caucasian counterparts. It was estimated that vitamin D intakes of 10.1, 13.1, 23.3 and ~30 μg/day would maintain serum 25(OH)D concentrations > 25, 30, 40 and 50 nmol/l respectively in 97.5% of the adolescents. Adolescents with serum 25(OH)D concentrations below 50 nmol/l had significantly lower radial trabecular volumetric bone mineral density and presented with a poorer cardiometabolic profile, with greater waist circumference and higher triglyceride and glucose concentrations than their more replete counterparts. However cardiometabolic risk was lost after controlling for potential confounders. Positive, sex-specific associations were found for serum 25(OH)D concentrations and radial mass, total area and cortical volumetric bone mineral density in mother-child pairs, but not for dietary vitamin D and calcium intakes. A high prevalence of vitamin D deficiency was found in African Caribbean and South Asian females (serum 25(OH)D < 30 nmol/l: 75% and 63% respectively) and serum 25(OH)D concentrations in these ethnic minority populations was half that of their white Caucasian counterparts (22.7 [14.5, 34.0], 22.8 [19.2, 37.1] and 44.4 [36.6, 60.3] nmol/l respectively). In conclusion, dietary vitamin D intakes of between 10 and ~30 μg/day are required by adolescents during the winter-time to maintain serum 25(OH)D concentrations > 25-50 nmol/l, depending on the cut-off threshold selected. These data will allow for future refinement of evidence-based dietary requirements for adolescents. Further studies are now urgently needed to investigate the vitamin D requirements of ethnic minority populations via targeted dose-response vitamin D trials. Finally, the beneficial effects of maintaining serum 25(OH)D concentrations above 50 nmol/l on musculoskeletal health parameters requires confirmation in further randomised trials.