Dr Kathryn Hart

The ubiquitous nature of smartphone ownership, its broad application and usage, along with its interactive delivery of timely feedback are appealing for health-related behavior change interventions via mobile apps. However, users' perspectives about such apps are vital in better bridging the gap between their design intention and effective practical usage. In this vein, a modified technology acceptance model (mTAM) is proposed here, to explain the relationship between users' perspectives when using an AI-based smartphone app for personalized nutrition and healthy living, namely, PROTEIN, and the mTAM constructs toward behavior change in their nutrition and physical activity habits. In particular, online survey data from 85 users of the PROTEIN app within a period of 2 months were subjected to confirmatory factor analysis (CFA) and regression analysis (RA) to reveal the relationship of the mTAM constructs, i.e., perceived usefulness (PU), perceived ease of use (PEoU), perceived novelty (PN), perceived personalization (PP), usage attitude (UA), and usage intention (UI) with the users' behavior change (BC), as expressed via the acceptance/rejection of six related hypotheses (H1–H6), respectively. The resulted CFA-related parameters, i.e., factor loading (FL) with the related p -value, average variance extracted (AVE), and composite reliability (CR), along with the RA results, have shown that all hypotheses H1–H6 can be accepted ( p< 0.001). In particular, it was found that, in all cases, FL > 0.5, CR > 0.7, AVE > 0.5, indicating that the items/constructs within the mTAM framework have good convergent validity. Moreover, the adjusted coefficient of determination ( R 2 ) was found within the range of 0.224–0.732, justifying the positive effect of PU, PEoU, PN, and PP on the UA, that in turn positively affects the UI, leading to the BC. Additionally, using a hierarchical RA, a significant change in the prediction of BC from UA when the UI is used as a mediating variable was identified. The explored mTAM framework provides the means for explaining the role of each construct in the functionality of the PROTEIN app as a supportive tool for the users to improve their healthy living by adopting behavior change in their dietary and physical activity habits. The findings herein offer insights and references for formulating new strategies and policies to improve the collaboration among app designers, developers, behavior scientists, nutritionists, physical activity/exercise physiology experts, and marketing experts for app design/development toward behavior change.

Non-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other non-medical healthcare professionals who have completed an approved training programme. NMP is deemed to facilitate better patient care and timely access to medicine. The aim of this scoping review is to identify, synthesise and report the evidence on the costs, consequences and value for money of NMP provided by non-medical healthcare professionals. Scoping review DATA SOURCES: MEDLINE, Cochrane Library, Scopus, PubMed, ISI Web of Science and Google Scholar were systematically searched from 1999 to 2021. Peer-reviewed and grey literature written in English were included. The research was limited to original studies evaluating economic values only or both consequences and costs of NMP. The identified studies were screened independently by two reviewers for final inclusion. The results were reported in tabular form and descriptively. A total of 420 records were identified. Of these, nine studies evaluating and comparing NMP with patient group discussions, general practitioner-led usual care or services provided by non-prescribing colleagues were included. All studies evaluated the costs and economic values of prescribing services by non-medical prescribers, and eight assessed patient, health or clinical outcomes. Three studies showed pharmacist prescribing was superior in all outcomes and cost saving at a large scale. Others reported similar results in most health and patient outcomes across other non-medical prescribers and control groups. NMP was deemed resource intensive for both providers and other groups of non-medical prescribers (eg, nurses, physiotherapists, podiatrists). The review demonstrated the need for quality evidence from more rigorous methodological studies examining all relevant costs and consequences to show value for money in NMP and inform the commissioning of NMP for different groups of healthcare professionals.

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.

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.

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.

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.

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.

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.

Abstract An increasing number of food-based recommendations promote a plant-based diet to address health concerns and environmental sustainability in global food systems. As the main sources of iodine in many countries are fish, eggs and dairy products, it is unclear whether plant-based diets, such as the EAT-Lancet reference diet, would provide sufficient iodine. This is important as iodine, through the thyroid hormones, is required for growth and brain development; adequate iodine intake is especially important before, and during, pregnancy. In this narrative review, we evaluated the current literature and estimated iodine provision from the EAT-Lancet reference diet. There is evidence that those following a strict plant-based diet, such as vegans, cannot reach the recommended iodine intake from food alone and are reliant on iodine supplements. Using the EAT-Lancet reference diet intake recommendations in combination with iodine values from UK food tables, we calculated that the diet would provide 128 μg/d (85 % of the adult recommendation of 150 μg/d and 51–64 % of the pregnancy recommendation of 200–250 μg/d). However, if milk is replaced with unfortified plant-based alternatives, total iodine provision would be just 54 μg/d (34 % and 22–27 % of the recommendations for adults and pregnancy, respectively). Plant-based dietary recommendations might place consumers at risk of iodine deficiency in countries without a fortification programme and where animal products provide the majority of iodine intake, such as the UK and Norway. It is essential that those following a predominantly plant-based diet are given appropriate dietary advice to ensure adequate iodine intake.

Vitamin D concentrations are a function of sunlight exposure and dietary intake. However, current dietary vitamin D recommendations do not consider differences in country-specific sunlight availability or spontaneous individual exposure. We aimed to investigate the effects of vitamin D supplementation and sunlight exposure on vitamin D concentrations in Brazilian women living in high compared with low latitudes. In 2 parallel, double-blind, randomized placebo-controlled trials, Brazilian women living in England (51°N) composed "without ultraviolet B (UVB) exposure" groups and those living in Brazil (16°S) composed the "with UVB exposure" groups (mean age, 31.39 ± 8.7 years). Participants received 15 μg cholecalciferol or placebo daily for 12 weeks during wintertime. Serum 25-hydroxyvitamin D [25(OH)D] concentrations, the primary outcome, were assessed by HPLC-MS/MS, vitamin D intakes were assessed by 4-day diet diaries, and sunlight exposure was assessed by UVB dosimeters. The effects of supplementation and UVB exposure were tested by the intention to treat with a linear mixed model. The 25(OH)D concentrations increased in both supplemented groups [from 75.1 ± 22.0 to 84.8 ± 21.0 nmol/L (P = 0.004) in the group with UVB exposure; from 38.1 ± 15.9 to 55.1 ± 12.2 nmol/L (P 

Vitamin D is best known for its role in maintaining bone health and calcium homeostasis. However, it also exerts a broad range of extra-skeletal effects on cellular physiology and on the immune system. Vitamins D and D share a high degree of structural similarity. Functional equivalence in their vitamin D-dependent effects on human physiology is usually assumed but has in fact not been well defined experimentally. In this study we seek to redress the gap in knowledge by undertaking an in-depth examination of changes in the human blood transcriptome following supplementation with physiological doses of vitamin D and D . Our work extends a previously published randomized placebo-controlled trial that recruited healthy white European and South Asian women who were given 15 µg of vitamin D or D daily over 12 weeks in wintertime in the UK (Nov-Mar) by additionally determining changes in the blood transcriptome over the intervention period using microarrays. An integrated comparison of the results defines both the effect of vitamin D or D on gene expression, and any influence of ethnic background. An important aspect of this analysis was the focus on the changes in expression from baseline to the 12-week endpoint of treatment each individual, harnessing the longitudinal design of the study. Whilst overlap in the repertoire of differentially expressed genes was present in the D or D -dependent effects identified, most changes were specific to either one vitamin or the other. The data also pointed to the possibility of ethnic differences in the responses. Notably, following vitamin D supplementation, the majority of changes in gene expression reflected a down-regulation in the activity of genes, many encoding pathways of the innate and adaptive immune systems, potentially shifting the immune system to a more tolerogenic status. Surprisingly, gene expression associated with type I and type II interferon activity, critical to the innate response to bacterial and viral infections, differed following supplementation with either vitamin D or vitamin D , with only vitamin D having a stimulatory effect. This study suggests that further investigation of the respective physiological roles of vitamin D and vitamin D is warranted.

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.

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

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: 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 (

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.

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.

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].

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

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

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.

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.

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

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.

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

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.

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.

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.

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.

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

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

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 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.

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.

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 

Obesity can negatively influence quality of life (QoL). Polycystic ovarian syndrome (PCOS), associated with obesity, presents with sub-fertility, hyperandrogenism, and/or insulin resistance. These features can also negatively influence QoL. This study aimed to determine whether bariatric surgery improves QoL in women of reproductive age, with and without PCOS. We hypothesized greater QoL improvements would be seen post-operatively in women with PCOS. Women undergoing bariatric surgery (N.=77) completed questionnaires exploring health-related quality of life (HR-QoL) prior to and at 3, 6 and 12 months post-surgery. Weight loss, symptoms, and association with change in QoL were assessed. Bariatric surgery resulted in significant QoL improvements, independent of PCOS status. Oligo/amenorrhea was reported in 68% of women at baseline, decreasing to 35% by 12 months. Sixty-five percent of women whose menstrual irregularity resolved over follow-up had PCOS. Hirsutism was reported in 64% of women at baseline (all of whom had PCOS), decreasing to 19% by 12 months. Weight loss at 12-months was 45.8±20.7 kg for women without PCOS compared to 44.3±16.8 kg in women with PCOS (P=0.07). Weight loss was moderately associated with 12-month QoL improvements for both groups. Bariatric surgery provides significant physical and psychological health benefits for women with obesity both with and without PCOS. Surgery can also ameliorate the clinical syndrome of PCOS, including oligomenorrhoea, hirsutism, and subfertility, with subsequent QoL benefits. Psychological support perioperatively may aid QoL outcomes by acknowledging factors influencing QoL beside absolute weight loss.

Malnutrition is common among dialysis patients, but there is insufficient literature on the problem from resource-poor settings of the sub-Saharan region. We conducted a cross-sectional investigation of dietary intake and nutritional status of haemodialysis (HD) patients to inform the current status of this population group in the region. HD patients aged >= 18 years, with dialysis vintage of >= 3 months, at one nephrology unit in Tanzania were assessed for their habitual diet and nutrient intake. Anthropometric measures and biochemistry tests were also performed. The diet was predominantly starchy food based, accompanied by a limited selection of vegetables. Fruits and animal protein were also minimally consumed (1 portion/day each). Fruit consumption was higher in females than males (median (25(th), 75(th)) = 2 (1, 2.3) versus 0.5 (0, 1.7) portions, p = 0.008). More than 70% of participants had suboptimal measures for protein and energy intake, dietary iron, serum albumin, muscle mass, and hand grip strength (HGS). Inadequacies in protein and energy intake and dialysis clearance (URR) increased with the increase in body weight/BMI and other specific components (MAMC and FMI). Consumption of red meats correlated significantly and positively with serum creatinine (r = 0.46, p = 0.01), potassium (r = 0.39, p = 0.03), and HGS (r = 0.43, p = 0.02) and was approaching significance for a correlation with serum iron (r = 0.32, p = 0.07). C-RP correlated negatively with albumin concentration (r = -0.32, p = 0.02), and participants with C-RP within acceptable ranges had significantly higher levels of haemoglobin (p = 0.03, effect size = -0.28). URR correlated negatively with haemoglobin concentration (r = -0.36, p = 0.02). Patients will benefit from improved nutritional services that deliver individually tailored and culturally practical dietary advice to enable them to make informed food choices whilst optimizing disease management.

Objectives: Vitamin D deficiency remains a global public health issue, particularly in minority ethnic groups. This review investigates the vitamin D status (as measured by 25(OH)D and dietary intake) of the African-Caribbean population globally. Methods: A systematic review was conducted by searching key databases (PUBMED, Web of Science, Scopus) from inception until October 2019. Search terms included ‘Vitamin D status’ and ‘African-Caribbean’. A random effects and fixed effects meta-analysis was performed by combining means and standard error of the mean. Results: The search yielded 19 papers that included n=5,670 African-Caribbean participants from six countries. A meta-analysis found this population to have sufficient (>50 nmol/L) 25(OH)D levels at 67.8 nmol/L, 95% CI (57.9, 7.6) but poor dietary intake of vitamin D at only 3.0µg/day, 95% CI (1.67,4.31). For those living at low latitudes ‘insufficient’ (as defined by study authors) 25(OH)D levels were found only in participants with type 2 diabetes and in those undergoing haemodialysis. Suboptimal dietary vitamin D intake (according to the UK recommended nutrient intake of 10µg/day) was reported in all studies at high latitudes. Studies at lower latitudes, with lower recommended dietary intakes (Caribbean recommended dietary intake: 2.5µg/day) found ’sufficient’ intake in two out of three studies. Conclusions: 25(OH)D sufficiency was found in African-Caribbean populations at lower latitudes. However, at higher latitudes, 25(OH)D deficiency and low dietary vitamin D intake was prevalent. Trial registration: PROSPERO registration number: CRD42019158108.

The vitamin D status of the United Kingdom (UK) African-Caribbean (AC) population remains under-researched, despite an increased risk of vitamin D deficiency due to darker skin phenotypes and living at a high latitude. This cross-sectional study explored the vitamin D status and intake of AC individuals (n = 4046 with a valid serum 25(OH)D measurement) from the UK Biobank Cohort, aged ≥40 years at baseline (2006–2010). Over one third of the population were deficient (50 nmol/L). Median (IQR) 25(OH)D was 30.0 (20.9) nmol/L. Logistic regression showed that brown/black skin phenotype, winter blood draw, not consuming oily fish and not using vitamin D supplements predicted increased odds of vitamin D deficiency, whilst older age and a summer or autumn blood draw were significantly associated with reduced odds of vitamin D deficiency. Vitamin D deficiency and insufficiency were prevalent in this AC population and is of considerable concern given the individual and societal implications of increased morbidity. Public health messaging for this group should focus on year-round vitamin D supplementation and increasing intakes of culturally appropriate vitamin D-rich foods. These data also support the urgent requirement for a revised vitamin D RNI for ethnic groups.

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.

Processed foods are increasingly under the spotlight since the development of classification systems based on proxies for food processing. Published critical reviews and commentaries suggest different views among professional disciplines about the definition and classification of processed food. There is a need to further understand perspectives of professionals on the conceptualisation of processed food and the agreements and disagreements among experts, to encourage interdisciplinary dialogue and aid communication to the public. The aim of this research was to elicit views and understandings of professionals on processed food, their perceptions of lay people's perceptions of the same, and their perspectives on the challenges of communicating about processed foods to the public. The online discussion groups brought together a range of professionals (n = 27), covering the fields of nutrition, food technology, policy making, industry, and civil society, mixed in 5 heterogenous groups. Through thematic analysis the following themes relating to the conceptualisation of processed food and challenges for communication were identified: (1) Broad concepts that need differentiation; (2) Disagreements on scope and degree of processing; (3) The role of food processing within the food system: the challenges in framing risks and benefits; and (4) The challenge of different perspectives and interests for risk communication. Throughout the discussions blurred lines in the characterisation of processing, processed foods, and unhealthy foods were observed. Participants agreed that consensus is important, but difficult. Participants identified a need for further interdisciplinary dialogue, including public engagement, to break down the observed issues, and work towards a mutual understanding and develop clear communication messages.

Malnutrition in chronic pancreatitis is complex and multifactorial, with malabsorption, pain, toxic dependencies and co-morbidities, such as diabetes, each playing a role. The aims of this systematic review were to assess the impact of nutritional intervention on markers of nutritional status in this complex patient group, A systematic review of EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short term changes (less than 3 months), with only one data point, or in the wrong population, eight papers were selected for analysis. Seven studies documented the impact of a nutritional intervention, one was an observational study only. Overall, studies were limited by predominantly retrospective designs, heterogenous populations and poor control of potentially confounding variables. Data could not be combined due to variability in reporting methods. All studies exploring nutritional intervention, whether that consisted of advice by a specialist dietitian, dose escalation of pancreatic enzymes, oral nutritional supplements or enteral feeding, demonstrated improved body weight and pain control, whereas patients who did not receive an intervention deteriorated nutritionally. Patients with chronic pancreatitis benefit from nutritional intervention. Further work is required to explore the impact of nutritional intervention on body composition and functional outcomes.

Current research implicates pre- and probiotic supplementation as a potential tool for improving symptomology in physical and mental ailments, which makes it an attractive concept for clinicians and consumers alike. Here we focus on the transitional period of late adolescence and early adulthood during which effective interventions, such as nutritional supplementation to influence the gut microbiota, have the potential to offset health-related costs in later life. We examined multiple indices of mood and well-being in 64 healthy females in a 4-week double blind, placebo controlled galacto-oligosaccharides (GOS) prebiotic supplement intervention and obtained stool samples at baseline and follow-up for gut microbiota sequencing and analyses. We report effects of the GOS intervention on self-reported high trait anxiety, attentional bias, and bacterial abundance, suggesting that dietary supplementation with a GOS prebiotic may improve indices of pre-clinical anxiety. Gut microbiota research has captured the imagination of the scientific and lay community alike, yet we are now at a stage where this early enthusiasm will need to be met with rigorous research in humans. Our work makes an important contribution to this effort by combining a psychobiotic intervention in a human sample with comprehensive behavioural and gut microbiota measures.

Breastfeeding has many known benefits, but rates vary globally. We propose two main reasons why psychological theory and interventions have not been successful to date in explaining breastfeeding behaviours. Specifically, prior research underestimates the importance of (1) specific emotions and (2) wider injunctive influences (i.e., societal and moral norms about what women feel they ought to be doing) in the breastfeeding experience. Therefore, we conducted a systematic review of quantitative, qualitative, and mixed-methods studies that explored whether injunctive norms and/ or specific emotions are associated with breastfeeding behaviours (i.e., intentions, initiation and duration). Seventy-two papers were included in this review; data were extracted and quality appraisals conducted for all included studies. A meta-analysis of effect sizes was performed with the quantitative data. A convergent qualitative synthesis of the data was conducted, resulting in the following line of argument: Breastfeeding is a social behaviour and not a personal/individual behaviour. From this line of argument, three themes with associated sub-themes were developed, highlighting the importance of both specific emotions and injunctive norms on breastfeeding behaviours. These influences are discussed in relation to both theoretical and practical implications, as well as future research.

Background and aims Patients with pancreatic cancer often experience significant deterioration in nutritional status over time. Malnutrition is complex and multifactorial, with malabsorption, pain, toxic dependencies, co-morbidities and malignant processes all playing a role. The aims of this systematic review were to assess nutritional changes over time and identify tolerance of nutritional intervention, thus identifying potential areas for further research to improve patient outcomes. Materials and methods A systematic review of MEDLINE, EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short-term measures, with only one data point, or in the wrong population, thirteen papers were selected for analysis (four trials in neo-adjuvant treatment, five in populations undergoing palliative treatment for pancreatic cancer, and four in mixed populations undergoing pancreatic resection). Results Overall, studies were limited by predominantly retrospective designs, and poor control of potentially confounding variables. Meta-analysis could not be performed due to heterogenicity in study design and reporting methods. Surgery in mixed cohorts did not appear to result in weight loss. Only one small intervention study was identified. Patients with pancreatic cancer experienced a decline in nutritional status, with 44-63% of patients undergoing neoadjuvant chemotherapy having low muscle mass prior to starting treatment. Conclusion There is a paucity of data regarding nutritional intervention in pancreatic cancer. Future work should include the use of validated functional and clinical assessment tools to further explore the impact of nutritional intervention, and the relationship between nutritional status and outcome.

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.

Iodine deficiency has been demonstrated in UK women, which is of concern as iodine is required for fetal brain development during pregnancy. Plant-based diets are increasingly popular, especially with young females, which may affect iodine intake as the main dietary sources are dairy and fish; plant-based products are naturally low in iodine. We, therefore, aimed to (i) assess the iodine fortification of milk-, yoghurt-, cheese- and fish-alternative products available in UK supermarkets and (ii) model the impact that substitution with such products would have on iodine intake using portion-based scenarios. A cross-sectional survey of retail outlets was conducted in 2020 and nutritional data was extracted from food labels. We identified 300 products, including plant-based alternatives to: (i) milk (n=146), (ii) yoghurt (n=76), (iii) cheese (n=67), and (iv) fish (n=11). After excluding organic products (n=48), which cannot be fortified, only 28% (n=29) of milk alternatives and 6% (n=4) of yoghurt alternatives were fortified with iodine, compared to 88% (n=92) and 73% (n=51) respectively with calcium. No cheese alternative was fortified with iodine but 55% were fortified with calcium. None of the fish-alternatives were iodine-fortified. Substitution of three portions of dairy (milk/yoghurt/cheese) per day with unfortified alternatives would reduce iodine provision by 97.9% (124 vs. 2.6 µg) and substantially reduce the contribution to adult intake recommendations (83 vs. 1.8%). Our study highlights that the majority of plant-based alternatives are not iodine-fortified and that use of unfortified alternatives in place of dairy and fish may put consumers at risk of iodine deficiency.

Recent interest in the gut-brain-axis has highlighted the potential of prebiotics to impact wellbeing, and to affect behavioral change in humans. In this clinical trial, we examined the impact of four-weeks daily supplementation of galacto-oligosaccharides (GOS) on self-reported nutrient intake and relationships on gut microbiota in a four-week two-armed parallel double-blind placebo controlled GOS supplement trial in young adult females. Food diaries and stool samples were collected prior to and following 28 days of supplement consumption. It was found that four weeks of GOS supplementation influenced macronutrient intake, as evident by reduced carbohydrate and sugars and increased fats intake. Further analysis showed that the reduction in carbohydrates was predicted by increasing abundances of Bifidobacterium in the GOS group in comparison to the placebo group. This suggests that Bifidobacterium increase via GOS supplementation may help improve the gut microbiota composition by altering the desire for specific types of carbohydrates and boosting Bifidobacterium availability when fiber intake is below recommended levels, without compromising appetite for fiber from food.

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.

© 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.

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.