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Low Income Diet and Nutrition Survey:summary and analysis of the main findingsprepared by

Dr Alan Stewart

www.stewartnutrition.co.uk


Low Income Diet and Nutrition Survey: Lecture Contents and Slides

  • Introduction 3-5

  • Methodology, Analysis, Population Characteristics 6-12

  • Malnutrition: undernutrition 13-20

  • Malnutrition: overnutrition 21-24

  • Malnutrition Risk Factors: socio-economic and personal 25-55

  • Lessons from History


Poverty and Malnutrition: Background

  • Though the industrial and agricultural revolutions did much to reduce widespread food shortages malnutrition still occurs

  • Landmark discoveries in nutrition made in the 20th century began to document the specific impact of poor nutrient intake on health

  • These discoveries and the need for even food distribution during the two World Wars resulted in the formulation of advice and food policies to prevent undernutrition in the general population

  • Financial hardship and deprivation are not the only determinants of inadequate food intake and malnutrition in the UK population

  • Poor nutrient status affects all age groups - growth, development, physical and mental health, earning capability and longevity

  • Correcting undernutrition benefits both the individual and society

  • To correct problems of malnutrition requires an understanding of the findings of nutritional surveys as well as lessons from history


Malnutrition and Health

  • The term malnutrition covers both undernutrition and overnutrition

  • In the UK obvious severe undernutrition is not common outside of serious illness or dietary problems but overnutrition – obesity, is

  • Numerous nutritional surveys of the UK population reveal that mild deficiencies of micronutrients are not uncommon, may co-exist with overnutrition and can adversely influence physical or mental health

  • Deficiencies of three micronutrients (iron, vitamin A and iodine) in all countries are monitored by the WHO and are only marginally more common in the low income groups in the UK. www.int/vmnis/en

  • However, deficiencies of folate, vitamins D and C are more common and potentially affect health in all age groups

  • The causes of the these and other deficiencies include poor food choices, illness, smoking, alcohol excess and lack of sun exposure


Classifying Diet-Related Health Problems

Undernutrition

  • Poor Growth - Protein-energy, vitamin A and iodine

  • Underweight – Protein-energy

  • Anaemia – Iron, folate, vitamins B12 and C

  • Rickets and Osteoporosis - Calcium and vitamin D

  • Poor Pregnancy Outcome – Folate, severe anaemia, vitamins C and D

  • Major Deficiency Syndromes – Vitamin C (scurvy), vitamin B1(beri-beri) etc.

    Overnutrition

  • Obesity – Energy from food or alcohol

  • Hypertension – Obesity, excess of sodium and alcohol

  • Poor Pregnancy Outcome – Obesity, excess of vitamin A

  • Liver disease – Obesity, alcohol, excess of iron or vitamin A

    Unwise Food Choices

  • Increased Mortality – vascular disease and cancer mainly

  • Increased Morbidity – many: dental caries, digestive problems, food allergy


Low Income Diet and Nutrition Survey of the UK Population (2008): Methodology

  • Being in receipt of benefits has often been associated with a less healthy diet and poorer nutritional state and health

  • The LIDNS was commissioned by the Food Standards Agency to assess the nutritional status of this group

  • A representative sample aged 2 to over 80 years was drawn from those in the most deprived 15% of society, living in a household where at least one adult was in receipt of benefits

  • Data was collected on food intake over 4 days, measures of height, weight and blood pressure and, on those aged 8 years and over, blood samples to assess specific nutrients

  • Information about alcohol consumption, smoking, medication, supplement use, physical activity and oral health was collected

  • See www.food.gov.uk/science/dietsurveys/lidnsbranch/


LIDNS: Data Analysis and Presentation

  • 3,728 people took part in the survey and completed the diet record and 1,435 (age >8yrs) provided a blood sample

  • As in the previous four National Diet and Nutrition Surveys (NDNS) those in institutions, of no fixed abode or who were pregnant or very ill were not included

  • The data have been analysed by sex, age, geographic location, whether urban or non-urban dwelling and by ethnicity

  • In the report data on micronutrient intake is presented from Food Sources only and not All Sources (food and supplements)

  • This means that the prevalence of inadequate intake (below the LRNI) may have been slightly overestimated

  • Supplements usually provided <10% of total intake

  • Direct comparison with the corresponding NDNS, which looked at intakes from All Sources, is thus not straightforward


LIDNS: Socio-demographic Characteristics

  • SexMale40%Female60%

  • Ages2-10yrs19%11-18 yrs14%19-34 yrs17%35-49 yrs17%50-64 yrs12%65+ yrs21%

  • Marital StatusMarried28%Separated6%Divorced19%Widowed18%Never married, single29%

  • Dwelling LocationUrban 19% Sub-urban 78% Rural 3%

  • EducationThose aged >16 yrs with no qualification Men 51% Women 58%


LIDNS: Location of Dwelling All participants (aged >2yrs)

  • England n = 2433. Scotland n = 392, Wales n = 437, N. Ireland n = 466

  • Total n = 3728


LIDNS: Ethnic Group

  • The small number of people in the different ethnic minorities makes detailed interpretation of nutritional differences unreliable


LIDNS: Health Status –Limiting/Not-Limiting Illness


LIDNS: Sources of Income

  • Many had income from more than one type of source/benefit


Undernutrition: Main Nutrients of Concern


LIDNS: Undernutrition Prevalence - Macronutrients


LIDNS/NDNS: Prevalence of Low Protein IntakeLower 2.5 percentile of percentage of energy as protein

  • Protein intakes <10% of energy intake are likely to be inadequate for some people unless total energy intakes are very high

  • Intake of protein/kg body weight and related measures were not presented

  • Low protein diets are often low in iron, vitamin B12 and other nutrients


LIDNS: Fruit and Vegetable ConsumptionPortions per day. (Advised Adult Target = 5)

  • NDNS Adult (19-64 yrs) intakes of those in receipt of benefits are 70% of those who are not

  • Low intakes of fruit and vegetables will often result in poorer status of vitamin C and folate and reduced iron absorption


LIDNS: Prevalence of Anaemia

  • Haemoglobin Normal Ranges World Health Organisation; 1.5-6.0 yrs >11.0g/dl, adult women >12.0g/dl, adult men >13.0g/dl.

  • Adult ranges have been adopted from ages 15yrs and upward

  • British laboratories often use a normal range of >11.5g/dl for adult women

  • Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency


LIDNS: Undernutrition Prevalence - Micronutrients


LIDNS: Prevalence of Folate Deficiency IRed Cell Folate

  • Test red cell folate; normal range is >350 nmol/l

  • Group Boys age 8-10 yrs only 7 subjects - too few to analyse

  • Symptomatic deficiency often develops before macrocytic anaemia develops


LIDNS: Prevalence of Folate Deficiency IIPlasma Folate

  • Test plasma folate; normal range is >7 nmol/l

  • Group Boys age 8-10 yrs only 7 subjects - too few to analyse

  • Plasma folate is easily raised by supplements and may not reflect tissue status

  • Multivitamin supplements were taken by men 6%, women 10%, children 4%


LIDNS: Prevalence of Vitamin B12 DeficiencySerum Vitamin B12

  • Test serum vitamin B12; normal range is > 118 pmol/l

  • Serum level may be reduced by o.c. pill without deficiency developing

  • Symptomatic deficiency often develops before macrocytic anaemia


LIDNS: Prevalence of Vitamin C DeficiencyPlasma Vitamin C

  • Test plasma vitamin C; normal range is >11 umol/l

  • Milder depletion was present in ~7% of 8-18yr olds and ~20% of adults


LIDNS: Prevalence of Vitamin D DeficiencySerum 25 Hydroxy vitamin D

  • Test serum 25-hydroxy vitamin D; normal range >25 nmol/l

  • Group Boys age 8-10 yrs only 7 subjects - too few to analyse

  • No measure of correlation between intake and serum status was made


NDNS/DNSBA: Correlation Coefficients between Intake and Laboratory Level of the Nutrient

  • No attempt was made as part of LIDNS to determine the degree of correlation between intake of a nutrient and its level on testing

  • This was assessed in other nutritional surveys (see opposite)

  • Data presented for males (above) and females (below)

  • All data from NDNS except adults 19-64 yrs – vit. B12, from DNSBA

  • All correlations were significant (p<0.05) except for vit. D (4-18 yrs) and vit. B12 men 65+ yrs

  • The higher the correlation coefficient the more likely that a deficiency could be caused or treated by dietary factors alone


Overnutrition: Main Nutrients of Concern


LIDNS: Overnutrition Prevalence


LIDNS: Distribution of BMI - Men


LIDNS: Distribution of BMI - Women


LIDNS: Non-Milk Extrinsic Sugars Intake Percentage of Food Energy means and upper 2.5 percentiles

  • Population advised mean intakes for adults is 11% of food energy

  • Highest Mean Intakes were observed in:White men and boys and Black women and girlsWomen and girls in Scotland and boys in Northern Ireland


LIDNS: Dietary Sources of Non-Milk Extrinsic SugarsPercentage of total intake of NMES


LIDNS: Carbohydrate Provision by Fruit and Sugary DrinksMean percentage contribution to total carbohydrate intake

  • Sugary drinks = carbonated + not carbonated (approximately 75% are carbonated)

  • No other food groups show anything like the same degree of age-related variation in carbohydrate provision as fruit and nuts, and sugary drinks

  • Soft, sugary drinks occupy the “space” left by the lack of dietary fruit


NDNS: Carbohydrate Provision by Fruit and Sugary DrinksMean percentage contribution to total carbohydrate intake

  • Sugary drinks = carbonated + not carbonated (approximately 75% are carbonated)

  • No other food groups show anything like the same degree of age-related variation in carbohydrate provision as fruit and nuts, and sugary drinks

  • Age ranges for young people are slightly different to those of LIDNS


NDNS: Carbohydrate Provision by Fruit and Fizzy Sugary DrinksMean percentage contribution to total carbohydrate intake

  • Drink figures for 1.5 to 4.5 years are estimates

  • Approximately 15% of participants in NDNS were in receipt of benefits

  • Age-related change in carbohydrate source is similar to but less marked than LIDNS


NMES: Adverse Health Effects of High IntakesNon-Milk Extrinsic Sugars


LIDNS: Vitamin A Status – Plasma Retinol umol/lUpper 2.5% percentiles and Mean values

  • Levels >2.8 umol/l indicate excess and an increased risk of osteoporosis

  • They can be due to excessive intake (diet or supplements), obesity, type 2 diabetes, alcohol excess or renal failure [LIDNS causes are unclear]

  • Retinol supplements were taken by <13% of men and <22% of women

  • The highest regional upper 2.5 percentile levels were: Northern Irish men 4.0 umol/l and Scottish women 3.78 umol/l


LIDNS: Iron Status – Plasma Ferritin ug/lUpper 2.5% percentiles and Mean values

  • Plasma ferritin levels are lower in women due to menstrual losses of iron

  • Levels >300 ug/l can be due to chronic inflammation, infection, injury, liver disease, iron excess (diet or supplements) or haemochromatosis

  • Iron supplements were taken by <6% of men and <9% of women

  • In Wales the upper 2.5 percentiles were: men 3,338 ug/l, women 620 ug/l


Malnutrition: causes, significance and treatment

The Scientific Advisory Committee on Nutrition

reviewed the LIDNS and concluded… “ Identification of the pathways of causality linking deprivation, diet and health are critical to understanding of the clustering of diet-related disease and the development of targeted interventions designed to lessen inequalities in diet-related ill health in the UK.”

www.sacn.gov.uk


Socio-economic

Low income/food expenditure*

Food insecurity*

Lack of domestic facilities* (cooker, fridge, microwave etc)

Poor mobility/access to shops*

Poor educational attainment*

Poor ability or cooking skills*

Household type and number of dependents

Lone dweller or lone parent family*

Ethnic origin

Personal

Poor dental health*

Alcohol excess

Obesity*

Smoking*

Life stage – infant, menstruating woman, pregnant/lactating, elderly

Physical illness*

Lack of exercise*

Country or location of dwelling

Malnutrition: potential risk factors*More common in the low income group compared with the general population


LIDNS: Household Income and Nutrient Intake Difference in consumption between those with a net weekly equivalised income <£160 compared (lowest two quintiles) vs. >£160 (upper three quintiles)

  • All differences shown are significant p<0.05.

  • Males and females in the lower income group tended to consume less food

  • Few differences between the groups were significant (only limited data presented)

  • Differences: men - energy (-8%), sodium (-5.5%) and iron (-6.0%); women - none


What would Facilitate Dietary Change?Factors expressed by the 35% of men wanting to change

  • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <6%


What would Facilitate Dietary Change?Factors expressed by the 44% of women wanting to change

  • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <7%


LIDNS: Weekly Expenditure on Food and Drink£s per capita and household type

  • There would appear to be a saving of ~10% if not dwelling alone

  • Older people did not spend less than younger people but drank less alcohol


LIDNS: Transport and Food Intake – AdultsDifference in consumption between those who do not use a private car for food shopping and those who do

* Differences significant p<0.05, for men and women ** Differences significant p<0.05, for women only


LIDNS: Transport and Nutrient Intake – AdultsDifference in consumption between those who do not use a private car for food shopping and those who do

All differences are significant p<0.05


Food Security/Insecurity

Defined as:

  • Security “Access by all people at all times to enough food for an active and healthy life”

  • Insecurity “Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways”

    Assessed by:

    A series of questions to determine current and past availability of food, whether the person is regularly able to obtain the food that they need


Food Security and Nutrient Intake:% difference in intake if moderately/severely food insecure compared with food secure

  • Only limited data on men presented

  • All differences in women were significant p <0.031

  • Food insecurity in women approximately doubled the risk of inadequate intake (<LRNI) for iron, zinc, magnesium and potassium


LIDNS: Household Amenitiespercentage of participating households with adequate facilities


Educational Attainment and Nutrient Intake:% less intake if education < 5 GCSE grades A-C or equivalent

  • In males energy difference significant p <0.031; all other nutrients p <0.004

  • In females all nutrients difference significant p <0.009


What would Facilitate Dietary Change?Factors expressed by the 35% of men wanting to change

  • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <6%


What would Facilitate Dietary Change?Factors expressed by the 44% of women wanting to change

  • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <7%


Cooking Skills and Nutrient IntakePercentage difference in intakes of those living with a Main Food Provider with Less Developed Skills compared with a person with Better Skills

  • Less Skilled = would need help cooking a main dish from basic ingredients

  • Differences were statistically significant p<0.05 and adjusted for sex of Main Food Provider and age of the respondent


Household Type and Protein Intake g/day Ages 19 and over, mean and lower 2.5 percentiles

  • Being an adult in a house with children does not appear to increase the risk of poor protein intake for adults


Household Type and cis n-3 EFAs Intake g/dayAges 19 and over mean and lower 2.5 percentiles

  • Being an adult in a house with children does not appear to increase the risk of poor n-3 Essential Fatty Acid intake for adults


Ethnic group of LIDNS population


Ethnic Group and Protein Intake g/dayAges 19 and over mean and lower 2.5 percentiles

  • For men intakes <45g/day are unlikely to be adequate

  • For women intakes <35 g/day are unlikely to be adequate

  • Such diets are also likely be low in iron, zinc, copper and some B vitamins


Other National Surveys: Dietary Intake

Other similar National Surveys have been conducted over the last 25 years in Britain and include (date of publication)

  • DNSBA (1990)The Diet and Nutritional Survey of British Adults ages 16 to 64 yrs looked at the influence of social class on nutrient intake

  • NDNS (1995 - 2004)Four National Diet and Nutrition Surveys looked at nutrient intake and, sometimes, status of those in receipt of benefits compared with those who were not


Social Class and Nutrient Intake: Men 16-64 yrs% difference between averages from lowest social class. DNSBA

  • Data presented on adults aged 16=64 yrs n=1070, who participated in the Dietary and Nutritional Survey of British Adults

  • Intakes were from dietary sources only and adjusted for energy intake


Social Class and Nutrient Intake: Women 16-64 yrs% difference between averages from lowest social class. DNSBA

  • Data presented on adults aged 16=64 yrs n=1096, who participated in the Dietary and Nutritional Survey of British Adults

  • Intakes were from dietary sources only and adjusted for energy intake


Protein Intake and Benefit StatusMean Intakes g/day LIDNS and NDNS data


NDNS Benefit Status and Nutrient IntakePercentage of Females 19-64yrs with intake <Lower Reference Nutrient Intake*

  • Data from National Diet and Nutrition Survey British Adults. TSO 2003/4

  • Intakes <LRNI are likely to be adequate for <2.5% of the population


NDNS Benefit Status and Nutrient IntakePercentage of Females 19-64yrs with intake <Lower Reference Nutrient Intake*

  • Data from National Diet and Nutrition Survey British Adults. TSO 2003/4

  • Intakes <LRNI are likely to be adequate for <2.5% of the population


Income and Nutrient Intake: Men age>65 yrs% difference from lowest income group. NDNS data (1993/4)

  • Data presented on free-living elderly n=491

  • All nutrients were deficient in >10% of subjects

  • Dietary vitamin D provides ~10% of requirement only


Income and Nutrient Intake: Women age>65 yrs% difference from lowest income group. NDNS data (1993/4)

  • Data presented on free-living elderly n=491

  • All nutrients were deficient in >10% of subjects

  • Dietary vitamin D provides ~10% of requirement only


Stated Influences on Food Choice: Men age>19 yrsWhen asked for the most Important Influence when choosing food

  • Other options – taste, special dietary requirements or slimming, habit and convenience were each rated, on average, at <12%


Stated Influences on Food Choice: Women age >19 yrs When asked for the most Important Influence when choosing food

  • Other options – taste, special dietary requirements or slimming, convenience and habit were each rated, on average, at <7%


Potential Effect of Risk Factors on Undernutrition


Socio-economic

Low income/food expenditure*

Food insecurity*

Lack of domestic facilities* (cooker, fridge, microwave etc)

Poor mobility/access to shops*

Poor educational attainment*

Poor ability or cooking skills*

Household type and number of dependents

Lone dweller or lone parent family*

Ethnic origin

Personal

Poor dental health*

Alcohol excess

Obesity*

Smoking*

Life stage – infant, menstruating woman, pregnant/lactating, elderly

Physical illness*

Lack of exercise*

Country or location of dwelling

Malnutrition: potential risk factors*More common in the low income group compared with the general population


Dental Health and Nutrient Intake:% difference in intake if edentate compared with dentate

  • NSP Non-starch polysaccharides; NMES Non-milk extrinsic sugars

  • No data on differences in intake of potassium, magnesium or folate were presented but are likely to be similar to but less than those for vitamin C

  • Data on younger age groups were not presented


DNSBA: Employment Status and Alcohol consumptionpercentage of energy intake from alcohol

  • Men % consuming alcohol: working 83%, unemployed 65%, economically inactive 64%

  • Women % consuming alcohol: working 72%, unemployed 58%, economically inactive 54%


NDNS/LIDNS: Benefit Status and Alcohol consumptionpercentage of energy intake from alcohol

  • NDNS Men: % consuming alcohol; no benefits 84%, benefits 59%

  • NDNS Women: % consuming alcohol; no benefits 71%, benefits 55%

  • LIDNS % consuming alcohol; Men 49%, Women 39%

  • Methodology: LIDNS – 4 day (vs NDNS 7 day) diary may skew data


Prevalence of High Alcohol Consumption>21/14 units/week NDNS Data


Prevalence of High Alcohol Consumption>21/14 units/week LIDNS Data


Other National Surveys: Dietary Intake

Other National Surveys have been conducted over the last 25 years in

Britain and include (date of publication)

  • DNSBA (1990)The Diet and Nutritional Survey of British Adults looked at the influence of social class on nutrient intake

  • NDNS (1995 - 2004)Four National Diet and Nutrition Surveys looked at nutrient intake and, sometimes, status of those in receipt of benefits compared with those who were not


Daily Alcohol Intake and Nutritional Status: DNSBA% difference in status compared with non/low drinkers

  • Intake determined from 7 day diary of adults aged 16 to 64 years

  • Caution, no adjustment for age, health, diet or supplements was made

  • Vitamins C and D not measured. Heavy drinking women n = 14.


Daily Alcohol Intake and Nutritional Status: NDNS 65+% difference in status compared with non/low drinkers

  • Intake determined from 4 day diary

  • Caution, no adjustment for age, health, diet or supplements was made

  • Non-drinkers were more likely to be older and have abnormal liver test


Prevalence of Smoking: LIDNS Data

  • Smoking prevalence in the general adult population (2008) males 24%, females 20%


Smoking and Nutritional Status: DNSBA% difference in status compared with non smokers

  • Smoking status determined by interview of adults aged 16 to 64 years

  • Caution, no adjustment for age, health, diet or supplements was made

  • Vitamins C and D not measured.


Smoking and Nutritional Status: NDNS 65+% difference in status compared with non smokers

  • Smoking status determined by interview of adults aged > 65 years

  • Caution, no adjustment for age, health, diet or supplements was made

  • Heavy smoking men n = 28; women n = 13


LIDNS: Life Stage and Iron Intake Percentage of those with intakes below the LRNI

  • Intakes from food sources only were compared with Lower Reference Nutrient Intakes for the relevant age group and sex

  • “Lower Reference Nutrient Intake – an amount of the nutrient that is enough for only the few people in a group who have low needs”. ~2.5% of the population

  • Prevalence of low intake may be slightly overestimated by the methods used


LIDNS: Life Stage and Iron Status Percentage of those with low serum ferritin

  • Serum ferritin low: children < 15ug/l, men <20ug/l, women <15 ug/l

  • Ferritin levels may be increased by chronic inflammation and heavy smoking both common in the LIDNS population


LIDNS: Health Status - Limiting/Not-Limiting Illness


LIDNS: Elevated Serum C-Reactive ProteinElevated CRP is a sensitive marker for inflammation and chronic illness


LIDNS: Location and Elevated CRPCRP = C-Reactive Protein

  • Regional data on young people not presented

  • An elevated C-Reactive protein is a marker of current inflammation and thus “illness” as well as signifying an increased cardiovascular risk.


LIDNS: Exercise Levels in Children and Adults


Factors Associated with Physical ActivityNDNS data, adults 19-64 yrs – those in and not in receipt of benefits* p<0.05; **p<0.01; NS Not Significant

  • The causal relationship between these variables is not clear

  • Employment and income appear to be the best determinants of physical activity


LIDNS: Location and Anaemia

  • Regional data on young people <19 yrs not presented

  • Anaemia defined as Hb <13.0g/dl (men) and <12.0 g/dl (women)


LIDNS: Location and Iron Deficiency% with low serum ferritin

  • Data presented relates to adults only


LIDNS: Location and Fruit and Vegetable IntakeAdults: Portions per day

  • 5-a-day was achieved in England – 10%, Scotland – 4%, Wales – 6%, N. Ireland – 8%

  • Low intakes of fruit and vegetables are likely to cause a poor status of vitamin C, folate and reduced iron absorption


LIDNS: Location and Fruit and Vegetable IntakeChildren : Portions per day

  • Only 1% of boys and 4% of girls achieved 5-a-day

  • A more appropriate target for most young people is 3 to 4 portions per day


LIDNS: Location and Folate Deficiency

  • Regional data on young people not presented

  • Folate deficiency defined as Red Cell Folate <350 nmol/l


LIDNS: Location and Vitamin B12 Deficiency

  • Regional data on young people not presented

  • Deficiency defined as Serum <118 pmol/l


LIDNS: Location and Vitamin C Deficiency

  • Regional data on young people not presented

  • Deficiency defined as Plasma vitamin C <11umol/l


LIDNS: Location and Vitamin D DeficiencyPrevalence of plasma 25-hydroxy vitamin D <25 nmol/l

  • Regional data on young people not presented

  • National prevalence of deficiency: boys 6%, girls 20%


Potential Effect of Risk Factors on Undernutrition


Potential Effect of Risk Factors on Overnutrition


LIDNS: Summary of Problems

  • Moderate undernutrition (vitamins C, D and folate ) is more common in those who are in receipt of benefits in the UK

  • Moderate overnutrition (obesity and possibly iron) is also more common

  • The causes of poorer nutritional state are many and include poor dietary intake, lack of education and cooking skills, smoking, alcohol, chronic illness and poor dental health

  • Lack of money and poor food access are rarely issues

  • The impact of malnutrition on health and the social divide was not assessed as part of LIDNS but the effects of malnutrition on children and pregnant women are likely to be lasting

  • Any solution will need to involve many professionals as well as motivating the individuals/families concerned


LIDNS: Overnutrition Dietary & Non-Dietary Solutions

The commonest problems of overnutrition are obesity, dietary sodium excess and biochemical excesses of retinol and iron. Solutions require:

  • Personal Change and Responsibility Dietary change to limit obesity especially in children, the immobile or unwellPersonal measures to avoid an excess of alcohol and sugarIncreased daily exercise, sport and, for children, walking to schoolAvoidance of excessive or inappropriate use of nutritional supplements

  • Education ServicesTo improve general educational levelTo teach the basis of a healthy diet, limiting intake of fats, sugar and alcoholTo instruct on basic cooking skills and preparation of balanced meals To inform of the likely consequences of overnutrition across the age-groups

  • Health ServicesMedical and dietetic help to identify and treat: obesity with health problems, those with hypertension, liver or renal disease with micronutrient excess Medical help for those with mental or alcohol problemsDental services to improve oral health and prevent loss of dental function


LIDNS: Undernutrition - Non-Dietary Solutions

The problems of undernutrition, low protein-energy intake and micronutrient deficiencies, will involve action by professionals to reduce the risks

  • Education ServicesTo improve general educational levelTo teach the basics of a healthy, nutritious and economic dietTo instruct on basic cooking skills, preservation of nutrients, kitchen thriftTo inform of the likely consequences of a poor diet across the age-groups

  • Health ServicesDental services to improve oral health and prevent loss of dental function Medical services to identify and treat significant undernutrition and those with illnesses likely to be caused or worsened by undernutritionMedical help for those who wish to quit smokingMedical help for those with mental or alcohol problems

  • Other Services Social services to support those most at risk of poor nutrient intake Local services to ensure adequate supply of and access to nutritious foods Government policies to discourage alcohol, smoking and other risk-taking behaviour and encourage and facilitate a healthy diet and lifestyle


LIDNS: Undernutrition – Diet and Lifestyle Solutions

The commonest problems of undernutrition, anaemia, vitamins C, D and folate deficiencies would be often be lessened by diet and lifestyle changes

  • Personal Dietary ChangesEmphasising foods that are nutritious, inexpensive, widely-available and easily prepared: eggstinned oily fish (sardines and mackerel)potatoes with their skins dark green leafy vegetables – cabbage and spinach apples, pears and oranges

  • Personal Lifestyle ChangesLimiting alcohol and stopping smoking Increased sun-exposure and more physical activity Growing of own vegetables and fruit and their preservationAppropriate use of nutritional supplements

  • Other ChangesMeasures that reduce social isolation and improve a sense of community e.g. allotments, food cooperatives, family and community eating


LIDNS: Economic Nutritious Food Diet

  • Eggs for breakfast, omlettes, spinach egg and cheese

  • Jacket potatoes, wedgies, boiled potatoes, Bubble and Squeak

  • Roast meat with cabbage, cabbage and potato soup, spinach added to meat curry

  • Sardine (not tuna) in pasta bake, fish curry, add to jacket potato

  • Fruit as a desert, stewed cooking apples/apple pie or crumble

    Other Key Foods

  • Traditional roast – left over for curry, cold cuts; liver once per month

  • Abundant dairy foods – milk, cheese and custard; low-fat if obese

  • Wholemeal bread, Hovis, quality breakfast cereals

  • Vegetarian proteins, peanuts, chickpeas, beans – in casseroles

  • Peas and beans – fresh and frozen

  • Healthy fats – margarine, butter and rapeseed oil

  • Variety of fruits and vegetables – seasonal, local or home-grown


LIDNS: Economic Nutritious Diet – Other Foods


Nutrient Content of Starchy FoodsPercentage of daily requirement for a woman provided by 120g portion


White and Brown Breads – Nutrient ContentPercentage of Reference Nutrient Intake for women age 19 – 50 years from a 200 kcl servingData from McCance and Widdowson 6th Edition


LIDNS/NDNS: Current Consumption of Nutritious Foodsg/week. * Children in LIDNS age 2-18 yrs. Figures in [ ] are estimates


LIDNS/NDNS: Current Consumption of Nutritious Foods g/week. * Children in LIDNS age 2-18 yrs. Figures in [ ] are estimates

  • * Children in LIDNS are aged 2-18 yrs

  • Figures in [ ] are estimates


Current and Suggested Intakes of Nutritious FoodsLIDNS/NDNS: Adults 19-64 yrs Mean consumption including non-consumers


Nutrient Provision by Nutritious Foods IIComposition of Foods McCance and Widdowson 5th Edition


Nutrient Provision by Nutritious Foods IComposition of Foods McCance and Widdowson 5th Edition


LIDNS: Effect of Dietary Changes on Nutrient IntakeEstimates assume 100% compliance, 20% reduction in existing food intake

  • There would also be a small decline in sodium intake, men – 11%, women – 6%

  • Oily fish intake (and long chain n-3 EFAs) would increase several hundred percent


LIDNS: Effect of Dietary Changes on Nutrient IntakeEstimates assume 50% of adult target, 10% reduction in existing food intake

  • There would also be a small decline in sodium intake, men – 5%, women – 3%

  • Oily fish intake (and long chain n-3 EFAs) would increase several hundred percent


LIDNS: Effect of Dietary Changes on Nutrient IntakeEstimates assume 50% of adult target, 10% reduction in existing food intake

  • There would also be a small decline in sodium intake, boys – 4%, girls – 3.5%

  • Oily fish intake (and long chain n-3 EFAs) would increase several hundred percent


LIDNS: Current Education Attainment and Food ConsumptionAdults not in full-time education, grams/day

  • Education “More” = GCSE grades A-C or above, “Less” = lower or no qualifications

  • P = significance level, linear regression analysis adjusted for age


Risk Factors

Rented 3 Bed-roomed terraced house, no garden

7 People in house

Urban-dwelling South London

Father working class (skilled)

Father smoked and sometimes drank heavily

Father sometimes away for prolonged periods

No car

Limited facilities – no fridge or microwave

Parents poor dental health – sugar in tea

Case Study: Ethnic white family


Risk Factors

Rented 3 Bed-roomed terraced house, no garden

7 People in house

Urban-dwelling South London

Father working class (skilled)

Father smoked and sometimes drank heavily

Father sometimes away for prolonged periods

No car

Limited facilities – no fridge or microwave

Parents poor dental health – sugar in tea

Outcome:

3 boys >6’, athletic, employeddaughter tall but overweight

All children well-educated (2/4 at grammar school)

2 Boys long lived 91 and 83 yrs2 died – obesity & alcohol related

Case Study: Ethnic white family


Risk Factors

Rented 3 Bed-roomed terraced house, no garden

7 People in house

Urban-dwelling South London

Father working class (skilled)

Father smoked and sometimes drank heavily

Father sometimes away for prolonged periods

No car

Limited facilities – no fridge or microwave

Parents poor dental health – sugar in tea

Outcome:

3 boys >6’, athletic, employeddaughter tall but overweight

All children well-educated (2/4 at grammar school)

2 Boys long lived 91 and 83 yrs2 died – obesity & alcohol related

Protective Factors

Father usually employed

Mother (82) well-educated

M-grandmother (90) lived in house

Abundant food shops nearby

Traditional meals: meat, fish, milk eggs, potatoes, fresh fruit & veg++

Public nutrition education

Children received cod liver oil

Case Study: Ethnic white family


LIDNS: Doctors role in lessening malnutrition“All doctors should be able to diagnose nutritional deficiencies” RCP 2002

Doctors have a unique role in managing malnutrition

  • Identify obesity: advise children, women before and during pregnancy, those with weight-related disease

  • Identify those with significant nutritional needs: children-growing or developing poorly anaemic children, women and the elderly pregnant, deprived or at-risk women underweight adults – BMI <18.5kg/m2 or unintentional weight loss chronic illness – liver, kidney disease, osteoporosis, depression alcohol excess at any age anyone with symptoms or signs of nutritional deficiency

  • Assess risk factors for undernutrition – poor intake, alcohol, smoking, illness, medical drugs, poor sun exposure

  • Investigate – tests for anaemia, vitamin and mineral status, x-Rays

  • Treat – diet, supplements, disease management, lifestyle change

  • Measures to reduce smoking, alcohol excess and inactivity

  • Measures to improve local and national food provision


Symptoms and Signs of Nutritional DeficiencyDoctors should recognise that symptoms usually precede signs in deficiency


Thank you for your attention.

I would welcome you comments. Contact me at dr.stewart@stewartnutrition.co.uk


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