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

prepared 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

• SexMale 40% Female 60%

• Ages2-10 yrs 19% 11-18 yrs 14%19-34 yrs 17% 35-49 yrs 17%50-64 yrs 12% 65+ yrs 21%

• Marital StatusMarried 28% Separated 6%Divorced 19% Widowed 18%Never married, single 29%

• 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)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

England Scotland Wales N.Ireland Total

SuburbanUrbanRural

• England n = 2433. Scotland n = 392, Wales n = 437, N. Ireland n = 466• Total n = 3728

LIDNS: Ethnic Group

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

White Black Asian Mixed Other

MaleFemale

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

LIDNS: Health Status –Limiting/Not-Limiting Illness

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2-10yr 11-18yr 19-34yr 35-49yr 50-64yr 65+yr

Male Not-Limiting

Male Limiting

Female Not-Limiting

Female Limiting

LIDNS: Sources of Income

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Reg Job Occ Job Inc SupPens Cr

Ch Benf StatePens

Dis LivAllow

Ch TaxCredit

IncapBenf

CareAllow

JobSeekers

Allow

Other

Male

Female

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

Undernutrition: Main Nutrients of Concern

Nutrient Potential Adverse Health EffectsProtein-energy Poor growth, underweight, poor immunity

Iron Anaemia, fatigue, poor school performance

Folate Poor pregnancy outcome, depression

Vitamin B12 Fatigue and cognitive impairment

Vitamin C Elderly - increased stroke risk, rare scurvy

Vitamin D Poor bone health, increased mortality

Vitamin A – infants Poor immunity and growth

Potassium High blood pressure, muscle fatigue

Iodine Possibly poor child development

Essential Fatty Acids Mental illness, vascular/inflammatory dis.

LIDNS: Undernutrition Prevalence - Macronutrients

Nutrient Prevalence of Deficiency from dietary assessment, test or anthropometry

Status compared with NDNS (normal) population

Children Adults ElderlyMale Female Male Female Male Female

Energy % low intake not presented; rarely low Similar

Protein % low intake not presented; occasionally low Similar; lower in some sub-groups

Anaemia 8% 2% 2% 12% 20% 11% Similar but higher in young and elderly males

Underweight BMI<18.5kg/m2

Not assessed 1% 3% 3% 1% Similar

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

8%

9%

10%

11%

12%

13%

14%

LIDNS19-34

yrs

NDNS19-34

yrs

LIDNS35-49

yrs

NDNS35-49

yrs

LIDNS50-64

yrs

NDNS50-64

yrs

LIDNS65+ yrs

NDNS65+ yrs

Men

Women

• 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)

0

0.5

1

1.5

2

2.5

3

3.5

4

Males 2-18 yrs

Females2-18 yrs

Males 19-64 yrs

Females19-64 yrs

Males 65+ yrs

Females65+ yrs

Fruit

Vegetables

Total

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

11-14yr 15-18yr 19-24yr 25-34yr 35-49yr 50-64yr 65-74yr 75-84yr 85+yr

Male

Female

• 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

Nutrient Prevalence of Deficiency

by laboratory test or *dietary assessment

Status compared with NDNS (normal) populationChildren Adults Elderly

Male Female Male Female Male Female

Iron 1% 10% 4% 10% 4% 11% Similar

Folate 17% 21% 12% 13% 10% 13% More common

Vitamin B12 1% 2% 2% 5% 10% 5% Similar

Vitamin C 12% 3% 25% 16% 28% 16% More common

Vitamin D 6% 20% 22% 18% 14% 14% More common

Vitamin A ~30% ~5% ~2% ~1% ~3% <1% Similar

Potassium* 10% 10% 14% 34% 28% 37% Similar

Magnesium* 15% 21% 25% 26% 36% 26% Similar

Iodine* 5% 7% 5% 11% 3% 6% A little worse

LIDNS: Prevalence of Folate Deficiency IRed Cell Folate

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8-10 yr 11-18 yr 19-34 yr 35-49 yr 50-64 yr 65+ yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8-10 yr 11-18 yr 19-34 yr 35-49 yr 50-64 yr 65+ yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8-10 yr 11-18 yr 19-34 yr 35-49 yr 50-64 yr 65+ yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8-10 yr 11-18 yr 19-34 yr 35-49 yr 50-64 yr 65+ yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

8-10 yr 11-18 yr 19-34 yr 35-49 yr 50-64 yr 65+ yr

Male

Female

• 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

0

0.2

0.4

0.6

0.8

Folate Vit. B12 Vit. C Vit. D

4-18 yrs

19-64 yrs

65+ yrs

0

0.2

0.4

0.6

0.8

Folate Vit. B12 Vit. C Vit. D

4-18 yrs

19-64 yrs

65+ yrs

Overnutrition: Main Nutrients of Concern

Nutrient Potential Adverse Health EffectsProtein-energy Obesity, vascular disease, type 2 diabetes

and some cancers

Saturated fats Vascular disease especially if other risk factors – obesity, smoking, low birth weight

NMES – non-milk extrinsic sugars; sucrose & fructose

Dental caries, obesity, type 2 diabetes and fatty liver

Sodium Hypertension, fluid retention, heart failure and osteoporosis

Vitamin A Osteoporosis, birth defects and headache

Micronutrients from diet or supplements

Cancer, neurological and other adverse effects; elderly and ill are at increased risk

LIDNS: Overnutrition Prevalence

Nutritional Parameter/ Nutrient

Prevalence of Nutrient Excess from anthropometry, dietary assessment, test

Status compared with NDNS (normal) population

Children Adults Elderly

Male Female Male Female Male Female

Obesity

BMI>30kg/m2

Not assessed 26% 31% 29% 35% More common

Saturated Fat

% of food energy

14.2% 14% 13.4% 13.4% 14.4% 14.5% Similar

Sugar NMES

% of food energy

17.1% 16.5% 15.1% 13.3% 13.1% 12.1% Higher especially in some

Sodium from food

g/day

2.59 2.3 3.0 2.15 2.7 2.0 Similar

Vitamin A

Pl. Retinol <2.8umol/l

None ~10% ~5% ~15% ~10% Similar

IronPl.Ferritin >300 nmol/l

None ~5% ~1% ~5% ~2.5% More common

LIDNS: Distribution of BMI - Men

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

19-34 yrs 35-49 yrs 50-64 yrs 65+yrs

BMI <18.5

BMI >18.5, <25.0kg/m2

BMI >25, <30kg/m2

BMI >30, <40.0kg/m2

BMI >40kg/m2

LIDNS: Distribution of BMI - Women

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

19-34 yrs 35-49 yrs 50-64 yrs 65+yrs

BMI <18.5

BMI >18.5, <25.0kg/m2

BMI >25, <30kg/m2

BMI >30, <40.0kg/m2

BMI >40kg/m2

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

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

MenMean

WomenMean

MenUpper2.5 pc

WomenUpper2.5 pc

2-10 yrs

11-18 yrs

19-34 yrs

35-49 yrs

50-64 yrs

65+ yrs

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

Boys 2-18 yrs

Girls 2-18 yrs

Men 19-64 yrs

Women 19-64 yrs

Men 65+ yrs

Women65+ yrs

Cereals andCereal Products

Table Sugar(sucrose)

Chocolate andConfectionary

Carbonated Soft Drinks

Other Drinks

AlcoholicDrinks

LIDNS: Carbohydrate Provision by Fruit and Sugary Drinks

Mean percentage contribution to total carbohydrate intake

0%

2%

4%

6%

8%

10%

12%

14%

16%

Males Fruitand Nuts

MalesSugaryDrinks

FemalesFruit and

Nuts

FemalesSugaryDrinks

2-10 yrs

11-18 yrs

19-34 yrs

35-49 yrs

50-64 yrs

65+ yrs

• 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 Drinks

Mean percentage contribution to total carbohydrate intake

0%

2%

4%

6%

8%

10%

12%

14%

16%

Males Fruitand Nuts

MalesSugaryDrinks

FemalesFruit and

Nuts

FemalesSugaryDrinks

1.5-4.5 yrs

4-10 yrs

11-18 yrs

19-34 yrs

35-49 yrs

50-64 yrs

65+ yrs

• 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 Drinks

Mean percentage contribution to total carbohydrate intake

0%

2%

4%

6%

8%

10%

12%

Males Fruit and

Nuts

MalesCarbon.SugaryDrinks

FemalesFruit and

Nuts

FemalesCarbon.SugaryDrinks

1.5-4.5 yrs

4-10 yrs

11-18 yrs

19-34 yrs

35-49 yrs

50-64 yrs

65+ yrs

• 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

Health Effect Likely Health Consequences

Short-term Long-termDental Caries Lower intake of fruit and

vegetablesPoorer folate and vitamin C status

Obesity Reduced mobility and increased morbidity

Poorer vitamin D status; shorter life expectancy

Displaces Healthy Foods

Less vegetables and fruits; more constipation and appendicitis

Increased risks of cancer and vascular disease

High childhood intake may increase adult alcohol intake

More nutritional deficiencies

More social dependence, poor mental and physical health

Acne Depression, social isolation

Increased suicide risk

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

0

1

2

3

4

19-34 yr 35-49 yr 50-64 yr 65+ yr

Men - mean Women - mean

• 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

0

1

2

3

4

19-34 yr 35-49 yr 50-64 yr 65+ yr

Men - upper 2.5 pc Women - upper 2.5 pc

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

0

100

200

300

19-34 yr 35-49 yr 50-64 yr 65+ yr

Men - mean Women - mean

• 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

0

300

600

900

19-34 yr 35-49 yr 50-64 yr 65+ yr

Men - upper 2.5 pc Women - upper 2.5 pc

Malnutrition: causes, significance and treatment

The Scientific Advisory Committee on Nutritionreviewed 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

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

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

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)

-30%

-20%

-10%

0%

10%

20%

30%

Energy Protein Folate Vit. B12 Potassium Sodium

Boys

Girls

• 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

0%

10%

20%

30%

40%

50%

60%

FinancialFactors

Attitude andSkills

Willpowerand Self-discipline

BetterHealth or

Teeth

Other notListed

19-34 yrs35-49 yrs50-64 yrs65+yrs

• 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

0%

10%

20%

30%

40%

50%

60%

FinancialFactors

Attitude andSkills

Willpowerand Self-discipline

BetterHealth or

Teeth

Other notListed

19-34 yrs35-49 yrs50-64 yrs65+yrs

• 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

0

10

20

30

40

50

1 Adult<65yr

1 Adult>65yr

2 Adults<65yr

2 Adults>65 yr

Men

Women

• 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

-30%

-20%-10%

0%

10%

20%30%

40%

50%60%

70%

Milk andCream*

Cheese FreshVeg**

FreshFruit**

Potatoes- not

Chips

PastaRice

Pizza*

Alcohol+Low

Alcohol

Men

Women

* 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

-30%

-20%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

Protein Riboflavin Vitamin C Folate Potassium

Men

Women

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

-35%

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

Protein Zinc Folate Iron Magnesium Thiamin

Males 19+ yrsFemales 19+ yrs

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Fridge Freezer Microwave Hob Oven FoodStorage

England Scotland Wales N. Ireland

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

-25%

-20%

-15%

-10%

-5%

0%

Energy Protein Folate Potassium Magnes'm Copper Zinc

Males

Females

• 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

0%

10%

20%

30%

40%

50%

60%

FinancialFactors

Attitude andSkills

Willpowerand Self-discipline

BetterHealth or

Teeth

Other notListed

19-34 yrs35-49 yrs50-64 yrs65+yrs

• 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

0%

10%

20%

30%

40%

50%

60%

FinancialFactors

Attitude andSkills

Willpowerand Self-discipline

BetterHealth or

Teeth

Other notListed

19-34 yrs35-49 yrs50-64 yrs65+yrs

• 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

-15%

-10%

-5%

0%

5%

10%

15%

20%

Protein NMES Folate Zinc

Men

Women

• 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

0102030405060708090

100

MenMean

WomenMean

MenLower2.5 pc

WomenLower2.5 pc

1 Adult

1 Retired Adult

2 Adults

2 Retired Adults

1 Adult, 1+ child

2+ Adults, 1+child

• 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/day Ages 19 and over mean and lower 2.5 percentiles

0

0.5

1

1.5

2

2.5

MenMean

WomenMean

MenLower 2.5 pc

womenLower 2.5 pc

1 Adult

1 Retired Adult

2 Adults

2 Retired Adults

1 Adult, 1+ child

2+ Adults, 1+child

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

White Black Asian Mixed Other

Male

Female

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

0102030405060708090

100

Men Mean

WomenMean

Men Lower2.5 pc

WomenLower 2.5

pc

White

Black

Asian

Other

• 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

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

Energy Vit. C Folate Vit. D Iron Zinc

S. Class IV & V

S. Class III manual

S. Class III non-manual

S. Class I & II

• 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

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

Energy Vit. C Folate Vit. D Iron Zinc

S. Class IV & V

S. Class III manual

S. Class III non-manual

S. Class I & II

• 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

0

10

20

30

40

50

60

70

80

90

100

AdultMen

AdultWomen

ElderlyMen

ElderlyWomen

LIDNS

NDNS Benefits

NDNS No Benefits

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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I

Men No Benefits n=724

Men Benefits n=110

• 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*

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I

Women No Benefits n=741

Women Benefits n=150

• 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)

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

Vit. C Folate Vit. D Iron Zinc

<£4,000

£4k to <£6k

£6k to <£10k

£10k or more

• 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)

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

200%

Vit. C Folate Vit. D Iron Zinc

<£4,000

£4k to <£6k

£6k to <£10k

£10k or more

• 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

0%

10%

20%

30%

40%

50%

60%

Price andValue

Quality andFreshness

Healthy Diet

Acceptabilityto Others

19-34 yrs

35-49 yrs

50-64 yrs

65+yrs

• 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

0%

10%

20%

30%

40%

50%

60%

Price andValue

Quality andFreshness

Healthy Diet

Acceptabilityto Others

19-34 yrs

35-49 yrs

50-64 yrs

65+yrs

• 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 Factor Nutrients Likely to be Inadequate

Low income or social class Little effect on nutrient intake except vit. C

Food insecurity Many nutrients: women – mainly iron and folate as well as protein and zinc

Lack of domestic facilities Possibly some fresh and frozen foods

Lack of access to shops Low fresh fruit, vegetables, meat and fish

Poor educational attainment Adults – folate, men – protein and minerals

Poor cooking skills Adults - protein; women - folate and zinc

Household type and number of dependents

Living alone – 10% higher food costs; many dependents may increase undernutrition risk

Lone parent family/dweller Protein, EFAs and some other nutrients

Ethnicity Asian/Blacks - iron, protein, vit. D in some

Location – country Scottish women - vit. D, Welsh men - vit. C, N. Irish - folate, N. Irish men - vit B12

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

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

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

-35.00%

-25.00%

-15.00%

-5.00%

5.00%

15.00%

25.00%

35.00%

Energy Protein NSP NMES Vitamin C Iron

Males 50-64yrs

Males 65+ yrs

Females 50-64 yrs

Females 65+ yrs

• 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

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

Working Unemployed EconomicallyInactive

Men - All

Men - Consumers

Women - All

Women - Consumers

• 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

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%18.00%20.00%

NDNS No Benefits

NDNS Benefits

LIDNS

Men - All

Men - Consumers

Women - All

Women - Consumers

• 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

0%

10%

20%

30%

40%

50%

60%

15-18yr 19-24yr 25-34yr 35-49yr 50-64yr 65-74yr 75-84yr 85+yr

Male >21 units

Female >14units

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

0%

10%

20%

30%

40%

50%

60%

19-34yr 35-49yr 50-64yr 65+yr

Male >21units

Female >14 units

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

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

PlasmaVitamin C

PlasmaVitamin D

Red CellFolate

SerumVitamin B12

Males <168gMales 168-399gMales 400+gFemales <112gFemales 112-279gFemales 280+g

• 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

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

PlasmaVitamin C

PlasmaVitamin D

Red CellFolate

SerumVitamin B12

Males <10gMales 10-20gMales =/>20gFemales <10gFemales =/>10g

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

19-34yr 35-49yr 50-64yr 65+yr Total

Male Smokers

Female Smokers

Male Ex-smokers

Female Ex-smokers

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

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

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

PlasmaVitamin C

PlasmaVitamin D

Red CellFolate

SerumVitamin B12

Males <20 cigs/dayMales 20+ cigs/dayFemales <20 cigs/dayFemales 20+ cigs/day

• 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

-30.00%

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

PlasmaVitamin C

PlasmaVitamin D

Red CellFolate

SerumVitamin B12

Males <20 cigs/dayMales 20+ cigs/dayFemales <20 cigs/dayFemales 20+ cigs/day

• 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

0%

10%

20%

30%

40%

50%

60%

2-10yrs 11-18yrs

19-49yrs

50-64yrs

65+ yrs

Females

0%

10%

20%

30%

40%

50%

60%

2-10yrs

11-18yrs

19-50yrs

50-64yrs

65+ yrs

Males

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

0%

10%

20%

30%

40%

50%

60%

8-10yrs

11-18yrs

19-49yrs

50-64yrs

65+ yrs

Females

0%

10%

20%

30%

40%

50%

60%

8-10yrs

11-18yrs

19-50yrs

50-64yrs

65+ yrs

Males

LIDNS: Health Status - Limiting/Not-Limiting Illness

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2-10yr 11-18yr 19-34yr 35-49yr 50-64yr 65+yr

Male Not-Limiting

Male Limiting

Female Not-Limiting

Female Limiting

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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

11-18 yrs 19-34 yrs 35-49 yrs 50-64 yrs 65+ yrs 65+yr

Men

Women

LIDNS: Location and Elevated CRPCRP = C-Reactive Protein

0%

10%

20%

30%

40%

50%

60%

70%

80%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LIDNSBoys

LIDNSGirls

LIDNSMen

NDNS Men LIDNSWomen

NDNSWomen

Low

Medium

High

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

Factor Significance Level

Men Women

Age ** *

Energy Intake ** NS

Employment Status ** **

Gross household income ** *

Energy from protein * NS

Energy from Alcohol NS **

Social Class of household reference person ** *

• 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

0%

5%

10%

15%

20%

25%

30%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• 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

0%

5%

10%

15%

20%

25%

30%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• Data presented relates to adults only

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

0

0.5

1

1.5

2

2.5

3

3.5

4

England Scotland Wales N. Ireland Total

Men

Women

• 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

0

0.5

1

1.5

2

2.5

3

3.5

4

England Scotland Wales N. Ireland Total

Boys

Girls

• 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

0%

5%

10%

15%

20%

25%

30%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• Regional data on young people not presented• Folate deficiency defined as Red Cell Folate <350 nmol/l

LIDNS: Location and Vitamin B12 Deficiency

0%

5%

10%

15%

20%

25%

30%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• Regional data on young people not presented• Deficiency defined as Serum <118 pmol/l

LIDNS: Location and Vitamin C Deficiency

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

England Scotland Wales NorthernIreland

Total

Adult Men

Adult Women

• Regional data on young people not presented• National prevalence of deficiency: boys 6%, girls 20%

Potential Effect of Risk Factors on Undernutrition

Personal Factor Nutrients Likely to be Inadequate

Lack of exercise Vitamin D if sun exposure is low

Poor dental health Vitamin C from fresh fruit and vegetables

Alcohol excess Many especially the B vitamins, but not iron

Obesity Vitamin D

Smoking Vitamins C, (D and B12 slightly), folate but not iron

Life stage Infants/children – iron, vit D, sometimes A and C Women menstruating – iron; preg. – folate, vit. D, I2 Elderly – vitamins D, C and B12, and folate

Physical illness Many especially if unintentional weight loss Liver disease vitamin D; renal dis. zinc, B vitamins

Medication use Aspirin/NSAIDs – vitamin C Diuretics – potassium, magnesium

Anti-convulscents – folate, vitamin D

Location – country Scottish women – vit. D, Welsh men - vit. C, Northern Irish - folate, N. Irish men - vit B12

Potential Effect of Risk Factors on Overnutrition

Factor Nutrients Likely to be in Excess

Alcohol excess Energy – obesity

Lack of exercise Energy – obesity

Lack of fresh fruit and vegetables

Lack of potassium enhances the adverse effect of excess sodium (salt) on blood pressure

Regular liver eater Vitamin A

Obesity/ T2 Diabetes Vitamin A

Supplement overuse Vitamin A and iron; rarely manganese and zinc

Renal disease Vitamin A, potassium and magnesium

Liver disease Iron, manganese and vit. A (may be deficient)

Life stage >50 yrs Increased risk of iron accumulation

Genetic predisposition Haemochromatosis – iron

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

Healthy Food Food Replaced Nutrition & Health BenefitsTraditional Roast Processed meats Lower in salt; iron, zinc and vit. B12

Dairy Foods: milk, yoghurt, cheese

Soft drinks, alcohol Protein, calcium, iodine, zinc,,vits. B12 and A; low-fat less disease risk

Wholegrains: bread and cereals

White bread, sugar, sugary cereals

Folate, B vitamins, trace elements; breakfast cereals – iron and folate

Veget. Proteins: beans, peanuts etc

Excess of high fat meat

Cheap nutritious protein, folate, iron, zinc; lowers cholesterol

Peas and Beans: frozen or tinned

Excess of pasta and rice

Frozen peas - popular; protein, fibre, folate, vitamin C, zinc and iron

Healthy Fats: rape seed oil, margarine

Butter, ghee, lard & palm oil; XS olive oil

Rapeseed n-3 EFAs, vitamin K; marg. vits. A & D; less disease risk

Variety of Fruit and Vegetables

Alcohol, sugary and salty snacks

Achieves 5-a-day, fibre, vitamin C, folate, potassium; less disease risk

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

0%

10%

20%

30%

40%

50%

60%

70%

Protein Magnesium Potassium Iron Vit B1 Folate Vit C

White Rice 166kcal

White Pasta 125kcal

Corn on the Cob 79kcal

Jacket Potato 163kcal

White and Brown Breads – Nutrient Content Percentage of Reference Nutrient Intake for women age 19 – 50 years from a 200 kcl serving

Data from McCance and Widdowson 6th Edition

0%

10%

20%

30%

40%

50%

60%

70%

Protein Calcium* Magnesium Iron * Zinc B1* B3* Folate

White Bread *Fortified nutrientWholemeal Bread

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

Food Children 4 to 18 yrs

Adults

19 to 64 yrs

Elderly

65 years and overMale

LIDNS/NDNS

FemaleLIDNS/NDNS

MaleLIDNS/NDNS

FemaleLIDNS/NDNS

MaleLIDNS/NDNS

FemaleLIDNS/NDNS

Eggs and egg dishes

63* 71 70* 64 [175] 157 [98] 101 140 127 91 85

Oily Fish 3* 24 7* 28 [28] 81 [49] 90 49 93 49 55

Leafy Green Vegetables

35* 36 42* 45 [84] 76 [84] 84 112 123 119 116

Potatoes not chips, fried or roast

280* 293 308* 261 [462] 407 [399] 376 560 593 469 432

Fruit: apples, pears, citrus

196* 202 266* 232 [186] 290 [203] 308 280 322 301 310

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

Food Children 4 to 18 yrs

Adults

19 to 64 yrs

Elderly

65 years and overMale

LIDNS/NDNS

FemaleLIDNS/NDNS

MaleLIDNS/NDNS

FemaleLIDNS/NDNS

MaleLIDNS/NDNS

FemaleLIDNS/NDNS

Eggs and egg dishes

63* 71 70* 64 [175] 157 [98] 101 140 127 91 85

Oily Fish 3* 24 7* 28 [28] 81 [49] 90 49 93 49 55

Leafy Green Vegetables

35* 36 42* 45 [84] 76 [84] 84 112 123 119 116

Potatoes not chips, fried or roast

280* 293 308* 261 [462] 407 [399] 376 560 593 469 432

Fruit: apples, pears, citrus

196* 202 266* 232 [186] 290 [203] 308 280 322 301 310

• * 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

Food Consumption g/week Simple Dietary Advice

Weekly consumption of:NDNS/LIDNS

(% consumers)

New Target

Eggs and egg dishes

132

(63%)

126

(50%)

300+ 6-7 eggs

Oily Fish 85

(44%)

42

(12%)

168 2 tins served with/as jacket potato, curry or sandwich

Leafy Green Vegetables

80

(53%)

98

(53%)

500 7 servings as part of 5-a-day

Potatoes, not chips, fried or roast

394

(84%)

427

(64%)

700 5 portions of jacket potato, wedgies, boiled + skin

Apples, pears and citrus

298

(~60%)

224

(~50%)

960 12 pieces as part of 5-a-day

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

Food Vit. A ug RE

Iron mg

Iodineug

K mg

Mg mg

Zinc mg

Fibre g

Eggs, boiled x 6 = 300g 570 5.7 318 390 36 3.9 0

Oily Fish x 2 tins = 168g 19 4.9 39 722 87.5 5.0 0

Green leafy vegetables

250g cabbage

250g spinach

87

1,600

0.75

4.0

5

5

300

575

10

85

0.25

1.25

4.5

5.25

Potatoes, baked + skin

700g King Edward0 4.9 35 4410 224 3.5 18.9

Fresh Fruit 3 x 4 pieces

320g Apple - eating

320g Pear

320g Orange

10

10

14

0.3

0.3

0.3

0

3

6

384

384

480

16

22

32

0.3

0.3

0.3

6.4

7.0

5.8

Total Weekly 2,310 21.1 411 7,645 512.5 14.8 47.8

Total Daily 330 3.0 59 1,092 73 2.1 6.8

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

Food Vit. D ug Vit. C mg Folate ug

Energy kcl

Protein g

Cost £

2011

Eggs, boiled x 6 = 300g 5.25 0 240 441 37.5 0.63

Oily Fish x 2 tins = 168g

12.5 0 14 350 40.0 0.84

Green Leafy Vegetables

250 g cabbage

250 g spinach0

0

20

50

225

73

48

62

5.5

4.5

0.76

1.40

Potatoes, baked + skin

700 g King Edward0 98 308 540 15.4 0.60

Fresh Fruit 3 x 3 pieces

320 g Apple - eating

320 g Pear

320 g Orange

0

0

0

19

19

173

3

6

99

150

132

118

1.3

0.96

3.5

0.69

0.63

0.90

Total Weekly 17.75 399 968 1841 108.7 6.45

Total Daily 2.55 57 138 263 15.5 0.92

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

-20.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Prot. Vit. D Vit. C Folate Vit. A Fe Iod K Mg Zn Fibre

Males 19-64 yr

Females 19-64 yr

• 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

-20%

0%

20%

40%

60%

80%

100%

Prot. Vit. D Vit. C Folate Vit. A Fe Iod K Mg Zn Fibre

Elderly men

Elderly women

• 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

-20.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Prot. Vit. D Vit. C Folate Vit. A Fe Iod K Mg Zn Fibre

Boys Girls

• 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 Consumption

Adults not in full-time education, grams/day

Food Group

Men Women

Education Level P Education Level P

More Less More Less

Eggs and egg dishes 27 22 0.322 16 14 0.138

Oily fish 5 5 0.178 12 5 0.120

All vegetables, not potatoes and beans

119 99 0.011 114 97 <0.001

Potatoes not chips, fried or roast

72 72 0.332 55 62 0.666

Chips, fried and roast potatoes

50 52 0.001 40 36 0.007

Fruit, not fruit juice 60 63 0.15 65 70 0.005

Fruit juice 42 29 0.335 46 30 0.04

Non-processed meat and meat dishes

170 127 0.013 107 98 0.227• Education “More” = GCSE grades A-C or above, “Less” = lower or no qualifications

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

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

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, employed

daughter tall but overweight• All children well-educated

(2/4 at grammar school)• 2 Boys long lived 91 and 83 yrs

2 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, employed

daughter tall but overweight• All children well-educated

(2/4 at grammar school)• 2 Boys long lived 91 and 83 yrs

2 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

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

Nutrient Symptoms Signs

Iron Fatigue, poor concentration, recurrent mouth ulcers

Pallor (anaemia), shortness of breath, loss of scalp hair

Folate Depression, irritability Birth defects, anaemia

Vitamin B12 Fatigue, mental decline, loss of sensation, sore tongue

Poor balance, birth defects, anaemia, weakness

Vitamin C Fatigue, depression, mental change

Easy bruising or bleeding, anaemia, strokes

Vitamin D Muscle weakness, difficulty walking, increased infections

Rickets - children; adults - osteomalacia/osteoporosis

Vitamin A Poor growth and vision, infections Usually none

Zinc Poor growth and vision, infections Poor quality skin

Potassium Fatigue, muscle cramps Hypertension, palpitations

Thank you for your attention.

I would welcome you comments. Contact me at

dr.stewart@stewartnutrition.co.uk