Elaine Bannerman

Corrected Arm Muscle Area: An Independent Predictor of Long-Term Mortality in Community-Dwelling Older Adults?

OBJECTIVES: Older people are at risk of undernutrition because of a number of physiological conditions and lifestyle factors. The purpose of this study was to explore the predictive relationship of corrected arm muscle area (CAMA) with 8‐year mortality in a representative sample of older Australians.

A dietary survey to determine if patients with coeliac disease are meeting current healthy eating guidelines and how their diet compares to that of the British general population

Objectives:To assess the dietary intake of people with coeliac disease (CD) and to determine if they are meeting the current dietary reference values (DRVs). To compare dietary intakes of people with CD to the dietary intake of the general population. The nutritional contribution of gluten-free products (GFPs) and current purchasing trends was also evaluated.Subjects/Methods:106 patients were invited to participate via post. Three-day food diary to assess intake and a short simple questionnaire that looked at purchasing trends of GFP.Results:Forty-nine patients returned the food diary and 48 returned the questionnaire. Patients were found to have a low intake of energy, non-starch polysaccharides (NSPs), vitamin D and calcium. They were obtaining a significantly lower proportion of energy from fat and a significantly higher proportion of energy from protein than the DRVs (P<0.05). Intake was comparable to the general population for most nutrients, except they had a significantly greater intake of protein, a lower intake of fat and a significantly lower intake of vitamin D (P<0.05). Specialist GFP, especially those obtained on prescription, were an important source of energy, carbohydrate, NSP, calcium and iron.Conclusions:Patients with CD are at risk of having an inadequate intake of calcium, NSP and vitamin D. Specialist GFP, which were obtained on prescription, helped patients get a balanced diet and without these patients would be at an increased risk of many deficiencies.

Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial

Objective: To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture. Design: Randomized controlled trial with 12-week masked outcome assessment. Setting: Teaching hospital. Participants: One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture. Intervention: Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n =25), tri-weekly resistance training for 12 weeks (n =25), combined treatment (n =24) or attention control plus usual care and general nutrition and exercise advice (n =26). Measurements: Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention. Results: At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P = 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome. Conclusion: Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements. Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention. In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

The rising incidence of celiac disease in Scotland.

BACKGROUND AND OBJECTIVES: Although the incidence of pediatric celiac disease (CD) is increasing globally, it is uncertain whether this is attributed to improved case ascertainment or signifies a true rise. We aimed to identify all incident cases of childhood CD in southeast Scotland over the period 1990 to 2009 to assess trends in total incidence and cases diagnosed as a result of (1) a classic presentation, (2) a nonclassic presentation, or (3) targeted screening. METHODS: Twenty-year retrospective cohort study of case notes, pathology databases, endoscopy, and patient records for all children (<16 years of age) diagnosed with CD on biopsy in southeast Scotland (at-risk population of 225 000–233 000). Data were age-gender standardized and Poisson regression models used to calculate changes in incidence over time. RESULTS: A total of 266 children were diagnosed from 1990 to 2009 with an increase in incidence from 1.8/100 000 (95% confidence interval [CI] 1.1–2.7) to 11.7/100 000 (95% CI 9.8–13.9) between the epochs 1990 to 1994 and 2005 to 2009, respectively (P < .0001). The incidence of nonclassic presentation (children with a monosymptomatic presentation and those with extraintestinal symptoms) and actively screened cases increased by 1566% (P < .05) and 1170% (P < .001) from 1990 to 1999 to 2000 to 2009, respectively. However, a rise in the incidence of Oslo classic cases from 1.51/100 000 (95% CI 0.91–2.38) in 1990 to 1994 to 5.22/100 000 (95% CI 3.98–6.75) in 2005 to 2009 (P < .01) remained evident. CONCLUSIONS: The incidence of pediatric CD increased 6.4-fold over the 20 years. This study demonstrates that this rise is significant for classic CD, indicating a true rise in the incidence of pediatric CD.

Evaluation of validity of British anthropometric reference data for assessing nutritional state of elderly people in Edinburgh: cross sectional study

Abstract Objectives:To evaluate the appropriateness of two sets of commonly used anthropometric reference data for nutritional assessment of elderly people. Design:Cross sectional study. Setting:Two general practices in Edinburgh. Subjects:200 independently living men and women aged 75 or over randomly recruited from the age and sex register of the practices. Main outcome measures:Weight (kg), knee height (cm), demispan (cm), mid-upper arm circumference (cm), triceps skinfold thickness (mm), arm muscle circumference (cm) body mass index (kg/m2), and demiquet (kg/m2) in men and mindex (kg/m) in women. Results:Men and women in Edinburgh were significantly shorter than those in measured for the Nottingham reference data (demispan 0.79 v 0.80 (P<0.05) for men and 0.72 v 0.73 (P<0.01) for women). Comparison with data from South Wales showed that men and women from Edinburgh had significantly greater mid-upper arm circumference, triceps skinfold thickness, and arm muscle circumference. No one fell below the 10th centile of the South Wales data (the commonly used cut off point for determining malnutrition) for these measures. Conclusions:Both sets of reference data commonly used in Britain may be inappropriate for nutritional screening of elderly people in Edinburgh. Contemporary reference data appropriate for the whole of Britain need to be developed, and in the longer term biologically or clinically defined criteria for undernutrition should be established. Key messages Anthropometric reference data for assessing the nutrition of elderly people in Britain are limited This Edinburgh population showed significant differences from the commonly used reference data in several anthropometric measures Existing anthropometric reference data could lead to significant biases when used for screening for undernutrition or determining prevalence of malnutrition

Lower Limb Fracture, Cognitive Impairment and Risk of Subsequent Malnutrition: A Prospective Evaluation of Dietary Energy and Protein Intake on an Orthopaedic Ward

Objective:To report the dietary energy and protein intake of undernourished older adults (with and without cognitive impairment) admitted to hospital following a lower limb fracture and to determine whether dietary intakes met estimated requirements.Design:An observational study of a sequential sample.Setting:The orthopaedic ward of a South Australian metropolitan teaching hospital.Subjects:Sixty-eight patients aged ⩾70 years screened as undernourished and admitted to hospital following lower limb fracture (50% cognitively impaired) provided 3 to 5 days of dietary data.Major outcome methods:Dietary energy and protein intake.Methods:Dietary assessment using plate waste methodology and snack record charts commenced within 6 days postinjury and continued for up to five consecutive days or until discharge. Estimated resting energy requirements were calculated and adjusted for activity equivalent to bed rest and physiological stress. Protein requirements were calculated as 1 g/kg/day. Cognition was assessed using the Short Portable Mental Status Questionnaire.Results:Cognitively impaired participants and those without cognitive impairment consumed, mean (95% CI) respectively, 3661 kJ/day (3201, 4121) versus 4208 kJ/day (3798, 4619) and 38 g (33, 44) versus 47 g (41, 52) protein/day. Cognitively impaired participants consumed mean (95% CI) 48% (43, 53) of estimated total energy expenditure and 78% (69, 87) of estimated protein requirements.Conclusions:Orthopaedic fracture patients at greatest nutritional risk, including those with cognitive impairment, do not achieve estimated energy or protein requirements from diet alone. Effective methods of achieving requirements in this vulnerable group are needed before improvements in outcomes will be observed.Sponsorship:The research was undertaken with support from the National Health and Medical Research Council who provided a Public Health Postgraduate Research Scholarship to assist the first author in completion of a PhD.

Childhood coeliac disease diagnoses in Scotland 2009–2010: the SPSU project

Objectives To establish the incidence of childhood coeliac disease (CD) in Scotland between 1 September 2009 and 31 August 2010, to determine clinical features at presentation and reasons for diagnosis, and to identify any differences in incidence and practice between regions. Design Prospective data collection through the Scottish Paediatric Surveillance Unit (SPSU). Strategic contacts in each tertiary gastrointestinal region (East, West and North) were emailed monthly to report new cases of CD (<16 years). A clinical questionnaire was completed for each case. Additionally, regional laboratories were asked to report the number of diagnostic antibody tests for CD performed over the year. Setting This national study looked at the total cases within Scotland. Scotland has a population of 5.2 million, with the mid-year estimate in 2009 of 912 144 children under the age of 16. Results 91 new cases were reported, giving an overall adjusted incidence of 10.0/100 000/year. Incidence in the East was 16.3/100 000/year, West 8.1/100 000/year and North 7.7/100 000/year. Cases diagnosed due to active screening in the East (4.6/100 000/year) were more than twice the number observed in the West (2.0/100 000/year) and North (1.3/100 000/year), as was the incidence of classic cases. The most frequent symptoms reported were abdominal pain (50/91; 54.9%), failure to thrive (29/91; 31.9%), fatigue (29/91; 31.9%), diarrhoea (27/91; 29.7%) and bloating (19/91; 20.9%). Twenty-two children (24.2%) were diagnosed due to active screening, of which 14 had associated type 1 diabetes mellitus, one Down syndrome and seven had family history. Fifty-five per cent (12/22) of the patients diagnosed through active screening were asymptomatic. Significantly more CD diagnostic antibody tests were performed per head of population in the East compared with the West (OR 1.65, 95% CI 1.57 to 1.73) and North (OR 1.81, 95% CI 1.70 to 1.92). Conclusions Approximately double the incidence of paediatric CD was observed in the East of Scotland. Evidence of more actively screened cases diagnosed and more antibody tests performed in the region suggests a lower threshold to test. An environmental influence cannot be dismissed since more classic cases were also captured. Further research is needed to highlight the role of any exogenous factors.

Resting energy expenditure measured longitudinally following hip fracture compared to predictive equations: is an injury adjustment required?

The present study measuring resting energy expenditure (REE; kJ/d) longitudinally using indirect calorimetry in six elderly women aged > or =70 years following surgery for hip fracture, describes changes over time (days 10, 42 and 84 post-injury) and compares measured values to those calculated from routinely applied predictive equations. REE was compared to REE predicted using the Harris Benedict and Schofield equations, with and without accounting for the theoretical increase in energy expenditure of 35 % secondary to physiological stress of injury and surgery. Mean (95 % CI) measured REE (kJ/d) was 4704 (4354, 5054), 4090 (3719, 4461) and 4145 (3908, 4382) for days 10, 42 and 84, respectively. A time effect was observed for measured REE, P=0.003. Without adjusting for stress the mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Harris Benedict equation were 1 (-9, 12), 10 (2, 18) and 9 (1, 17) for days 10, 42 and 84, respectively. The mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Schofield equation without adjusting for stress were 8 (-3, 19), 16 (6, 26) and 16 (10, 22) for days 10, 42 and 84, respectively. After adjusting for stress, REE predicted from the Harris Benedict or Schofield equations overestimated measured REE by between 38 and 69 %. Energy expenditure following fracture is poorly understood. Our data suggest REE was relatively elevated early in recovery but declined during the first 6 weeks. Using the Harris Benedict or Schofield equations adjusted for stress may lead to overestimation of REE in the clinical setting. Further work is required to evaluate total energy expenditure before recommendations can be made to alter current practice for calculating theoretical total energy requirements of hip fracture patients.

Coeliac disease and the gluten-free diet: a review of the burdens; factors associated with adherence and impact on health-related quality of life, with specific focus on adolescence

Adherence and non-adherence to a gluten-free diet (GFD) may impact negatively on health-related quality of life (HRQoL). Understanding the factors that influence compliance could help inform management and also guide support. With a particular focus on adolescence, this narrative review critiques current literature on the burdens associated with following a GFD and the factors associated with adherence. Studies highlight a variety of burdens faced by individuals with coeliac disease, including the cost, access and availability of gluten-free (GF) foods, as well as the dilemmas experienced when eating out, travelling and socialising with friends. A number of studies report that adolescents face stigmatisation and feel isolated in social situations and at school. Additional burdens that are highlighted are a lack of knowledge regarding CD and GFD difficulties in interpreting food labels, as well as dissatisfaction with the organoleptic properties of GF foods. Factors associated with poor adherence in adolescence include older age, an absence of immediate symptoms, difficulties eating out and poor palatability of GF foods. Conversely, better emotional support and stronger organisation skills have been associated with superior adherence. Significant associations have been reported between HRQoL measures and adherence, although the findings are inconsistent. Limitations in research methodologies exist and data are restricted to just a few countries. Further research specific to adolescence is required to identify independent predictors of adherence.

A randomised trial of the impact of energy density and texture of a meal on food and energy intake, satiation, satiety, appetite and palatability responses in healthy adults

BACKGROUND & AIMS Texture modified diets may be enriched to optimise the opportunity for individuals to meet their required energy intakes; however there is insufficient evidence supporting this strategy. Thus we sought to investigate the effect of texture and energy density on food (g) and energy intakes (kcal), appetite (satiation and satiety), and palatability in healthy adults. METHODS A single blind within-subjects randomised crossover design, where 33 healthy adults consumed a test meal with either its texture and/or energy density altered, until satiation was reached whilst rating their appetite parameters. Subsequent intakes were recorded in a food diary to determine the effect of the treatments on satiety and identify any evidence of energy compensation. RESULTS Test meal energy intakes (kcal) were significantly higher with energy enrichment of both meals (standard texture; 315 kcal and texture modified; 303 kcal (p = 0.001)) and remained higher over the day for both (260 kcal/d and, 225 kcal/d respectively (p < 0.05)). Area under the curve (AUC) did not differ between meals for hunger, fullness, or desire to eat however palatability was significantly reduced with texture modification. CONCLUSIONS Enriching meals (standard texture and texture modified) is an effective method to increase short term energy intakes in healthy adults over a 24 h period and may have application to optimise energy intakes in a clinical setting.