Wholegrain cereals for coronary heart disease

BACKGROUND

There is increasing evidence from observational studies that wholegrains can have a beneficial effect on risk factors for coronary heart disease (CHD).

OBJECTIVES

The primary objective is to review the current evidence from randomised controlled trials (RCTs) that assess the relationship between the consumption of wholegrain foods and the effects on CHD mortality, morbidity and on risk factors for CHD, in participants previously diagnosed with CHD or with existing risk factors for CHD.

SEARCH STRATEGY

We searched CENTRAL (Issue 4, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), ProQuest Digital Dissertations (2004 to 2005). No language restrictions were applied.

SELECTION CRITERIA

We selected randomised controlled trials that assessed the effects of wholegrain foods or diets containing wholegrains, over a minimum of 4 weeks, on CHD and risk factors. Participants included were adults with existing CHD or who had at least one risk factor for CHD, such as abnormal lipids, raised blood pressure or being overweight.

DATA COLLECTION AND ANALYSIS

Two of our research team independently assessed trial quality and extracted data. Authors of the included studies were contacted for additional information where this was appropriate.

MAIN RESULTS

Ten trials met the inclusion criteria. None of the studies found reported the effect of wholegrain diets on CHD mortality or CHD events or morbidity. All 10 included studies reported the effect of wholegrain foods or diets on risk factors for CHD. Studies ranged in duration from 4 to 8 weeks. In eight of the included studies, the wholegrain component was oats. Seven of the eight studies reported lower total and low density lipoproteins (LDL) cholesterol with oatmeal foods than control foods. When the studies were combined in a meta-analysis lower total cholesterol (-0.20 mmol/L, 95% confidence interval (CI) -0.31 to -0.10, P = 0.0001 ) and LDL cholesterol (0.18 mmol/L, 95% CI -0.28 to -0.09, P < 0.0001) were found with oatmeal foods. However, there is a lack of studies on other wholegrains or wholegrain diets.

AUTHORS' CONCLUSIONS

Despite the consistency of effects seen in trials of wholegrain oats, the positive findings should be interpreted cautiously. Many of the trials identified were short term, of poor quality and had insufficient power. Most of the trials were funded by companies with commercial interests in wholegrains. There is a need for well-designed, adequately powered, longer term randomised controlled studies in this area. In particular there is a need for randomised controlled trials on wholegrain foods and diets other than oats.

Ghrelin increases food intake in obese as well as lean subjects

OBJECTIVE

To investigate whether effects on food intake are seen in obese subjects receiving exogenous administration of ghrelin.

DESIGN

Randomised, double-blind, placebo-controlled study of intravenous ghrelin at doses 1 pmol/kg/min and 5 pmol/kg/min.

SUBJECTS

In all, 12 healthy lean subjects (mean body mass index (BMI) 20.5+/-0.17 kg/m(2)) and 12 healthy overweight and obese subjects (mean BMI 31.9+/-1.02 kg/m(2)).

MEASUREMENTS

Food intake, appetite and palatability of food, ghrelin and other obesity-related hormones, growth hormone.

RESULTS

Low-dose infusion of ghrelin increased ad libitum energy intake at a buffet meal in the obese group only (mean increase 36.6+/-9.4%, P<0.01.) High-dose ghrelin infusion increased energy intake in both groups (mean increase 20.1+/-10.6% in the lean and 70.1+/-15.5% in the obese, P<0.01 in both cases.) Ghrelin infusion increased palatability of food in the obese group.

CONCLUSION

Ghrelin increases food intake in obese as well as lean subjects. Obese people are sensitive to the appetite-stimulating effects of ghrelin and inhibition of circulating ghrelin may be a useful therapeutic target in the treatment of obesity.

Eating together is important: using a dining room in an acute elderly medical ward increases energy intake

AIM

To investigate the effect of eating in a supervised dining room, on nutritional intake and weight, for elderly patients on an acute medicine for the elderly ward.

METHOD

Patients on the intervention ward were encouraged to attend a dining room every lunch time by a trained nursing assistant as part of the rehabilitation process. The patients on the control ward ate only by their bedside. Food intake and weight data were collected over the study period on each patient.

RESULTS

Forty-eight patients participated in the study. At the lunch time meal studied the dining room group had higher intakes of energy compared with the controls [489 kcal (95% CI: 438-554) versus 360 kcal (95% CI: 289-448), P < 0.013]. There was no difference in protein intake between the groups [18.9 g (95% CI: 16.6-21.2) versus 17.7 g (95% CI: 13.2-22.2), P=0.63]. No significant difference in weight gain between the two groups was seen (P=0.6). However, there was a trend towards weight gain in the dining room group.

CONCLUSION

Food intake can be improved by using a supervised dining room, and this will potentially lead to weight gain and corresponding improvements in nutritional status and rehabilitation.

Is supplementation with elemental diet feasible in patients undergoing pelvic radiotherapy?

BACKGROUND

Acute gastrointestinal upset occurs in approximately 80% of patients undergoing radiotherapy for pelvic cancers. Underlying changes relate to denudation of the mucosal layer which renders the small intestine vulnerable to additional damage from proteolytic enzymes and bile acids. Severe acute bowel symptoms may predispose to progressive fibrotic and ischaemic changes. Elemental diet given during treatment may reduce acute and chronic bowel symptoms induced by pelvic radiotherapy.

METHODS

This study aimed to assess compliance with elemental diet during pelvic radiotherapy. Patients with gynaecological, urological or rectal malignancy undergoing radical or adjuvant pelvic radiotherapy were randomised to one of five groups. Each group was assigned a target quantity of three different elemental sip feeds (Group 1, 20%, Group 2, 50%, Group 3, 75% of calorie requirements taken as E028 extra liquid; Group 4, 50% of calorie requirements taken as E028 extra powder; Group 5, 50% of calorie requirements taken as Emsogen powder). Compliance was assessed using a diary card and weekly assessment. Statistical analyses were conducted on an intention to treat basis.

RESULTS

Fifty patients (44 female, six male) mean age 58 yr (95% CI 55-61), were recruited to the study (24 endometrial, 17 cervical, 7 rectal, 1 vulval and 1 bladder carcinoma). Mean weight at baseline was 74.5 kg (95% CI 69-80) and this did not change during treatment. Full compliance was achieved in three patients, all from Group 1. By week 5, only 46% of patients were consuming elemental diet. Post hoc analysis of variance with repeated measures indicated that there were no significant differences in volume of elemental diet consumed between groups (P = 0.937). There was a significant inverse linear relationship between intake of elemental diet and time (P < 0.001).

CONCLUSIONS

Different formulations of elemental diet do not influence compliance. Patients are unlikely to be able to consume more than one-third of their calorie requirements in the form of an elemental sip feed. Further investigation is warranted to determine if intervention with this volume of elemental diet is beneficial.

Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet

BACKGROUND

There are very few studies looking at the energy and protein requirements of patients requiring texture modified diets. Dysphagia is the main indication for people to be recommended texture-modified diets. Older people post-stroke are the key group in the hospital setting who consume this type of diet. The diets can be of several consistencies ranging from pureed to soft textures.

OBJECTIVE

To compare the 24-hour dietary intake of older people consuming a texture modified diet in a clinical setting to older people consuming a normal hospital diet.

METHOD

Weighed food intakes and food record charts were used to quantify the patients' intakes, which were compared to their individual requirements.

RESULTS

The oral intake of 55 patients was measured. Twenty-five of the patients surveyed were eating a normal diet and acted as controls for 30 patients who were prescribed a texture-modified diet. The results showed that the texture-modified group had significantly lower intakes of energy (3877 versus 6115 kJ, P < 0.0001) and protein (40 versus 60 g, P < 0.003) compared to consumption of the normal diet. The energy and protein deficit from estimated requirements was significantly greater in the texture-modified group (2549 versus 357 kJ, P < 0.0001; 6 versus 22 g, P = 0.013; respectively).

CONCLUSION

These statistically significant results indicate that older people on texture-modified diets have a lower intake of energy and protein than those consuming a normal hospital diet and it is likely that other nutrients will be inadequate. All patients on texture-modified diets should be assessed by the dietitian for nutritional support. Evidence based strategies for improving overall nutrient intake should be identified.

Low glycaemic index diets for coronary heart disease

BACKGROUND

The glycaemic index (GI) is a physiological measure of the ability of a carbohydrate to affect blood glucose. Interest is growing in the low GI carbohydrate concept for the clinical management of people at risk of, or with established coronary heart disease. There is a need to review the current evidence from controlled trials in this area.

OBJECTIVES

The primary objective is to review the current evidence from RCTs that assess the relationship between the consumption of low glycaemic index diets and the effects on coronary heart disease and on risk factors for coronary heart disease.

SEARCH STRATEGY

We searched CENTRAL (Issue 4, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003) and CINAHL (1982 to 2003). We also contacted experts in the field.

SELECTION CRITERIA

We selected randomised controlled trials that assessed the effects of low glycaemic index diets, over a minimum of 4 weeks, on coronary heart disease (CHD) and risk factors. Participants included were adults who carry at least one major risk factor for coronary heart disease such as abnormal lipids, diabetes or being overweight.

DATA COLLECTION AND ANALYSIS

Two of our research team independently assessed trial quality and extracted data. Authors of the included studies were contacted for additional information when this was appropriate.

MAIN RESULTS

Fifteen randomised controlled trials met the inclusion criteria. No studies found reported the effect of low glycaemic index diets on CHD mortality or CHD events and morbidity. All fifteen included studies report the effect of low glycaemic index diets on major risk factors for CHD. Meta-analysis detected limited and weak evidence of a relationship between low glycaemic index diets and slightly lower total cholesterol, compared with higher glycaemic index diets. There is also limited and weak evidence of a small reduction in HbA1c after 12 weeks on low glycaemic index diets but not at 4 to 5 weeks. There is no evidence that low glycaemic index diets have an effect on LDL cholesterol or HDL cholesterol, triglycerides, fasting glucose or fasting insulin levels.

REVIEWERS' CONCLUSIONS

The evidence from randomised controlled trials showing that low glycaemic index diets reduces coronary heart disease and CHD risk factors is weak. Many of the trials identified were short-term, of poor quality and conducted on small sample sizes. There is a need for well designed, adequately powered, randomised controlled studies, of greater than 12 weeks duration to assess the effects of low glycaemic index diets for CHD.

Role of nutritional intervention in patients treated with radiotherapy for pelvic malignancy

Up to 12000 patients with gynaecological, urological and rectal cancer undergo radical pelvic radiotherapy annually in the UK. More than 70% develop acute inflammatory changes causing gastrointestinal symptoms during treatment because healthy bowel tissue is encompassed in the radiation field. In total, 50% go on to develop chronic bowel symptoms, which affect quality of life due to permanent changes in the small and large intestine. Nutritional intervention may influence acute and chronic bowel symptoms but the validity of the advice given to patients is not clear. To assess the incidence and significance of malnutrition and to examine the efficacy of therapeutic nutritional interventions used to manage gastrointestinal side effects in patients undergoing pelvic radiotherapy and those with chronic bowel side effects after treatment, a critical review of relevant original studies on human subjects was carried out using a specific set of mesh terms in MEDLINE and EMBASE databases and the Cochrane Library in September 2003. Full texts of all relevant articles were collected and reference lists were checked. Sources of grey literature including conference abstracts and web-based information were also reviewed. A total of 36 papers published in peer-reviewed journals between 1966 and 2003 were identified. In all, 14 randomised controlled trials, 12 prospective cohorts, four retrospective, two qualitative, one validation, one pilot study and two case reports were obtained. These included 2646 patients. Eight articles including three conference abstracts and web-based information were found. None of the studies was definitive because of weakness in methodology. No studies could be combined because the interventions and the end points were different. There is no evidence base for the use of nutritional interventions to prevent or manage bowel symptoms attributable to radiotherapy. Low-fat diets, probiotic supplementation and elemental diet merit further investigation.

An investigation into the relationships between quality of life, nutritional status and physical function

BACKGROUND & AIMS

The measurement of quality of life adds a holistic dimension to the assessment of a clinical state or the response to an intervention. The relationship between quality of life and nutritional status is not well studied. This study aimed to investigate this relationship in a group of sick elderly in-patients.

METHODS

We used data from a RCT investigating the benefits of intensive feeding support on acute medicine for the elderly wards. The EuroQol EQ-5D questionnaire was administered to patients on admission and the results were then related to parameters of nutritional status, physical function, depression and serum albumin collected at the same time.

RESULTS

Two hundred and thirty-three patients completed the EQ-5D questionnaire. Comparisons with UK norms for community living elderly showed significantly lower scores. No direct relationship was found between the EQ-5D scores and markers of nutritional status. However, clear differences were observed between patients with and without swallowing problems, those with good and poor appetite and those with good and poor physical function. Increasing risk of depression had a profound effect on quality of life scores.

CONCLUSIONS

Nutritional status does not appear to directly influence quality of life, as measured by the EQ-5D, but may affect it through the consequences of reduced physical function. Additionally, factors that directly affect a persons food intake seem to have a greater impact on quality of life, which underlines the importance of food and eating as an aspect of life quality.

A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: clinical and health economic outcomes

BACKGROUND & AIMS

Malnutrition is common in sick elderly people on admission to hospital and in the community. We conducted a randomised controlled trial to determine if nutritional supplementation after discharge from hospital improved nutritional status and functional outcomes, or reduced health-care costs.

METHODS

Elderly malnourished subjects were randomised to 8 weeks of supplementation or no supplementation post discharge, and followed up for 24 weeks. Weight, body mass index, anthropometrics, handgrip strength, quality of life and requirements for health-care professionals' services and social services were measured throughout the study.

RESULTS

Nutritional status improved significantly from baseline to week 24 in the intervention group (P<0.05), but not in the control group. There was no significant difference in nutritional status between groups at week 24. Handgrip strength improved significantly in the intervention group during supplementation, and was significantly different from that of the control group at week 8, but decreased thereafter. There was no significant difference in quality of life or health economic outcomes between groups at week 24.

CONCLUSIONS

In already malnourished elderly subjects, it may be too late to expect to improve function or quality of life or to reduce health-care costs simply by providing nutritional supplements after hospitalisation. Prevention is key. All elderly patients should be nutritionally assessed as part of their routine care, and appropriate intervention initiated early.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.

A comparison of three methods for estimating height in the acutely ill elderly population

BACKGROUND

Most estimates of nutritional status rely on accurate recording of not only body weight but also height. Standing height is difficult to measure accurately in older adults due to mobility problems and kyphosis. Surrogate methods have been developed to estimate height including arm-span, demi-span and knee height. There are currently little data on the accuracy of these methods in the sick elderly population or which method is the most suitable in the clinical situation.

OBJECTIVE

To compare three commonly used clinical measurements that can estimate height and analyse their agreement with current height. Also to evaluate which method can be used most frequently.

METHODS

We used data collected as part of a larger intervention trial, in which elderly in-patients (over 65 years), were measured for demi-span, half arm-span, knee height and standing height.

RESULTS

The results showed that demi-span and half arm-span could be measured in the largest proportions of our population, 75.6 and 72.3%, respectively. The correlation coefficients were high for all three estimates of height, r = 0.86 for demi-span, r = 0.87 for arm-span, and r = 0.89 for knee height (P < 0.0001 for all three). However, agreement analysis demonstrated very poor agreement between standing height and all the methods of estimation. The mean differences were 4.33 cm for demi-span, 7.04 cm for arm-span and -0.6 cm for knee height.

Intensive lifestyle intervention combined with the choice of pharmacotherapy improves weight loss and cardiac risk factors in the obese

BACKGROUND

Obesity is on the increase yet within the National Health Service (NHS) treatment approaches differ greatly and service is patchy. Our aim was to compare current practice within a general dietetic clinic with a new clinic developed specifically for patients of higher morbidity risk.

METHODS

Locally referred patients to the dietitians from within or without Hammersmith Hospitals NHS Trust of higher morbidity risk were invited to attend a new Lifestyle Clinic. Treatment was of a contractual nature and included more time with the dietitian, the offer of pharmacotherapy if appropriate and an emphasis on achieving a realistic weight loss of 10% within a 6-month period. Cognitive behavioural strategies were utilized focusing on achieving changes in dietary intake and physical activity levels.

RESULTS

A total of 103 patients have been enrolled of whom 34 have been discharged before completion of the clinic programme. Twenty-six patients have completed (18 started pharmocotherapy with Orlistat and eight remained on lifestyle advice only), with the remainder still attending the Lifestyle Clinic. The results for these 26 patients demonstrate clinically significant benefits with regard to exercise tolerance 390.8 +/- 37.5 m vs. 473 +/- 46.6 m (P < 0.001), waist measurement 121.5 +/- 4.4 cm vs. 110.9 +/- 3.6 cm (P < 0.001), and total cholesterol : HDL ratio 1.17 +/- 0.05 mmol L-1 vs. 1.27 +/- 0.07 mmol L-1 (P < 0.05). A weight loss comparison with historical data collected in the general dietetic clinic achieves a 7.8 +/- 0.7 kg reduction in weight (with pharmocotherapy 8.96 +/- 0.98 kg, with lifestyle only 5.23 +/- 0.657) vs. 1.7 +/- 0.4 kg (P < 0.05).

CONCLUSION

Lifestyle clinics facilitate beneficial lifestyle changes which impact positively on morbidity risk factors demonstrating an improvement on current service offered within the NHS. There is an obvious resource implication of offering an intensive management package. There is need for a randomized control trial with analysis to evaluate whether there is cost benefit from this type of intervention.

The principles of dietary management of gestational diabetes: reflection on current evidence

BACKGROUND

Gestational diabetes (GDM) is the commonest metabolic disorder of pregnancy. Most women with GDM are treated with nutritional management alone. There are conflicting guidelines surrounding its dietary management and this has resulted in a lack of conformity to the dietary advice currently prescribed. There is also conflicting opinions to the effectiveness of dietary management of GDM on pregnancy outcomes. The aim of this review was to examine the scientific evidence for the optimal nutritional management of GDM.

METHODS

A Medline search of all English papers published between 1995 and 2001 that cross-referenced GDM with diet was under taken. Because of the poor quality of many of these papers, literature prior to 1995 known to the authors and considered relevant to the review were also included.

RESULTS

The evidence base in this area is of poor quality. One systematic review based on randomized control trials failed to show any benefit from dietary intervention in GDM. However, that review did not include informative clinical and observational studies that are not classified as randomized controlled trials. Overall current evidence points to the effectiveness of dietary advice as a means of improving maternal hyperglycaemia and reducing the risk of accelerated foetal growth. The evidence surrounding energy restriction, carbohydrate and fat manipulation in GDM remains controversial.

CONCLUSIONS

Current but limited evidence supports dietary alterations to reduce rates of accelerated foetal growth. There is a clear need for good quality randomized control trials in this area.

Fast and reproducible method for the direct quantitation of adipose tissue in newborn infants

The role of body fat content and distribution in infants is becoming an area of increasing interest, especially as perception of its function appears to be rapidly evolving. Although a number of methods are available to estimate body fat content in adults, many are of limited use in infants, especially in the context of regional distribution and internal depots. In this study we developed and implemented a whole-body magnetic resonance imaging (MRI)-based protocol that allows fast and reproducible measurements of adipose tissue content in newborn infants, with an intra-observer variability of <2.4% and an inter-observed variability of <7%. The percentage total body fat for this cohort of infants ranged from 13.3-22.6% (mean and standard deviation: 16.6 +/- 2.9%), which agrees closely with published data. Subcutaneous fat accounted for just over 89% of the total body fat, whereas internal fat corresponded to almost 11%, most of which was nonabdominal fat. There were no gender differences in total or regional body fat content. These results show that whole-body MRI can be readily applied to the study of adipose tissue content and distribution in newborn infants. Furthermore, its noninvasive nature makes it an ideal method for longitudinal and interventional studies in newborn infants.

Visceral adipose tissue and metabolic complications of obesity are reduced in Prader-Willi syndrome female adults: evidence for novel influences on body fat distribution

Visceral obesity is detrimental to health, but the mechanisms controlling body fat distribution are not fully understood. In premenopausal adult females (30 nonobese, 14 obese [body mass index >30 kg/m(2)]), variance in fasting insulin, glucose, insulin/glucose ratio, C-peptide/insulin ratio, triglycerides, and high-density lipoprotein/low-density lipoprotein-cholesterol ratio, were independently influenced by visceral but not total sc or abdominal sc adipose tissue, as measured by whole-body magnetic resonance imaging. Adult females with Prader-Willi syndrome (n = 13) had significantly reduced visceral adiposity, compared with obese controls (visceral/total sc adipose tissue ratio: 0.067 +/- 0.017 vs. 0.108 +/- 0.021), independent of their total adiposity (P < 0.001), or use of exogenous sex steroids. This is in contrast to that expected by their physical inactivity, hypogonadism, adult GH deficiency, and psychiatric problems. Females with Prader-Willi syndrome not receiving sex steroids (n = 8) had significantly reduced fasting insulin, insulin/glucose ratio, and triglycerides and increased C-peptide/insulin ratio, compared with obese controls, adjusting for total (P < 0.05) but not visceral adiposity (P = 0.3-0.6), supporting their association. The cause of the reduced visceral adiposity in Prader-Willi syndrome may reflect novel hormonal, hypothalamic, and/or genetic influences on body fat distribution.

What nutritional support literature do hospital nursing staff require?

BACKGROUND

Many patients require nutritional intervention to help treat and/or prevent malnutrition. Nursing staff play a key role in identifying malnourished patients. To improve the management of artificial nutritional support, the Hammersmith Hospital NHS Trust has produced guidelines. This audit aimed to assess the need and adequacy of these guidelines and to examine any additional information required.

METHODS

The dietetic department and nursing practice group developed a questionnaire. A total of 260 questionnaires were distributed by dietitians, 10 copies of the questionnaire to nurses on 26 wards. The completed forms were returned by internal post or collected the dietitian.

RESULTS

The response rate was 29%. All 77 nurses who responded felt there was a need for nutrition literature. Seventy-three per cent of nurses were aware that the guidelines existed; however, referral to the resource was poor. Requests for additional information encompassed tube feeding and catering information. To provide this information, 84% requested a nutrition tutorial, 81% a preprinted care plan and 96% a ward manual specific to their speciality.

CONCLUSIONS

All nurses who were surveyed requested nutrition information. The current guidelines already reflect the requested information, but usage is poor. We aim to improve access and awareness by the hospital intranet, nutrition education and induction programme. The next update will cover gaps identified and additional requirements outside the guidelines remit will be discussed with the nursing practice group.