Showing papers in "Journal of Human Nutrition and Dietetics in 2004"

The health benefits of omega-3 polyunsaturated fatty acids: a review of the evidence

Abstract: The UK dietary guidelines for cardiovascular disease acknowledge the importance of long-chain omega-3 polyunsaturated fatty acids (PUFA) - a component of fish oils - in reducing heart disease risk. At the time, it was recommended that the average n-3 PUFA intake should be increased from 0.1 to 0.2 g day(-1). However, since the publication of these guidelines, a plethora of evidence relating to the beneficial effects of n-3 PUFAs, in areas other than heart disease, has emerged. The majority of intervention studies, which found associations between various conditions and the intake of fish oils or their derivatives, used n-3 intakes well above the 0.2 g day(-1) recommended by Committee on Medical Aspects of Food Policy (COMA). Furthermore, in 2004, the Food Standards Agency changed its advice on oil-rich fish creating a discrepancy between the levels of n-3 PUFA implied by the new advice and the 1994 COMA guideline. This review will examine published evidence from observational and intervention studies relating to the health effects of n-3 PUFAs, and discuss whether the current UK recommendation for long-chain n-3 PUFA needs to be revisited.

What interventions should we add to weight reducing diets in adults with obesity? A systematic review of randomized controlled trials of adding drug therapy, exercise, behaviour therapy or combinations of these interventions.

Abstract: Background Evidence is needed for the effectiveness of interventions given with reducing diets for obese adults: drug therapy, exercise, or behaviour therapy. Methods We systematically reviewed randomized controlled trials in any language. We searched 13 databases and handsearched journals. Trials lasted 1 year or more. One investigator extracted data and a second checked data extraction. Trial quality was assessed. Results Adding orlistat to diet was associated with weight change for up to 24 months (−3.26 kg, 95% CI, −4.15 to −2.37 kg), and statistically significant beneficial changes were found for total and LDL cholesterol, blood pressure and glycaemic control. Adding sibutramine to diet was associated with a 12 month weight change of −4.18 kg (95% CI, −5.14 to −3.21 kg), and statistically significant beneficial effects on high density lipoprotein cholesterol (HDL) and triglycerides (TGs), but an increase in diastolic blood pressure. Adding exercise to diet, or to diet and behaviour therapy, was associated with improved weight loss for up to 36 months and improvements in HDL, TGs and blood pressure. Adding behaviour therapy to diet, or to diet and sibutramine together, was associated with improved weight loss for up to 18 months. Adding drugs, exercise or behaviour therapy to dietary advice was each associated with similar weight change. Conclusions Adding orlistat, sibutramine, exercise, or behaviour modification to dietary advice can improve long-term weight loss.

What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials.

Abstract: Background Evidence is needed for the best long-term diet for weight loss, and improvement in cardiac risk and disease in obese adults. Methods We systematically reviewed randomized controlled trials (RCTs) in any language. We searched 13 databases and handsearched journals. Trials lasted 1 year or more. One investigator extracted the data and a second checked data extraction. Trial quality was assessed. Results Low fat diets (LFDs) produced significant weight losses up to 36 months (−3.55 kg; 95% CI, −4.54 to −2.55 kg). Blood pressure, lipids and fasting plasma glucose improved with these diets after 12 months. Four studies found that LFDs may prevent type 2 diabetes and reduce antihypertensive medication for up to 3 years. A very low calorie diet (VLCD, <4.2 MJ day−1) was associated with the most weight loss after 12 months (−13.40 kg; 95% CI, −18.43 to −8.37 kg) in one small study with beneficial effects on asthma. There was no evidence that low carbohydrate protein sparing modified fasts (PSMFs) were associated with greater long-term weight loss than low calorie diets (LCDs, 4.2–6.7 MJ day−1) or VLCDs. PSMFs were, however, associated with greater lowering of fasting plasma glucose and HbA1c than LCDs. Conclusions Little evidence supports the use of diets other than LFDs for weight reduction. With the increasing prevalence of morbid obesity, long-term follow-up in RCTs is needed to evaluate the effect of LCDs, VLCDs and PSMFs more fully.

A new evidence-based model for weight management in primary care: the Counterweight Programme.

Abstract: Background/Aims Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care. Methods The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit. Results By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months. Conclusion The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Current approaches to obesity management in UK Primary Care: the Counterweight Programme.

Abstract: Background/Aims Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care. Method A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self-reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) ‡30 kg m )2 , n ¼ 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti-obesity medication. Computerized medical records for the total practice population (n ¼ 206 341, 18–75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded. Results Eighty-three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight-related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice-based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti-obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected. Conclusion Obesity is under-recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice-based counselling being the most common intervention.

Intentional mis-reporting of food consumption and its relationship with body mass index and psychological scores in women

Abstract: Background The reasons for mis-reporting food consumption warrant investigation. Objective To document intention to mis-report food consumption and its associations with psychological measures in women. Design A total of 184 female volunteers aged 18–65 years, comprising 50 seeking help in primary care to lose weight with a body mass index (BMI) ≥30 kg m−2 (obese-clinical group) and 134 nurses (nonclinical groups) (BMI <25 kg m−2, n = 52; BMI 25–29.9 kg m−2, n = 45; BMI ≥30 kg m−2, n = 37) were studied. A questionnaire was administered containing three psychological tests (self-esteem, psychological well-being and Stunkard's three-factor eating questionnaire) and new items to address food intake mis-reporting. Results Overall, 68% of participants declared an inclination to mis-report (64% nonclinical, 78% clinical). Inclination to under-report was 29, 33 and 51% in the three nonclinical groups; and 46% among the obese clinical patients. Among the same groups, inclination to over-report were 39, 29, 11 and 32%. After adjusting for social deprivation and BMI, women inclined to mis-report had higher hunger (P = 0.008) and disinhibition (P = 0.005) scores than those intending to report accurately. These variables were associated with current dieting, frequency of dieting, self-reported bingeing and dissatisfaction with body weight. Conclusions These findings indicate that intentional under-reporting and over-reporting of food consumption are common in women of all BMI categories and are associated with eating behaviour. Current dieting, frequency of dieting in the past, self-reported bingeing and dissatisfaction with body weight seem to mediate this relationship.

Impact of tea drinking on iron status in the UK: a review.

Abstract: Background The aims of this review are (1) to evaluate the literature on the likely impact of tea drinking on the iron status of different groups within the UK population and (2) to formulate targeted and evidence based advice on tea drinking in the context of iron nutrition in different groups of people. Method A literature search identified 35 references specific to the effects of black tea on iron absorption and iron nutrition plus one recent review article. Each study was assessed in terms of methodogical quality and relevance to the tea drinking patterns of the UK population. Results There is clear evidence to show that tea drinking limits the absorption of nonhaem iron. However, there are few studies which have assessed the influence of tea drinking on indicators of iron status. There are no intervention studies and the conclusions reported in this review are based on 12 observational studies mostly from other countries. These studies have reported either significant negative correlations between tea drinking and blood indicators of iron status or more cases of anemia in tea drinkers compared with nontea drinkers. Many of the studies reviewed report additional relationships between iron status indices and other factors (both dietary and nondietary), highlighting the complexity of influences on iron absorption and iron status. Conclusion From the available evidence there is no need to advise any restriction on tea drinking in healthy people with no risk of iron deficiency. In groups at risk of iron deficiency the advice should be to drink tea between meals and to wait at least 1 h after eating before drinking tea.

The effect of practical portion size measurement aids on the accuracy of portion size estimates made by young adults

Abstract: A barrier to controlling the amount of food consumed may be the difficulty consumers have in accurately estimating portion sizes. Although portion size measurement aids (PSMAs) can improve estimation accuracy, their bulk and/or cost tends to make them impractical for regular use. The purpose of this study was to investigate the effect on portion size estimation accuracy of two practical PSMAs: a 2-D PSMA (life size picture of tennis and golf balls) and 3-D PSMAs (tennis and golf balls). Young adults were randomly assigned to one of two groups and estimated the portion sizes of 36 foods divided into three equal sets. PSMAs were not used to estimate portion sizes in Food Set 1. Study group 1 (n = 57) used the 2-D PSMA and study group 2 (n = 56) used the 3-D PSMAs to estimate the portion sizes in Food Set 2. Neither group used PSMAs to estimate portion sizes in Food Set 3. Repeated measures anova indicated that both groups significantly improved estimation accuracy between Food Sets 1 and 2 and between Foods Sets 1 and 3. Thus, even short-term exposure to practical PSMAs may improve estimation accuracy and these improvements persist when the PSMA is no longer available. However, the accuracy rate for Food Set 2 was only about 60% indicating that a great deal of estimation error remains.

A critical evaluation of the relationship between serum vitamin B12, folate and total homocysteine with cognitive impairment in the elderly

Abstract: Background Serum homocysteine increases with age and is also considered a marker for low serum vitamin B12 and folate. Furthermore, raised serum total homocysteine has been associated with atrophic changes in the brain. An association between serum vitamin B12/folate and cognitive impairment would be of considerable public health importance in view of the increasing numbers of elderly people. Aim To systematically review published studies on the relationship between serum vitamin B12, folate and total homocysteine and cognitive function in the elderly. Design and data sources A systematic review was undertaken of published evidence in English, examining the association between low serum vitamin B12/folate and raised total homocysteine with cognitive impairment (as indicated by low scores on neuropsychological testing) in subjects aged over 60 years. Sixteen electronic databases and cited articles were searched. Of 383 potential articles, six fulfilled the eligibility criteria: three case control and three cohort studies were identified. ‘The Cochrane Non-Randomized Studies Methods Group’ guidelines were used for assessment and extraction of data from these studies. Results All three case control studies found that serum total homocysteine was significantly higher in cases when compared with controls, and there was wide variation for both serum vitamin B12 and folate in both groups of participants. The relationship of serum folate and vitamin B12 status with cognitive impairment was heterogeneous and one case control study reported decreasing cognitive scores with increasing serum vitamin B12. In the cohort studies, although serum total homocysteine could predict the rate of decline in neuropsychological testing, the overall odds ratio/relative risk (RR) of developing cognitive impairment in relation to levels of serum B12 and serum folate were not significant. Although one study reported a significant RR of developing Alzheimer's disease when both serum folate and B12 levels were low. One cohort study reported an increased prevalence of Alzheimer's type dementia in subjects who had normal serum vitamin B12 at baseline. Conclusion Serum total homocysteine is negatively correlated with neuropsychological tests scores. But the evidence does not support a correlation between serum vitamin B12 or folate and cognitive impairment in people aged over 60 years. Hence, there is little evidence to justify treating cognitive impairment with vitamin B12 or folate supplementation. This is consistent with the findings from recent systematic reviews of randomized double-blind trials, which have not found any evidence of potential benefit of vitamin supplementation. Further research is required in order to establish whether raised serum total homocysteine is a cause or consequence of disease.

Comparison of Nutritional Risk Screening Tools in Patients on Admission to Hospital

Abstract: Background and aims Undernutrition has been frequently reported in patients on admission to hospital. Because this is not always detected promptly, screening for nutritional risk on admission has been widely advocated. Although there is no universally accepted ‘gold standard’ for defining undernutrition, the definition used by McWhirter, J.P. & Pennington, C.R. [(1994) Br. Med. J.308, 945] has been widely used by clinical nutrition specialists. This study aimed to compare the efficacy of two frequently used nutritional risk screening tools in detecting undernutrition according to this definition. Methods Both the Nutrition Risk Index [Veterans Affairs Total Parenteral Nutrition Co-operative Study Group (1991) N. Engl. J. Med.325, 525] and the Nutrition Risk Score [Reilly H.M. et al. (1995) Clin. Nutr.14, 269] were used to screen for undernutrition in 359 admissions to two acute teaching hospitals in Dublin. Undernutrition was defined as a Body Mass Index below 20 kg m−2 and a triceps skinfold thickness or mid-arm muscle circumference below the 15th percentile. Comparison of stratification of nutritional risk by the two screening tools was carried out. Results Both screening tools identified over 40% (Nutrition Risk Index, 44%; Nutrition Risk Score, 46%) of all patients assessed as at nutritional risk on admission. However, one-third of the undernourished patients were classified as at no nutrition risk by the Nutrition Risk Index, while almost one-fifth of those undernourished were classified as at low risk by the Nutrition Risk Score. The degree of nutritional risk differed with the screening tool used, the Nutrition Risk Score classifying 29% of all patients as high risk while the Nutrition Risk Index classified only 5% as in the high risk category. Conclusions Although a large proportion of patients on admission were classified as being at nutritional risk, the degree of risk was significantly different depending on the screening tool used. Both nutritional risk screening tools evaluated in this study failed to recognize many cases of undernutrition. Evaluation of the efficacy of nutritional screening tools should be promoted as seriously as the development of such tools.

Attitudes and barriers to dietary advice aimed at reducing risk of type 2 diabetes in first-degree relatives of patients with type 2 diabetes.

Abstract: Objective To evaluate the attitudes to and adoption of dietary advice in nondiabetic first-degree relatives of patients with type 2 diabetes and to examine barriers to adherence. Design One-year controlled intervention study, where treatment group (n ¼ 73) received lifestyle education. Attitudes towards dietary advice, change in dietary habits and importance of potential barriers to adherence were evaluated by questionnaires. Nondiabetic relatives (25–55 years; males and females) of individuals with type 2 diabetes were recruited. Education was based on current nutrition recommendations and aimed at improving dietary fat quality, increasing intake of fruit and vegetables, with additional advice to reduce dietary glycaemic index (GI). Main outcome measures Attitudes and importance of barriers were classified by the intervened subjects into four categories ranging from ‘No problem’ to ‘Yes, definitely a problem’. Dietary adherence was monitored by food frequency questionnaire at baseline and after 1 year. Results Participants were generally in favour of advice aimed at improving dietary fat quality. Attitudes towards advice to reduce GI varied widely. Food selection changed in accordance with predefined dietary goals. ‘Forgetfulness’, ‘low availability in lunch restaurant’ and ‘lack of ideas for cooking’ were barriers to adherence. Conclusions Dietary advice aimed at reducing risk of type 2 diabetes was generally positively received and adopted in subjects with heredity for the disease. The most prevalent barriers reported are potentially modifiable.

Canadian dietitians' views and practices regarding obesity and weight management.

Abstract: Objective To provide insight into Canadian dietitians’ attitudes and practices regarding obesity and weight management. Design Cross-sectional mail survey of a stratified random sample of members of Canadian dietetic associations. Subjects A total of 514 dietitians (74% of those surveyed), 350 (69%) of whom actively counselled overweight/obese clients. Measurements Participants received a questionnaire to assess dietitians’ attitudes regarding obesity and overweight, views regarding their role in weight management, counselling practices, and the criteria used to judge success. Demographic variables were collected. Results Most dietitians believed that obesity contributes to morbidity and mortality, and that small weight losses produced important health benefits. However, 80% agreed that health indicators other than weight loss should be the focus of obesity management, and 55% specifically recommended that clients not weigh themselves. Instead, weight management was promoted by recommending healthy eating and increased physical activity. Three-quarters agreed that they are the profession best trained to manage obesity but two-thirds believed their time would be better spent preventing rather than managing obesity. Dietitians most valued education received from on-the-job support and mentoring from other dietitians. Participants reported wanting to learn more about motivational and behavioural modification counselling techniques. Conclusions Canadian dietitians follow a lifestyle approach to weight management. Studies are required to formally assess the effectiveness of various aspects of this approach.

Increased intake of fruit and vegetables and a low-fat diet, with and without low-fat plant sterol-enriched spread consumption: effects on plasma lipoprotein and carotenoid metabolism.

Abstract: Background Regular intake of plant sterol (phytosterol)-enriched foods enhances the cholesterol lowering effect of diets. One side effect associated with plant sterol consumption is a modest reduction in plasma carotenoid concentrations. This study investigated the effect of consuming a low-fat National Cholesterol Education Programme (NCEP) Step 1 diet, including a low-fat plant sterol ester (PSE)-enriched spread on cholesterol metabolism to determine if specific dietary advice to increase daily fruit and vegetable intake could prevent reduced plasma carotenoid concentrations. Materials and methods In this randomised, crossover double-blind trial, 48 hypercholesterolaemic men received 21 g day−1 of a low-fat PSE-enriched spread or placebo for 3 weeks, interrupted by 3 weeks washout. Individuals also adhered to a NCEP Step 1 diet and repeated 3-day food diaries monitored adherence. Specific advice was provided to increase dietary fruit and vegetable intakes. Fasting blood samples were collected at pre- and post-intervention for lipoprotein and carotenoid analysis. Results Plasma total and low-density lipoprotein (LDL) cholesterol concentrations were significantly (P < 0.05) reduced, by 4.6 and 7.1%, respectively, after the PSE-enriched low-fat spread. Plasma apo B concentrations were significantly (P < 0.0005) lower after the PSE spread. PSE consumption was also associated with significantly (P < 0.05) lower total plasma β-carotene concentrations, but this change was not significant after lipid standardisation. PSE consumption had no effect on retinol, α-carotene, γ-tocopherol, α-tocopherol, lutein, zeaxanthin, β-crypyoxanthin or lycopene concentrations. Conclusion Dietary advice to increase daily fruit and vegetable consumption may be effective in preventing a reduction in plasma carotenoid concentrations previously associated with PSE consumption. Further, PSE incorporated in a low-fat spread and consumed as part of a NCEP Step 1 diet are effective in reducing total and LDL cholesterol.

Patient satisfaction is rated higher by radiation oncology outpatients receiving nutrition intervention compared with usual care.

Abstract: Background Satisfaction with services has been considered vital for the provision of quality health care, however, there are few published papers utilizing patient satisfaction with nutrition services as a measurable outcome.

Investigation into the nutritional status, dietary intake and smoking habits of patients with chronic obstructive pulmonary disease.

Abstract: Background and aims Weight loss and reduced fat-free mass are prevalent amongst patients with chronic obstructive pulmonary disease (COPD). However, the causes of this weight loss are not clear. The aims of this study are to investigate the factors affecting body weight and dietary intake in a group of outpatients with COPD, and to investigate any differences between adequately nourished and malnourished patients. Methods In 103 stable outpatients, nutritional status was assessed using Body Mass Index (BMI) and upper arm anthropometry. Lung function, smoking status, exercise tolerance, dietary intake, dietary problems and health-related quality of life were assessed. Patients were classed as either adequately nourished or malnourished. Results Twenty-three per cent of subjects were classed as malnourished. The malnourished subjects had lower lung function measurements, suffered more dietary problems and had lower nutritional intake compared with the adequately nourished subjects. They also had poorer fatigue scores. In linear regression analysis, the factors that had the most effect on BMI were a low transfer factor, presence of early satiety, and being a current smoker. Conclusion Important differences were found between adequately nourished and malnourished subjects. These differences move us closer to understanding how best to screen and treat this group of patients.

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003).

Abstract: Aim To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention). Methods The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group. Results Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear. Conclusion There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

The testing of clinical skills in dietetic students prior to entering clinical placement

Abstract: Background One of the most important requirements for contemporary education of a health care professional is to develop a framework for theory and practise which results in attainment of professional competencies suitably robust for a lifetime of practise (Howe, 2002). In the context of those educating preregistration dietitians, this offers the challenge of presenting the student with innovative curricula designed to deliver the appropriate level of knowledge and understanding together with emphasis on skill and attitude development. The purpose of this study was to allow preregistration students the opportunity to practise key clinical skills prior to clinical placement and test skills acquisition using the model of an objective structured clinical examination (OSCE). Methods The learning experience of the student was altered to accommodate a more conceptually-driven, problem-centred, case-based approach. The curriculum was adjusted to incorporate a short clinical skills programme where emphasis was deliberately placed on skill acquisition. At the conclusion of this clinical skills programme, and prior to the students entering clinical placement, skill performance by students was tested using the OSCE. The method of testing was also evaluated by students. Results The OSCE was delivered to 37 preclinical students. Four of the test candidates (11%) failed in at least one of the skill areas: these students performed similarly during clinical placement. Twenty-one (57%) students returned the post-OSCE questionnaire. Twenty (95%) students reported a positive experience; 20 (95%) students reported initial anxiety that diminished as the test progressed. Conclusion The Project Team was confident with the novel approach taken in re-designing the curriculum: to include a dedicated clinical skills programme, together with addition of the testing of clinical skills using the OSCE model. These curriculum changes were deemed to be highly appropriate additions to the student experience in determination of skill performance of students prior to clinical placement.

Advice available on the Internet for people with coeliac disease: an evaluation of the quality of websites

Abstract: Background The Internet may be a useful resource for people with coeliac disease as a great deal of health-related information is published online. However, not all of it is accurate. It has been suggested that accurate information is most likely found on transparent sites and kitemarks are awarded on this basis. This paper examines whether the Internet is a useful resource for people with coeliac disease and whether transparency criteria can be used in identifying accurate sites. Method An evaluation tool was developed using selected transparency criteria and clinical guidelines for accuracy. A total of 63 websites were evaluated. Results In the study, 66% of the websites scored less than 50% for accuracy. This was primarily because of incomplete information but 15.9% of sites contained inaccuracies. Over 50% of sites scored less than 50% for transparency. No correlation was found between sites that scored highly for accuracy and those that scored highly for transparency. Conclusion There are useful information available for people with coeliac disease but transparency criteria alone cannot be used to identify accurate sites.

Validation of energy intake by dietary recall against different methods to assess energy expenditure.

Abstract: Objectives To compare the validity of dietary recalls and physical activity recalls and investigate some factors influencing this validity. To provide an example showing how procedures based on recalls of physical activity can assess the validity of dietary recalls and identify subjects constantly underreporting their energy intake (EI). Design and subjects Thirty-seven women were studied using three 24-h dietary recalls, two kinds of physical activity recalls, indirect calorimetry and the doubly labelled water method. Results The EI obtained using dietary recalls were biased with respect to body mass index (BMI) and attitudes towards body weight and dieting, whereas results obtained using a physical activity recall were not. Eighteen women produced underreports (UR), i.e. their average EI was below 76% of total energy expenditure (TEE), whereas 24 women reported an EI that was lower than TEE on all three recall days, i.e. constantly underreporting subjects. A physical activity recall identified 13 URs and 20 of the constantly underreporting subjects. Conclusions In contrast to estimates of EI, TEE assessed using physical activity recalls was not biased with respect to BMI or attitudes towards body weight and dieting. Recalls of physical activity represent potentially useful procedures for identifying URs and constantly underreporting subjects but are not accurate enough for individuals.

The opinion of Dutch dietitians about functional foods

Abstract: Objective To obtain information about Dutch dietitian's attitudes, perceived knowledge, training preferences, counselling procedures, opinions about post-launch monitoring, and personal consumption of functional foods. Design A self-administered, 62-item, postal survey in 2002. Subjects Five hundred randomly selected registered dietitians. The response rate was 49% (n = 238). Results The responders (mean age ± SD: 40 ± 9 years) had regular contact with clients (90%), and many (71% of 90%) advised about functional food use. Sixty-nine per cent hardly consumed any functional food themselves. Eighty-seven per cent of the responders would greatly appreciate courses given by scientists. Confusion existed about usage practices, target groups, safety, efficacy, and claims: between 42 and 89% agreed with the statements about uncertainties. Nonetheless, 69% felt that functional foods could theoretically contribute to good bodily functioning. Ninety per cent thought post-launch monitoring (PLM) important, but ideas about a common dietetic contribution to PLM did not emerge. Conclusions Although functional foods potentially contribute to a healthful diet, there is still confusion among dietitians about claims, safety, efficacy and product-handling aspects. It is time to meet dietitians' repeated requests to provide education by noncommercial experts. In the meantime, dietitians themselves should have more say in the PLM debate because they should and could play an important role.

Effect of changing to a self-selected vegetarian diet on anthropometric measurements in UK adults.

Abstract: Background Vegetarians are often a little leaner compared with nonvegetarians and suffer less from obesity and its associated complications than nonvegetarians. Whether this is because of not eating meat specifically is unclear. Objective We investigated whether changing to a self-selected vegetarian diet resulted in changes to anthropometric measurements. Design Subjects (n = 33; seven males and 26 females) who were in the earliest stages of becoming vegetarian were observed for 6 months. Data on dietary intake, using a 3-day estimated dietary diary, and body composition were obtained at baseline and after 6 months of following a self-selected vegetarian diet. Results Dietary calculations showed that on changing to a self-selected vegetarian diet, there was a significant reduction (P < 0.05) in energy intake (8.9 MJ day−1 versus 8.1 MJ day−1), and in the proportion of energy from saturated fatty acids (12.9% versus 11.3%) and a significant increase (P < 0.05) in the proportion of energy from carbohydrates (44.9% versus 47.5%) and in intake of nonstarch polysaccharides (NSP) (1.6 g MJ−1 versus 2.0 g MJ−1). Significant reductions in mid-upper arm circumference, calculated body fat, biceps and triceps skinfolds and waist and hip circumferences were observed. No reduction in body weight was observed. Conclusion The findings of our study suggest that significant dietary changes, helping people to conform more closely to current dietary recommendations, occurred when people became vegetarian. In this study we did not find any significant change in body weight, but significant reductions were observed in skinfold thickness and waist : height ratio which imply that on changing to a self-selected vegetarian diet, the subjects became leaner.

Perceived role of fibre in a healthy diet among Finnish consumers

Abstract: Objective The aim was to study how Finnish consumers perceive the role of fibre in the diet, which foods are regarded as good sources of fibre and the relationship between the respondents’ self-estimated fibre intake and their measured intake. Methods A semistructured interview was conducted with 125 volunteers, including a background information questionnaire and an easy-to-use self-administered paper-and-pencil form estimating fibre intake. Results According to the self-administered form about half of the respondents had adequate fibre intake. Among those who estimated their fibre intake as adequate/maybe adequate, only 61% belonged to the highest fibre intake group. Most of the respondents defined their diet as being healthy. The key elements for a healthy diet were ‘vegetables’, ‘low in fat’, ‘fruit and berries’ and ‘variety’. Only 5% of the respondents mentioned fibre spontaneously here. However, fibre was considered important for health because of its effect on bowel function and general well-being. The recommended intake of fibre could not be described in nutritional terms, but respondents could identify relevant sources of fibre in the diet. Conclusion Finnish consumers considered fibre important for health and could recognize the sources of fibre correctly although they did not mention it spontaneously as a part of a healthy diet.

Process evaluation of two environmental nutrition programmes and an educational nutrition programme conducted at supermarkets and worksite cafeterias in the Netherlands.

Abstract: textThis article describes the process evaluation of two environmental programs and a educational nutrition program, implemented at supermarkets and worksite cafeterias. Studies conducted earlier, indicated that the programs had no effect on consumers’ eating behavior. Consequently, the more specific purpose of the present study was to identify explanations for the ineffectiveness of the programs and to formulate recommendations for future programs. Materials and Methods The environmental programs included labeling of healthy products and increasing the range of healthy foods on offer. The education program consisted of several elements, such as brochures and a self-help guide. Semi-structured interviews were conducted with twenty-one managers of supermarkets and worksite cafeterias where the programs were implemented. Results Although materials were not always entirely compatible with the different supermarkets and worksite cafeterias, the degree of implementation was satisfactory. According to the managers, the programs were not striking enough, the labeling would have been more effective if it had discriminated between different brands of a product, and the number of new products was too small compared to the total range of foods on offer. Discussion The results can be used to help design and check future intervention programs for use at supermarkets or worksite cafeterias. Recommendations for future programs and research are given.

Is dietary counselling effective in increasing dietary calcium, protein and energy intake in patients with osteoporotic fractures? A randomized controlled clinical trial.

Abstract: To determine the feasibility of increasing the calcium, protein and calorie intake of osteoporotic fracture patients by repeated dietary counselling delivered by a dietitian, a randomized controlled trial was conducted. Among 189 patients presenting with osteoporotic fractures to an Orthopaedics and Traumatology Department of a large regional hospital, 98 patients were randomized to the intervention group and 91 were randomized to the control group (with usual care). Intervention group received three sessions of dietary counselling with tailored made recommendations over a period of 4 months, while the control group only received dietary assessment and pamphlets on the prevention of osteoporosis. Almost all subjects in both intervention and control groups had calcium intake below the recommended level of 1000 mg at baseline. Half and 60% of subjects in both groups had total energy and protein intake below recommended levels respectively. The mean weights of control and intervention groups at baseline were 51.5 and 50.9 kg respectively, while the body mass index (BMI) were 22.6 (kg m(-2)) and 22.6 (kg m(-2)) respectively. After dietary intervention, significant increase of intake was seen in calcium intake (P = 0.0095 by t-test) in the intervention group. No significant increase was seen in protein or calorie intake. No significant change was observed in the body weight or BMI although there was a positive trend in the intervention group for all these parameters. We concluded that there was general malnutrition in Chinese elderly who presented with osteoporotic fractures. Dietary calcium could be increased by repeated professional dietary counselling. Future studies with longer duration and more objective clinical outcomes will be helpful to further demonstrate the long-term effects of dietary intervention on osteoporosis and other chronic diseases.

Monitoring the development of clinical skills during training in a clinical placement

Abstract: Background The education and training of health care practitioners has undergone recent reform, and indicate that curricula should place emphasis on the development of clinical skills and attitude. The purpose of this study was two-fold: to define the key skills necessary for a competent dietetic student practitioner and to devise a reliable assessment tool to measure and track performance in these key skill areas throughout the period of clinical placement. Methods Key clinical skills were identified by a concensus group of experienced dietitians and academic practitioners. An assessment tool was then developed to measure these attributes in 43 students undertaking clinical placement at a number of training centres in Scotland. Development of skills was tracked for the entire duration of placements using the novel assessment tool. The assessment tool used a visual analogue scale (VAS) as the measuring score. Results A high level of skill attainment was equated with high VAS scores. Performance in three of the four key skills (written skills: r = 0.762, P ≤ 0.001; interviewing skills: r = 0.697, P < 0.001; and dietary assessment technique: r = 0.697, P ≤ 0.001) showed impressive correlation co-efficients, indicating a striking and significant positive correlation with the length of training. A high skill performance level attainment was achieved by week 16/17 of training. Conclusion The authors are confident that the assessment tool is valid and reliable and measures skill performance objectively. A high level of skill attainment was observed in most students by about the mid-point in training: this allows the student to consolidate these skills in the latter stages of training which is in keeping with educational and practice philosophy of placement learning outcomes.

Nutrition in the community – an exploratory study of oral nutritional supplements in a health board area in Ireland

Abstract: Background A review of the General Medical (Payments) Scheme data in the Midland Health Board (MHB) Ireland identified a spend of just over € 0.5 million on enteral nutritional supplements (oral and tube feeds) in an 11-month period in 1998 [General Medical Services (Payments) Board, 1998, MHB Clinical Nutritional Products: January–December 1998, Dublin]. In 2000, a figure of €5 million was reported as the annual spend (oral and tube feeds) [General Medical Services (Payments) Board, 2000, MHB Clinical Nutritional Products: January–December 2000, Dublin]. Research has shown that a high proportion of Oral Nutritional Supplements (ONS) are inappropriately prescribed by primary care practitioners (Gall et al., 2001). The role of General Practitioners (GPs) and Public Health Nurses (PHNs) in prescribing ONS to patients aged 65 years and older was examined, as they are directly involved in the delivery of primary health care. Aim (i) Assess current trends, decision-making processes and monitoring procedures in the use of ONS for older patients in the community. (ii) Identify whether nutritional assessments and appropriate nutritional criteria are standard practice in determining selection of ONS. Methods A study was conducted among 99 GPs and 120 PHNs in the MHB. All GPs were selected to participate and 50% (60) of PHNs were randomly selected. A telephone questionnaire was administered to each subject over a 2-week period. Results Both GPs (78%) and PHNs (47%) reported that their prescription of/recommendations for ONS had increased in the last 4 years. None conducted a full nutritional assessment, but 25% of PHNs used a Nutrition Screening Tool when trying to ascertain whether a patient requires an ONS. Only 19.6% of GPs and 6.8% of PHNs surveyed were aware of the calorie content of a standard 200 mL ONS (sip-feed). In addition, a very significant proportion of both GPs and PHNs do not appear to give appropriate dietary advice to patients who may be at risk of malnutrition. Only 55% of GPs stated that they would specifically review a patient's ONS prescription. All GPs said that they would not conduct a full nutritional assessment at the review appointment. Conclusion The results of this study raise concerns as to the appropriateness of current ONS prescription and monitoring in the community. They also highlight the need for further intervention in the primary care setting in order to ensure that elderly malnourished patients are detected, treated and monitored in an appropriate and cost-effective manner.

A survey to assess physical activity promotion by Registered Dietitians

Abstract: Background Convincing evidence has emerged in recent years for the role of physical activity (PA) in the prevention and treatment of many chronic diseases. These include both physical and mental health problems, which are likely to be encountered by practicing dietitians. This study aimed to identify whether NHS based Registered Dietitians (RDs) currently promote PA to their patients and if so, how they do it and with which patients. Method An anonymous questionnaire sent to 516 RDs in NHS teaching hospitals achieved a 77% (n = 397) return rate. Results Ninety-three per cent of respondents reported regularly promoting PA particularly with new patients. Among active PA promoters, 87% reported encouraged daily accumulation of PA, 50% focused on sport and exercise and 52% referred patients to GPs or Physiotherapists for advice. Distinctive levels and styles of PA promotion were found to be related to levels of recent training in the field although fewer than one in four had actually received any formal training. Conclusions A high interest in further PA-specific training (95% of all respondents), together with high variability in the type and quality of advice suggests the need to develop further in-service training specifically for RDs.

Dietary macro‐ and micronutrient intakes of nonsupplemented pre‐ and postmenopausal women with a perspective on menopause‐associated diseases

Abstract: Objectives To assess the dietary intakes and diet quality of menopausal women relative to premenopausal women, and to determine whether their diets are compatible with reducing risks of cardiovascular disease (CVD) and osteoporosis. Design Cross-sectional study using 3-day food records and anthropometric measurements. Subjects Thirty apparently healthy, nonoestrogen using and nonsupplemented women menopausal since 3–5 years and 30 well-matched premenopausal women. Outcome measures Nutrient intakes, diet nutrient density, body mass index (BMI), waist circumference, waist-to-hip ratio and serum oestradiol. Results Energy intake and body weight of pre- and postmenopausal women were comparable. Their BMI, waist circumference and waist-to-hip ratios were within healthy ranges. The diet of postmenopausal women was compatible (less total lipids and saturated fatty acids; more fibres, antioxidant vitamins and potassium) with North American nutritional recommendations linked to cardiovascular health. Their dietary iron intakes exceeded their reduced physiological need, which may jeopardize their cardiovascular system. Their calcium and vitamin D intakes were far below recommendations for healthy bones. Five other nutrients were also suboptimal. Phosphorus intake (high in both groups) correlated with dietary proteins, sulphur amino acids and calcium. Conclusions The diet of the postmenopausal women studied were more compatible with national nutritional recommendations than that of premenopausal controls. However, these postmenopausal women, not taking hormone replacement therapy (HRT) and having inadequate dietary calcium and vitamin D intakes, may be at increased risk of osteoporotic fracture later in life. More studies on CVD risk inherent to body iron accumulation involving a large number of postmenopausal women are warranted before planning public health measures regarding dietary iron intake.

Maternal - neonatal folate and vitamin B12 serum concentrations in Greeks and in Albanian immigrants.

Abstract: BACKGROUND Low folate and vitamin B(12) concentrations during pregnancy are implicated with neural tube defects (NTD) and neurological manifestations in the neonates. AIM To compare serum concentrations of folate and vitamin B(12) in 1025 Greek mothers, 908 immigrant Albanian mothers at delivery and in the cord blood of their neonates. METHODS A 30 days food diary was kept from each mother. Folate and vitamin B(12) sera concentrations were measured with Bayer ADVIA Centaur System. RESULTS Energy, carbohydrates and total fat intake were significantly higher in Albanian mothers when compared with those of Greek origin. On the contrary, total protein, and especially animal protein intake were higher in the Greek mothers. Folate intake was similar between the two ethnic groups whereas vitamin B(12) intake in Albanians was evaluated lower (1.8 +/- 0.13 microg day(-1)) when compared with that of Greeks (2.8 +/- 0.12 microg day(-1); P 0.05) in the two ethnic groups. In contrast, vitamin B(12) serum concentration was significantly lower (135.0 +/- 19.6 pm) in the Albanian mothers compared with that of Greeks (164.5 +/- 17.7 pm, P < 0.0001). Consequently, the vitamin concentrations was found lower in the newborns of Albanian origin (133.6 +/- 11.8 pm) compared with that of Greek neonates (213.3 +/- 11.4 pm, P < 0.0001). CONCLUSIONS (a) Folate serum concentrations in Greek and Albanian mothers and in their neonates were similar, (b) vitamin B(12) serum concentrations, evaluated for first time in these ethnic groups, were significantly low in Albanians, both in mothers and newborns, (c) the low protein and especially the reduced animal protein intake from the Albanian mothers, possibly due to their low socio-economic status, may be responsible for their decreased vitamin B(12) serum concentrations and (d) vitamin B(12) supplementation along with an increase of animal protein intake might improve the vitamin serum status in the Albanians.