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ISBN 1-84544-825-1
ISSN 0034-6659
Volume 35 Number 5 2005
Nutrition & Food Science Obesity
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Nutrition & Food Science
ISSN 0034-6659 Volume 35 Number 5 2005
Obesity Editor Dr Mabel Blades
Access this journal online _________________________
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Editorial board ___________________________________
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Editorial _________________________________________
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Healthy lifestyle project for overweight and obese children: a pilot study Mary Tyers ___________________________________________________
298
Effects of an over-the-counter herbal weight management product (Zotrim1 ) on weight and waist circumference in a sample of overweight women: a consumer study C.H.S. Ruxton, F. Hinton and C.E.L. Evans _________________________
303
Predictors of physician overweight and obesity in the USA: an empiric analysis John La Puma, Philippe Szapary and Kevin C. Maki __________________
315
Modern diets converging: the move to low GI/GR diets Shane Landon_________________________________________________
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CONTENTS
CONTENTS continued
Low levels of cholesterol/saturated fat index (CSI) in a Japanese-Brazilian diet Elizabeth Aparecida Ferraz da Silva Torres, Geni Rodrigues Sampaio, Cla´udia Moreira Nery Castellucci, Edeli Simioni de Abreu and Marly Augusto Cardoso _________________________________________
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Diet, lifestyle factors and symptoms of premenstrual syndrome Katie L. Oliver and G. Jill Davies __________________________________
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Nutritional profiling vs guideline daily amounts as a means of helping consumers make appropriate food choices Gaynor Bussell ________________________________________________
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Functional foods and nutraceuticals in the management of obesity Gursevak S. Kasbia_____________________________________________
344
The potential role of peanuts in the prevention of obesity Jennette Higgs _________________________________________________
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Waist to height ratio and the Ashwell1 shape chart could predict the health risks of obesity in adults and children in all ethnic groups Margaret Ashwell ______________________________________________
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Food facts ________________________________________
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Conference reports _______________________________
372
Book reviews _____________________________________
377
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EDITORIAL BOARD
John J.B. Anderson, PhD Professor of Nutrition, University of Carolina School of Public Health and School of Medicine, USA
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David C. Nieman, DrPH MPH FACSM Professor, Appalachian State University, USA
Professor Winston Craig Andrews University, Berrien Springs, MI, USA
Claire Seaman, BSc, MPhil, SRD Lecturer on Food Studies, Queen Margaret College, Edinburgh, UK Christopher Strugnell, BSc, PhD, MIFST University of Ulster at Jordanstown, Northern Ireland
Marcel Hebbelinck, PhD Professor, Laboratory Human Biometry, Vrije Universiteit Brussels, Belgium
Margaret Thorogood, PhD Senior Lecturer, London School of Hygiene and Tropical Medicine, UK
Ann Reed Mangels, PhD RD FADA Nutrition Advisor, Vegetarian Resource Group, USA
Dr Wendy Wrieden Centre for Public Health Nutrition Research, Ninewells Medical School, Dundee, UK
Dr Margaret Ashwell OBE Ashwell Associates (Independent Scientific Co-ordinators & Consultants) Ashwell, UK
Editorial
Editorial
Obesity is such a tremendous problem that it is with great enthusiasm that I have compiled this special issue of Nutrition & Food Science as I hope that it will be of help to anyone with an interest in the topic. This is the first special issue of Nutrition & Food Science that I have written and I have tried to include a number of papers from various authors on this important topic as well as general information of where to get further information from web sites, organisations and books. This issue of Nutrition & Food Science focuses on obesity from a number of perspectives. Obesity is considered by the World Health Organisation to constitute a world-wide epidemic. In the UK one in five adults is obese with one in four predicted to be obese by the year 2010. Not only is obesity linked with disorders such as Type 2 diabetes, hypertension, coronary heart disease, certain cancers and varicose veins but it also exacerbates problems such as joint and breathing disorders. People who are obese find that obesity adversely affects their lives with problems of purchasing clothes, bullying, fitting into bus, theatre and cinema seats, mobility problems, employment discrimination and difficulties with relationships to mention but a few. The life expectancy of anyone who is obese is reduced by nine years while it is reduced by seven years in those who smoke. Indeed in a survey of people’s biggest fears, surprisingly, becoming obese was considered to be a far greater fear than nuclear war! There are all types of strategies and theories as regards obesity. However, as a practising dietitian with a number of grossly obese patients it seems to me that there is no one approach that suits every person who is obese. Also the approach that is required may change with time.
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Mabel Blades
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 297 # Emerald Group Publishing Limited 0034-6659
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The current issue and full text archive of this journal is available at www.emeraldinsight.com/0034-6659.htm
Healthy lifestyle project for overweight and obese children: a pilot study Mary Tyers
298
Nutrition and Dietetic Department, University Hospital of North Staffordshire, Stoke-on-Trent, UK Abstract Purpose – To describe a year-long pilot programme, based at a leisure centre combining access to a modified version of the existing ‘‘Physical Activity Referral Scheme’’ (‘‘Exercise on Prescription’’) in North Staffordshire with dietary intervention. Design/methodology/approach – A small group of overweight and obese children and their families participated in a year-long programme with psychologist input in initial design. The programme entailed dietary intervention, incorporating behavioural approaches coupled with advice and encouragement to access physical activity opportunities. School nurses recruited 16 primary school-aged children whose BMI fell within the inclusion areas of the BMI centile charts for overweight or obesity. Findings – Sixteen children with their families were initially involved in the programme of dietary and physical activity intervention and encouragement. Twelve children completed the year. Ten of the 12 children (83 per cent) had an improved BMI centile status (three children marginally so). A total 75 per cent of children had an improved waist circumference centile by the end of the project. Dietary markers showed an all-round improvement in the quality of children’s diets. Children became more physically active, participants citing that they were walking more and most were achieving 16-30 more minutes a day in various forms of physical activity. Research limitations/implications – Statistical advice is sought to obtain numbers of children required to run a comparative study with a control group (dietary intervention only) alongside intervention described in pilot study. Originality/value – The number of children involved has been small but the scheme appears to have been an effective means of enabling children and their families to achieve a healthier weight and lifestyle over the period of the programme. Keywords Children (age groups), Obesity, Diet, Activity sampling, Schools, Nurses Paper type Research paper
Introduction Families with overweight and obese children are requesting help and would benefit from treatment programmes. There is a lack of evidence of the efficacy of treatment programmes for overweight and obese children. It appears (Health Development Agency, 2003) that targeting parents and children together (family based interventions involving at least one parent with physical activity and health promotion) is effective. It has been suggested (SIGN, 1996; NHS CRD 2002) that it would be beneficial to target Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 298-302 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625485
The North Staffordshire Directorate of Health Promotion who funded the Physical Activity Consultant and coordinate the Physical Activity Referral Scheme. School Nurses: Mary Cooke, Sue Needham and Sandy Hammond. Child and Adolescent Psychologist, Carol Martin. Glendale Leisure and Staffordshire Moorlands District Council. The Nutrition and Dietetic Department. University Hospital of North Staffordshire.
high risk children for more intensive treatment programmes based on a joint approach which can be summarised as involving: .
healthy eating,
.
increased physical activity,
.
behavioural approaches,
.
involvement and support of family.
The programme aimed to facilitate families making specific dietary changes, being involved in increased everyday activities and the children themselves in preferred activities at the local leisure centre. This would enable overweight or obese children achieve an improved BMI profile. Subjects School nurses recruited 16 primary school aged children (10 girls and 6 boys) initially to participate in the programme. Eight of the children were in receipt of free school meals indicating limited family income. Twelve children (7 girls and 5 boys) completed the year. Two children from one family discontinued the programme after an initial consultation and two more half way through the programme giving no reason, despite a letter requesting feedback being sent. Methodology The involvement of a Child and Adolescent Psychologist helped ensure that the programme was approached in a sensitive and non-stigmatising way. Children were included in the programme if BMI fell within the inclusion areas of the BMI centile charts for overweight or obesity. The International Obesity Task Force have recommended cut-offs on the British Childhood BMI charts for obesity and overweight in children. These correspond to the adult definitions of overweight (BMI >25) and obesity (BMI >30) at age 18 (Cole, 2000). There is some evidence however that BMI measurements alone which give no indication of body fat distribution, in children, may be masking even higher levels of overweight and obesity than is currently realised (McCarthy, 2003). Trends in waist circumference during the past 10-20 years have greatly exceeded those of body mass index particularly in girls. Measuring BMI alone is therefore likely to be underestimating the prevalence of obesity in young people. For this reason waist circumference data was collected at the beginning and end of project period. This information was related to the published waist circumference percentiles in British children aged 5-16.9 years (McCarthy, 2001). Dietary markers (intake of fruit and vegetables, sugary drinks, crisps and sweets and chocolates) giving an indication of the quality of diet taken were collected from detailed diet histories the beginning and end of the programme. Participants, always with at least one main carer, (other family members were encouraged to attend if possible) were given the opportunity of seeing the dietitian, during daytime, in at the leisure centre on 5 occasions over a yearlong period for dietary education and intervention. Dietary targets were agreed initially and at each subsequent appointment if needed. Motivational charts with stickers were used as suggested by the psychologist to encourage children make agreed changes. There were also dietary educational activities throughout the year. These included children collecting wrappers and pictures of foods and drinks consumed and placing them, after
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discussion, on a large Balance of Good Health mat. Children with their parents also completed a food diary forming another discussion point. Work sheets from the British Dietetic Associations Food First’s Eat 2 B Fit educational pack were also used to reinforce changes being negotiated with the families. The families also had the opportunity of receiving expert advice on achieving a more physically active lifestyle by a Physical Activity Consultant. This input was accessed by modifying an existing arrangement of the adult’s scheme whereby suitable patients are able to obtain a prescription from their G.P to access a 10 week course at the local leisure centre gym coupled with two consultations with a physical activity consultant. As most gym-based activities are unsuitable for children, the programme offered was modified to include, at no cost for the involved child, swimming, badminton, football, table tennis and trampolining. An important emphasis taken by the physical activity consultant, however, was that increasing everyday activities such as walking were of equal importance. British Heart Foundation resources were used to help reinforce and motivate children. At all times the whole family was encouraged to be involved in both aspects of the programme and make family based changes. With this in mind two family walks were organised specifically for the group of children and their families. Results Sixteen children with their families were initially involved in the programme of dietary and physical activity intervention and encouragement. Incidence of presence of family history of obesity and associated health problems as reported by the families (Table I). Ten of the12 children (83 per cent) had an improved BMI centile status (although three children only marginally so), one child stayed on the same centile and one child’s weight profile worsened. At the beginning of the programme 67 per cent children were obese and 33 per cent were overweight. At the end 56 per cent were obese and 44 per cent overweight. In total, 75 per cent of children had an improved waist circumference centile by the end of the project. Advice sought from a statistician deemed this was a pilot study with a small number of children. Results are represented graphically in Figure 1. Using dietary markers as an indication of altered diet it appeared that the children generally achieved a healthier diet by the end of the project (Table II). All participants claimed that they and their families have become more physically more active as a result of the scheme and plan to continue to be so. All participants cited that they were walking more and most were achieving 16-30 minutes of increased physical activity a day. Five children had guardians who themselves became participants on the Physical Activity Referral Scheme as a result of their children’s involvement. This probably indicates that whole families were becoming more physically active as a result of their children’s involvement in the programme. One child had not taken part in school P.E. for several years but was now doing so.
Table I.
Obesity Diabetes Heart Disease
One side of family
Both sides of family
44% (7) 25% (4) 25% (4)
50% (8) 25% (4) 44% (7)
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Figure 1.
Dietary marker Fruit and vegetable intake Frequency of sweets/ chocolate intake Frequency of crisp intake Sugary Drink Consumption
Pre-programme
Post-programme
Average intake 2 portions/ day. Average frequency of consumption 3/week Average intake of 5 packets/week 50% 50%
Average intake of 3.5 portions/day Average frequency of consumption 2/week Average intake reduced to 3 packets/ 92% 8%
Table II.
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Conclusion The number of children involved in this pilot programme has been small but the scheme appears to have been an effective means of enabling children and their families achieve a healthier lifestyle. This conclusion is based on patient and their families self reporting of attained physical activity levels and changes in dietary intake as indicated by dietary markers. However BMI profiles and waist circumference centile data also support this conclusion showing general improvements in both weight and in decreased central fatness. Various suggested modifications were made by the families to improve the scheme. These were notably that offering special aerobic or circuit training type classes and more frequent support would be beneficial. The children will be screened for height, weight and therefore BMI by their school nurses a year on from the completion of the project. There are plans to modify the physical activity options and re-run the scheme in another town nearby. Referrals will be sought from the Primary Care Team as well as school nurses and in collaboration with Sure Start. Advice from a statistician will establish a statistically significant sample size. References Cole, T.J. et al. (2000), ‘‘Establishing a standard definition for child overweight and obesity worldwide international survey’’, BMJ, Vol. 320, pp. 1240-53. Health Development Agency (2003), The Management of Obesity and Overweight: An Analysis of Diet, Physical Activity and Behavioural Approaches, Health Development Agency. McCarthy, D. et al. (2003), ‘‘Central overweight and obesity in British Youth aged 11-16 years cross sectional surveys of waist circumference’’, BMJ, Vol. 326, pp. 624. McCarthy, D. et al. (2001), ‘‘The development of waist circumference percentiles in British children aged 5-16.9 years’’, European Journal of Clinical Nutrition, Vol. 55, 902-7. NHS CRD (Centre for reviews and Dissemination) (2002), ‘‘The prevention and treatment of childhood obesity’’, Effective Health Care, Vol. 7 No. 6. SIGN (1996), Obesity in Scotland: Integrating Prevention with Weight Management. A National Clinical Guideline, SIGN, Edinburgh. Further reading Edmund, et al. (n.d), ‘‘Scottish Intercollegiate Guidelines Network (SIGN) Obesity in Scotland: Integrating prevention with weight management’’, Childhood obesity. Anon (2001), ‘‘Evidence based management of childhood obesity’’, BMJ, Vol. 323, 20 October. Gibson, P. et al. (n.d), ‘‘An approach to weight management in children and adolescents (2-18 years) in primary care’’, produced for the Royal College of Paediatrics and Child Health and National Obesity Forum. Prescott-Clarke, P. et al. (1997), Health Survey for England 1995, The Stationery Office, London. Anon (2001), ‘‘School based programmes on obesity’’, BMJ, Vol. 323, 3 November. Third newsletter of All Party Parliamentary Obesity Group www.nationalobesityforum.org.uk Whitaker, R.C. et al. (1997), ‘‘Predicting obesity in young adulthood from childhood and parental obesity’’, N. Engl. J. Med., Vol. 337, pp. 869-73.
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Effects of an over-the-counter herbal weight management product (Zotrim1) on weight and waist circumference in a sample of overweight women: a consumer study
Effects of Zotrim on weight
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C.H.S. Ruxton Nutrition Communications, Cupar, Fife, UK
F. Hinton Edinburgh Dietetic Centre, Edinburgh, UK
C.E.L. Evans Stats and Figures, Leeds, UK Abstract Purpose – Aims to carry out a consumer intervention study to evaluate the impact of an over-thecounter herbal weight management product (Zotrim1 ) on weight and waist circumference. Design/methodology/approach – Overweight women were recruited using local media and 61 passed initial screening to begin a four-week intervention using a free sample of Zotrim at a dosage corresponding to manufacturers’ recommendations. A total of 56 subjects completed the study, but data on all 61 were included in the ‘‘intention to treat’’ analysis. Findings – There was a self-reported mean weight loss of 1.79 kg (0.45 kg per week) at week 4. Data on perceived hunger and fullness from three sets of questionnaires suggested that subjects felt less hungry between meals and fuller after meals at weeks 1 and 4 compared with base-line. This is likely to have impacted on energy intake and may account for the weight loss. Average weight loss as a percentage of baseline was 2.3 per cent, but this masked a broad range, suggesting that some subjects benefited more than others. Taking into account adjusted guidelines for clinically significant weight loss, 23 per cent of subjects achieved this cut-off, suggesting that their risk of chronic disease had reduced. Similarly, waist circumference (an independent measure of disease risk) decreased by an average of 4.3 cm during the four-week period. This reduced the number of subjects exceeding SIGN guidelines for central obesity from 93 per cent to 83 per cent. Originality/value – Adds to the body of knowledge by proring that Zotrim can aid weight loss and help reduce waist circumference. Keywords Obesity, Health education, Medicines, Body regions Paper type Research paper
Introduction Much research has focussed on the aetiology of obesity but relatively little on options for treatment. The Health Committee report (2004) highlighted not only the inadequate resources for weight management offered by the National Health Service, but the shortage of effective, evidence-based options. Systematic reviews of treatment and This study was funded by an educational grant from Natures Remedies Ltd whose employees played no role in the collection or analysis of data.
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prevention programmes (Health Development Agency, 2003; Avenell et al., 2004) suggest that low fat diets are as effective as calorie reduced diets, although the more extreme very low calorie diets (typically less than 1000 kcal per day) induce greater weight loss. Approved drug treatments in the UK are sibutramine and orlistat which can induce a significant weight loss after 12 months (Avenell et al., 2004), although weight seems to increase after this time despite continuation of the drugs (Torgerson et al., 2004). Adding exercise increases the efficacy of diets (Health Development Agency, 2003), while combination programmes of diet, exercise and behavioural therapy appear to give the best weight loss results (Avenell et al., 2003), although the number of published studies is small. Table I summarises mean weight changes and weekly rates of weight loss following various interventions for weight management. While the outcome of these options looks encouraging, albeit modest in terms of weight loss, there are downsides including weight regain (particularly when interventions come to an end), poor compliance, insufficient access to therapies in primary care, and the risk of side effects from drug treatments. Increasing numbers of consumers are now purchasing over-the-counter weight management remedies. However, the scientific evidence for most is sparse (Pittler and Ernst, 2004). One exception is the YGD formulation (now called Zotrim, Natures Remedies) which has been tested in a clinical trial (Anderson and Fogh, 2001) and a consumer study (Ruxton, 2004). Andersen and Fogh randomised 47 healthy overweight subjects to receive either YGD or a placebo. The results demonstrated a statistically significant weight loss of 5.1 kg over the 45-day period (0.8 kg per week) for YGD
Treatment Orlistat (Xenical)
Comparison a
Orlistat (Xenical)b Sibutramine (Reductil)b Low fat or 600 kcal deficit dietb Low calorie dietb Very low calorie dietb Low fat or 600 kcal deficit diet plus exerciseb Diet plus behavioural therapyb Table I. Expected weight loss from obesity treatments
Drug plus lifestyle changes vs placebo plus lifestyle Drug plus diet vs placebo plus diet (mean of 8 studies reported) Drug plus diet vs placebo plus diet (mean of 4 studies reported) Diet vs control (mean of 13 studies reported) Diet vs control (mean of 2 studies reported) Diet vs control (1 study reported) Diet and exercise vs control (mean of 4 studies reported) Diet and behavioural therapy vs control (mean of 3 studies reported)
Notes: a Torgerson et al. (2004); bAvenell et al. (2004)
Weight change at 12 months
Rate of weight loss (kg/week)
10.6 kg with drug vs 6.2 kg for placebo
0.2
5.9 kg with drug vs 3.0 kg with placebo
0.1
5.1 kg with drug vs 0.8 kg with placebo
0.1
4.5 kg with diet vs þ0.6 kg with control 5.7 kg with diet vs +0.4 kg with control 11.1 kg with diet vs +2.3 kg with control 5.9 kg with diet/ex vs +0.8 kg with control
0.1
7.3 kg with diet/ therapy vs +0.6 kg with control
0.1
0.1 0.2 0.1
compared with 0.3 kg for the placebo. No advice on diet or exercise was given to subjects. A follow-up of 22 subjects in the YGD group at 12 month revealed that the initial weight loss was maintained. YGD is likely to induce weight loss by impacting on satiety. A parallel study by Andersen and Fogh (2001) using ultrasound revealed that the rate of gastric emptying in seven volunteers was affected following consumption of YGD vs a placebo. Gastric emptying after YGD was 53 per cent slower than after the placebo. A shorter time to fullness has also been reported by subjects after consuming YGD (Andersen, 2002). The weight loss results of Anderson and Fogh (2001) were supported by previous consumer study (Ruxton, 2004). Forty-eight women given a free trial of Zotrim for 28 days demonstrated a mean weight loss was 2.3 kg (0.6 kg per week). These studies, the clinical and the consumer, provide evidence that the formulation is effective for weight management and can be useful in the field. However, weight on its own is not a good predictor of disease risk. Studies suggest that waist circumference, independent of body mass index (BMI), predicts the risk of chronic diseases such as diabetes and cardio-vascular disease (Zhu et al., 2004; Janssen et al., 2004). Previous studies have not evaluated how Zotrim might impact on measures other than weight and BMI, thus the aim of our study was to look at the effect of one month’s supply of Zotrim on weight, waist circumference and waist-to-hip ratio in free-living subjects. Subjects, recruitment and study design Articles in local newspapers in Fife and Buckinghamshire were used to recruit subjects for a consumer study on weight management. The articles called for overweight women aged over 18 years who were healthy and not currently pregnant or breastfeeding. The study was restricted to women in order to keep the sample as homogenous as possible. The first 115 responding to the articles were sent a recruitment pack, containing an information sheet, a tape measure, screening questionnaire and consent form, by the study dietitian (FH). Exclusion criteria were applied to all women returning the screening questionnaire. There were: BMI below 25 or above 35; poor reported health or multiple medical conditions; reported sensitivity to caffeine; thyroid disease; gastro-intestinal disease; pregnant or breast-feeding; poor motivation or unwillingness to take Zotrim; lack of signature on consent form; being male; aged under 18 years or over 70 years; no access to scales. Women with diabetes mellitus were included but were advised that the risk of hypoglycaemia could increase during the study (if they reduced their consumption of food). The selected sample was sent further instructions and a 4-week supply of Zotrim. Regular telephone calls from the study dietitian were used to prompt subjects to complete the questionnaires at week 1 and week 4, and to take anthropometric measurements at the correct time. Figure 1 gives an overview of the study design. Materials and methods Details of the product Zotrim is a commercially available herbal food supplement containing the active ingredients yerba mate´ (leaves of Ilex paraguayensis), guarana (seeds of Paullinia cupana) and damiana (leaves of Turnera diffusa var. aphrodisiaca). All are extracts of South American herbs which have a history of use in traditional culture. Subjects were asked to take two tablets 15 minutes before meals for seven days. At this point, they were prompted by telephone to increase the dose to three tablets 15 minutes before
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Figure 1. Study design overview
meals for the remainder of the study. These instructions were in line with the manufacturer’s guidance. Anthropometric measurements Subjects were asked to provide weight (kg or lb), height (m or feet), waist circumference (cm) and hip circumference (cm) at Screening. These data were used as the baseline measurements if no changes had occurred between screening and baseline. All measurements were repeated at week 1 and week 4. Full written instructions were given on how to take the measurements and the study dietitian checked comprehension by telephone. Data were converted to metric where necessary.
Questionnaires Four questionnaires were used. The screening questionnaire focussed on information relevant to the exclusion criteria i.e. health related. The baseline questionnaire had three sections: ratings of hunger and fullness around the main meals using a 10 point scale; questions on number and type of snacks consumed; statements on perceived control over eating to which subjects were asked to respond with ‘‘agree’’, ‘‘disagree’’ or ‘‘neutral’’. These three sections were repeated in the questionnaires at week 1 and week 4. Additional questions were added to cover compliance with Zotrim, perceived changes to eating habits and any reported side effects or benefits experienced during the study. Statistical analyses All data were entered into Stata (StataCorp) and analysed. Anthropometric measurements at baseline and at 4 weeks were compared using paired t-tests. Ratings for hunger and fullness were analysed using Wilcoxon Sign Rank tests. Results Subjects and compliance 115 women responded to the media articles and 105 were sent screening questionnaires. Of these, 88 returned their questionnaires and 61 were started on the consumer study with 56 completing all stages. All data from the 61 starters were included to enable an ‘‘intention to treat’’ analysis. Thus, the sample size for the results varies between 56 and 61 depending on the availability of data. Mean baseline weight was 77.9 kg (60.9 kg to 97.7 kg) and mean BMI was 29.4 kg/m2 (25.1 kg/m2 to 35 kg/m2). Mean baseline waist circumference was 93.7 cm (68 cm to 114 cm), while mean waist-to-hip ratio was 0.86 (0.67 to 1.1). 57 women (93 per cent) had a waist circumference in excess of the 80 cm SIGN (1996) guidelines cut-off for central obesity. Reported compliance with Zotrim was good. At week 1, 64 per cent had taken all tablets as instructed and no-one had missed more than a couple of occasions. By week 4, full compliance had gone down to 44 per cent but only 25 per cent had missed more than a couple of occasions. Reasons for lack of compliance included illness, holidays and forgetfulness. Weight and BMI Mean weight loss was 0.7 kg (CI +/0.31) at week 1, and 1.79 kg (CI +/0.65) at week 4, both statistically significant at p < 0.0001 when compared with baseline. The range of weight loss was broad (+2.27 kg to 9.55 kg), suggesting that some subjects responded better than others to the intervention. Figure 2 shows the spread of individual weight change between baseline and week 4. The overall mean rate of weight loss was 0.45 kg per week, although the rate between baseline and week 1 (0.7 kg) was greater than between week 1 and week 4 (0.37 kg). Mean weight loss at week 4 was 2.3 per cent of baseline but this masked a broad range of +2.7 per cent to 12 per cent. Mean BMI reduced by 0.27 at week 1 and by 0.68 by week 4. All changes were statistically significant at p < 0.0001.
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Waist and hip circumferences As Figure 3 shows, mean waist circumference reduced by 1.8 cm at week 1 ( p < 0.001), and by 4.3 cm by week 4, compared with baseline ( p < 0.0001). The range of overall waist circumference change was +3 cm to –11 cm at week 2, and +8 cm to –17 cm at week 4. The reductions brought 10 (17 per cent) subjects below the SIGN guideline cutoff for central obesity. Similar reductions were seen for hip circumference. At week 1, the mean reduction was 1.3 cm ( p < 0.001), while at week 4, it was 3.2 cm ( p < 0.0001). Waist-to-hip ratio remained stable throughout the study at around 0.85. Perceived hunger The 10 point rating scale for reported hunger at mid-morning, mid-afternoon and late evening was collapsed into three groups for ease of analysis. These were scale 1 to 3 ‘‘a little hungry’’, scale four to six ‘‘quite hungry’’, and scale seven to ten ‘‘very hungry’’. Figure 4 shows how hunger mid-morning changed over the study. More women reported feeling less hungry at both week 1 ( p < 0.0001) and week 4 ( p < 0.0001)
Figure 3. Mean change in waist circumference (cm)
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Figure 4. Number of subjects reporting various levels of mid-morning hunger at baseline, week 1 and week 4
compared with baseline. There was no significant difference in hunger between weeks 1 and 4. At the end of the study, 42 women said they were less hungry, eight said they felt the same and 11 said they were more hungry. The median score was five at the beginning of the study, decreasing to three at weeks 1 and 4. There was a similar pattern for the hunger ratings reported for mid-afternoon and late in the evening. Perceived fullness The ten point rating scale for reported fullness after breakfast, after lunch and after the evening meal was collapsed into three groups for ease of analysis. These were scale one to four ‘‘not full’’, scale five to seven ‘‘quite full’’, and scale eight to ten ‘‘very full’’. Figure 5 shows how fullness after lunch changed over the study. More women reported feeling fuller at both week 1 ( p < 0.005) and week 4 ( p < 0.05) compared with baseline. There was no significant difference in hunger between weeks 1 and 4. At the end of the study, 29 women said they were more full, ten said they felt the same and 18 said they were less full after lunch. The median score was seven at the beginning of the study, then eight at both weeks 1 and 4. There was a similar pattern for the hunger ratings reported after breakfast, however, the effect appeared to be greater after the evening meal with 33 women reporting that they were fuller, 12 saying they felt the same and 15 saying they were less full.
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Reported snacking Subjects were asked how many snacks they ate between main meals, and during the evening. Figure 6 shows consumption of snacks following the evening meal. Subjects were more likely to snack in the evening than at any other time with many subjects having two or more snacks. Compared with baseline measures, subjects reported fewer snacks in the evening at week 1 ( p > 0.05) and at week 4 ( p < 0.005). There was no significant change in the number of snacks eaten between weeks 1 and 4. At the end of the study, 25 women said they ate fewer snacks, 28 said they ate the same number and eight said they ate more snacks in the evening. Results were similar for reported snacking between breakfast and lunch, and between lunch and the evening meal. The reductions in snacking at these times of the day were more statistically significant than the evening reductions. Additional perceived effects of Zotrim In order to probe for positive or negative effects associated with taking Zotrim, subjects were asked how they felt at weeks 1 and 4. After a week, 20 subjects reported feeling better, 30 said they felt the same, and 9 said they felt worse. After 4 weeks, the numbers changed to 25 (better), 29 (same) and 5 (worse). Reasons for positive or negative responses were recorded. Subjects could offer more than one explanation. Reasons for a negative response at week 1 (n = 9) and week 4 (n = 5) were feeling unwell or tired, and experiencing a change in bowel habit. Feelings of sleeplessness and bloating were reported by two subjects at week 1, but not week 4. The main reason for a positive response at weeks 1 and 4 was a sense of greater energy (n = 11 both times). Other comments included feeling less hunger and increased well-being, eating more healthily and feeling positive about weight loss (n = 12 at week 1; n = 16 at week 4). Discussion This consumer study demonstrates statistically significant weight loss and changes in body shape over a 4-week period. Subjects were not asked to take a commercially available weight management remedy as per manufacturer’s instructions but not to make any changes to their diet or physical activity regime. While not intended as a scientifically rigorous study, i.e. there was no control group, the work nevertheless fulfils the objective of providing additional evidence in an uncontrolled setting to support the 45-day randomised, placebo-controlled trial of Anderson and Fogh (2001).
Figure 5. Number of subjects reporting various levels of post-lunch fullness at baseline, week 1 and week 4
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Figure 6. Number of subjects reporting snack consumption in the evening at baseline, week 1 and week 4
Although the methodology and duration of the studies differ, it is useful to compare our 28-day study with the results of Anderson and Fogh. Using a one-sample t-test, weight loss in the clinical trial was found to be significantly greater than in the present study. This is an indication that the samples differed and one obvious distinction is the inclusion of men in the clinical trial. A recent study found that men were more successful at losing weight than women (Truby et al., 2004), while another showed that men were better at maintaining resting energy expenditure while dieting (Volek et al., 2004). A second difference is that subjects in the clinical trial were recruited from a weight management clinic (suggesting a commitment to losing weight and perhaps greater dietary knowledge), while those recruited for the consumer study were recruited from the general population. A third difference is the duration – the clinical study was 17 days longer than the consumer study and the rate of weight loss increased from 0.52 kg per week in the first ten days to 0.79 kg per week for the entire study. In contrast, the rate of weight loss in our study decreased from 0.7 kg per week in the first seven days to 0.37 kg per week thereafter. This is more typical of weight management and yet still seems to exceed the rates of weight loss reported for other therapies (0.1 to 0.2 kg per week, see Table I), although it is acknowledged that these studies were conducted over 12 months. Given the changes in reported hunger, satiety and snacking, it is reasonable to assume that the weight changes in our study occurred because subjects were able to eat
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less and maintain this over the 4-week period. It could be assumed that subjects deliberately ate less because they knew they were receiving weight management therapy and being monitored. However, it is interesting to note that the weight change in the placebo group of the Anderson and Fogh clinical study – also a group aware of being monitored and believing that they may have been given an active therapy for weight loss – was only 0.3 kg over 45 days. This suggests that the weight loss in both studies was genuine. While statistically significant weight loss is important, guidelines for weight management place emphasis on the achievement of a clinically significant weight loss, i.e. one that lowers the risk of chronic disease. The National Obesity Forum (NOF, 2004) suggests a figure of 10 per cent of baseline body weight over 12 weeks for clinical significance. When this criterion is applied to our 4-week study, the pro-rata weight loss goal is 3.3 per cent. Fourteen subjects in our study (23 per cent) achieved a weight loss of 3.3 per cent of baseline or more, while a further ten (16 per cent) achieved a weight loss of 2.3 per cent to 3.2 per cent. Only three subjects gained weight over the 4 weeks with a mean gain of 2 kg. The use of Zotrim compares well with conventional therapies such as reduced calorie diets and exercise, particularly since our subjects were not asked to many any changes to either diet or physical activity. Apart from the 12-month studies summarised in Table I, which report an average rate of weight loss of 0.1 kg to 0.2 kg per week, there is evidence from short-term interventions. Drummond et al. (2004) used a 770kcal deficit diet in 76 men and reported a weight loss of 5.2 per cent baseline after 12 weeks (pro rata 1.7 per cent over 4 weeks). This is lower than the 2.3 per cent found in our consumer study. Another study which used a 600kcal deficit diet over 8 weeks in 68 adults reported a mean weight loss of 3.0 kg (pro rata 1.5 kg over 4 weeks). This, again, is lower than the 1.79 kg found in our consumer study. A key component of this study was to evaluate how Zotrim impacted on waist circumference, since this is an independent determinant of disease risk. Mean waist reduction was 4.3 cm which lowered the proportion of women exceeding the SIGN (1996) cut-off for central obesity from 93 per cent at baseline to 83 per cent at 4 weeks. The reduction in waist circumference compared well with that reported by other studies. Wien et al. (2004) achieved a 14 per cent reduction in waist circumference over 24 weeks in 65 adults using a low calorie formula diet enriched with almonds. The pro rata reduction of 2.3 per cent over 4 weeks is lower than the 4.5 per cent reduction in waist circumference seen in our study. Similarly, a 6-week high carbohydrate dietary intervention in 63 men achieved a 2.6 cm (2.7 per cent) reduction in waist circumference (Archer et al., 2003), while a 12-week energy restricted dietary intervention in 51 men achieved a 8.1 cm reduction in waist circumference (Ash et al., 2003). The pro rata reductions in these two studies would be 1.7 cm and 2.7 cm respectively, compared with the 4.3 cm in our study. Zotrim appeared to have a greater impact on waist circumference than the therapies reported in these studies. Conclusion This consumer study provides further evidence that an over-the-counter herbal weight management product (Zotrim) can help induce a statistically significant mean weight loss in a sample of overweight free-living women. The product also had
a significant impact on waist circumference, an independent determinant of chronic disease risk. Both the weight and waist circumference changes over 4 weeks compare favourably with longer-term conventional weight management therapies. References Andersen, T. and Fogh, J. (2001), ‘‘Weight loss and delayed gastric emptying following a South American herbal preparation in overweight patients’’, Journal of Human Nutrition and Dietetics, Vol. 14, pp. 243-50. Archer, W.R., Lamarche, B., Deriaz, O., Landry, N., Corneau, L., Despres, J.P., Bergeron, J., Couture, P. and Bergeron, N. (2003), ‘‘Variations in body composition and plasma lipids in response to a high-carbohydrate diet’’, Obesity Research, Vol. 11, pp. 978-86. Ash, S., Reeves, M.M., Yeo, S., Morrison, G., Carey, D. and Capra, S. (2003), ‘‘Effect of intensive dietetic interventions on weight and glycaemic control in overweight men with Type II diabetes: a randomised trial’’, International Journal of Obesity, Vol. 27, pp. 797-802. Avenell, A., Broom, J., Brown, T.J., Poobalan, A. et al. (2004), ‘‘Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement’’, Health Technology Assessment, Vol. 8 No. 21. Drummond, S., Dixon, K., Griffin, J. and De Looy, A. (2004), ‘‘Weight loss on an energy-restricted, low-fat, sugar-containing diet in overweight sedentary men’’, International Journal of Food Sciences and Nutrition, Vol. 55, pp. 279-90. Health Development Agency (2003), ‘‘The management of obesity and overweight’’, An Analysis of Reviews of Diet, Physical Activity and Behavioural Approaches, HDA, London. House of Commons, Health Committee (2004), Obesity, Third report of session 2003-04, Vol. 1, The Stationery Office, London. Janssen, I., Katzmarzyk, P.T. and Ross, R. (2004), ‘‘Waist circumference and not body mass index explains obesity-related health risk’’, American Journal of Clinical Nutrition, Vol. 79, pp. 379-84. National Obesity Forum (2004), Guidelines for Management of Adult Obesity and Overweight in Primary Care, National Obesity Forum, London, available at: www. nationalobesityforum.org.uk/ Pittler, M.H. and Ernst, E. (2004), ‘‘Dietary supplements for body-weight reduction: a systematic review’’, American Journal of Clinical Nutrition, Vol. 79, pp. 529-36. Torgerson, J.S., Boldrin, M.N., Hauptman, J., Sjo¨stro¨m, L. (2004), ‘‘XENical in the prevention of diabetes in obese subjects (XENDOS) study’’, Diabetes Care, Vol. 27, pp. 155-61. Truby, H., Millward, D., Morgan, L., Fox, K., Livingstone, M.B., DeLooy, A. and Macdonald, I. (2004), ‘‘A randomised controlled trial of 4 different commercial weight loss programmes in the UK in obese adults: body composition changes over six months’’, Asia Pacific Journal of Clinical Nutrition, Vol. 13(Suppl), pp. S146. Ruxton, C.H.S. (2004), ‘‘Efficacy of Zotrim: a herbal weight loss preparation’’, Nutrition & Food Science, Vol. 34, pp. 25-28. Volek, J.S., Sharman, M.J., Gomez, A.L., Judelson, D.A., Rubin, M.R., Watson, G., Sokmen, B., Silvestre, R., French, D.N. and Kraemer, W.J. (2004), ‘‘Comparison of energy-restricted very low-carbohydrate and low-fat diets on weight loss and body composition in overweight men and women Nutritional Metabolism’’, Vol. 1 No. 1, pp. 13.
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Wien, M.A., Sabate, J.M., Ikle, D.N., Cole, S.E. and Kandeel, F.R. (2004), ‘‘Almonds vs complex carbohydrates in a weight reduction program’’, International Journal of Obesity, Vol. 27, pp. 1365-72. Zhu, S., Heshka, S., Wang, Z., Shen, W., Allison, D.B., Ross, R. and Heymsfield, S.B. (2004), ‘‘Combination of BMI and waist circumference for identifying cardiovascular risk factors in whites’’, Obesity Research, Vol. 12, pp. 633-45. Further reading Scottish Intercollegiate Guidelines Network (SIGN) (1996), Obesity in Scotland. Integrating Prevention with Weight Management, publication No. 8, SIGN, Edinburgh. West, J.A., de Looy, A.E. (2001), ‘‘Weight loss in overweight subjects following low-sucrose or sucrose-containing diets’’, International Journal of Obesity, Vol. 25, pp. 1122-8.
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Predictors of physician overweight and obesity in the USA: an empiric analysis John La Puma
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Director, Santa Barbara Institute for Medical Nutrition and Healthy Weight, Santa Barbara, California, USA
Philippe Szapary Assistant Professor of Medicine, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
Kevin C. Maki President and CEO, Provident Clinical Research and Consulting, Wheaton, Illinois, USA Abstract Purpose – Because patients are more likely to follow advice from healthy weight rather than overweight physicians, seeks to determine whether physician overweight could be predicted by selfreported physician eating behaviors. Design methodology/approach – An anonymous, written, self-administered, pre-tested, confidential survey of practicing physicians in the Midwestern USA was undertaken. Findings – Most surveyed physicians (394 or 74 per cent) completed the survey. The results indicate that stress at home (OR 2.62, CI 1.35-5.08) was most significantly and strongly predictive of physician overweight (BMI > 25 kg/m2), as were particular eating behaviors, including eating food provided at the medical office. Assessment of overall health was significantly and strongly inversely proportionally predictive (OR 0.43, CI 0.30-0.62) of physician overweight as well. Research limitations/implications – The research implies that, like patients, practicing US physicians are susceptible to feelings other than hunger which prompt over-eating and weight gain. Limitations include study of a single, specific sample of physicians, and an exclusive focus on food and nutrition. Future research may wish to include measures of fitness and exercise. Originality/value – Physicians are susceptible to predictable, particular feelings other than hunger which prompt over-eating and overweight. Physician ability to respond to these feelings and to ameliorate the stresses and factors associated with them may help improve physician overweight and, in turn, physician ability to facilitate patient weight loss. Keywords Diet, Nutrition, Doctors, Obesity, Health education, Stress Paper type Viewpoint
Background McMenamin et al. report that nutrition programs are the second most prevalent health promotion intervention offered to physicians McMenamin et al. (2004), and attention Disclosures: Dr La Puma has received compensation from 1999-2004 for consulting with medical conference sponsors to create and supervise healthful conference meals. Dr Maki has received honoraria, research stipends and/or consulting fees related to products or research on weight management from: Roche Pharmaceuticals, Ross Products Division of Abbott Laboratories, Kao Corporation, Glanbia Foods, AMBI Corporation and General Mills. Dr Szapary has nothing to declare. Presented at the 4th Annual University of Chicago Conference on Alternative Medicine, Chicago, Illinois, December 13, 2002. Versions of this work have not been previously published; it is part of the CHEF Clinic study, and its other published studies are referenced.
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has been drawn to physicians’ own lifestyle and work habits with the rising prevalence of obesity Young (2004). As part of a study of physician overweight, we wondered whether certain behavioral factors are associated with physician overweight. Methods We conducted a descriptive, cross-sectional pilot study using an anonymous mailed, pre-tested, confidential questionnaire of a large, suburban, community, non-teaching Midwestern hospital in Fall 2001. We surveyed the entire active, current medical staff (MD or DO degree), totaling 538; 2 questionnaires could not be delivered. Using a 5point scale, using both Likert scales and multiple choice questions, we asked how often respondents ate while talking on the phone, reading or working at a computer, and watching television. We asked whether physicians often ate while lonely or bored; for pleasure using food as a reward; to help deal with stresses at home or work; when in a social situation; or while drinking alcohol (see Table I). The protocol and pilot instrument, derived from behavior modification literature Foreyt and Goodrick (1993) and the investigators’ clinical experience, were designated as exempt research by the institution’s IRB. Characteristics of the study sample categorized according to BMI (<25.0 kg/m2 vs. 25.0 kg/m2) were compared using the two-sample t-test and chisquare test as appropriate. The Mann-Whitney U test was used to compare ordinal responses to questions regarding eating behaviors between subjects grouped according to BMI categories. Multiple logistic regression analyses were used to assess the relationships between individual questionnaire responses and BMI category after adjustment for age, sex and race/ethnicity. Adjusted odds ratios (OR) and 95 per cent confidence intervals (CI) were calculated from logistic regression analyses. Results Of 536, 402 (75 per cent) responses were returned; 394 (74 per cent) included weight and height data. Most responders were male (75 per cent); mean age was 45 ± 9 (SD) years. Non-responders did not differ in age, gender and physician specialty. More than 83 per cent spent at least 75 per cent of their total work time in direct patient care. Average BMI was 25.1 kg/m2 ± 3.32 kg/m2; 44 per cent of respondents were overweight, including 8 per cent obese (BMI >30 kg/m2). The Table shows both univariate and multivariate behavioral predictors of overweight and obesity. In our multivariate analysis, adjusted for age, race/ethnicity, and gender, several self-reported behaviors were identified associated with overweight/ obesity. Greater self-rated overall health was strongly inversely associated with overweight/obesity [0.39 (0.26-0.57)] using data collapsed into a three point ordinal scale (poor/fair = 1, good = 2, very good/excellent = 3). Other reported eating behaviors, such as eating while talking on the phone, and working on a computer were not significantly related as predictors of overweight; neither was likelihood of overeating when in a social situation or when drinking alcohol. Discussion These data suggest that certain lifestyle and work factors may be associated with self-reported overweight in a population of US practicing physicians. Two factors concern self-reported stress. There is evidence that ‘‘stress-eaters’’ in the general population are more likely to be overweight than those who are not so identified Laitinen et al. (2002). Basic science research now links chronic stress and obesity Dallman et al. (2003). Abdominally obese people with metabolic syndrome have
Univariate analysis
Adjusted for age, race and sex
Odds ratioa
95% C.I.
Odds ratioa
95% C.I.
91 (23.1) 36 (16.4) 55 (31.6)
2.36
1.46, 3.82
2.65
1.57, 4.47
All physicians BMI <25 kg/m2 BMI 25 kg/m2
115 (29.2) 50 (22.7) 65 (37.4)
2.03
1.31, 3.15
2.20
1.37, 3.52
Eating when stressed at home
All physicians BMI <25 kg/m2 BMI 25 kg/m2
43 (10.9) 15 (6.8) 28 (16.1)
2.62
1.35, 5.08
3.16
1.55, 6.44
Eating when stressed at work
All physicians BMI <25 kg/m2 BMI 25 kg/m2
58 (14.7) 22 (10.0) 36 (20.7)
2.35
1.32, 4.17
2.78
1.47, 5.37
Eat food provided at the medical office
All physicians Never/rarely Sometimes Often/always
1.37
1.02, 1.83
1.50
1.08, 2.07
52 (14.4) 105 (29.0) 205 (56.6)
BMI <25 kg/m2 Never/rarely Sometimes Often/always
35 (17.5) 60 (30.0) 105 (52.5)
BMI 25 kg/m2 Never/rarely Sometimes Often/always
17 (10.5) 45 (57.8) 100 (61.7)
All physicians Poor/fair Good Very good/excellent
0.43
0.30, 0.62
0.39
0.26, 0.57
24 (6.1) 88 (22.4) 281 (71.5)
BMI <25 kg/m2 Poor/fair Good Very good/excellent
6 (2.7) 36 (16.4) 177 (80.8)
BMI 25 kg/m2 Poor/fair Good Very good/excellent
18 (10.3) 52 (29.9) 104 (59.8)
Behavior
Subgroup
Eating when lonely or bored
All physicians BMI <25 kg/m2 BMI 25 kg/m2
Eating using food as a reward
Assessment of overall health
n (per cent)
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Note: aThe odds ratios estimate the probability of a positive response using Healthy Weight (BMI <25 kg/m2) as the referent
higher physiologic markers of stress Hjemdahl (2002). High cortisol levels, an indicator of chronic stress, have been associated with leptin resistance in animal models of obesity. While specific stresses and heightened awareness are useful in particular medical settings (e.g. for dealing with medical emergencies), personal stress reduction is an accepted part of ameliorating cardiovascular risk and improving general health.
Table I. Significant predictors of body mass index (BMI) among respondent physicians (n = 394) grouped by overweight (BMI 25 kg/m2) and healthy weight (BMI <25 kg/m2)
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Previous studies have suggested that eating in response to loneliness Schumaker (1985), boredom Abramson and Stinson (1977) and as a reward Brink et al. (1999) are associated with excess weight, and our findings suggest these factors in physicians as well. While clinicians counsel patients to address these factors in other ways, and patients may recognize the need to do so, precisely how to do so is often difficult. For some patients, identifying the feelings of loneliness, boredom and the need for a reward as separate from the feeling of hunger may be a first step in eating less; for other patients, the feelings may be less important than simply what to do to avoid eating. The provision of free meals to physicians has been shown to be an independent predictor of change in attending physician practice Lurie et al. (1991). Although physicians disagree about whether pharmaceutically-sponsored free meals represent a meaningful conflict of interest Kassirer (2001), meals’ widespread availability and their practical value to individual clinical practices Backer (2000) are readily acknowledged. Choices for meals would seem readily amenable to the preferences of physicians and their staff, who themselves may conflict about which foods are preferred and delivered. To the best of our knowledge, the nutritional content of food provided in the medical office has not been studied, though data show that eating outside the home is associated with overweight and obesity French (2000); Guthri et al. (2002). Physicians appear to have a lower prevalence of overweight and obesity than the general population, and those who rated their overall health as excellent or good were less likely to be overweight or obese than those who reported poorer health. Although some physicians may report lower overall general health simply because they are overweight, we believe that physicians who self-reported healthfulness are likely to have fewer obesity-related medical problems, and to be more fit overall. Physicians tend to adopt and follow healthy lifestyle behaviors earlier than the general population Wyshak et al. (1980) and patients are reported to accept health advice more readily from nonobese physicians than obese physicians Hash et al. (2003). Thus, if physicians can limit their weight gain and practice better eating behaviors, their encouragement and empathy may both grow. Limitations of this short study include a single population under study and an exclusive focus on food and nutrition: future research surveys may wish to include measures of fitness and exercise. While the sample size of physicians is small and may be representative only of the community identified, these data with the associated CHEF Clinic studies La Puma et al. (2004a, b, c) suggest that like patients, physicians are susceptible to feelings other than hunger which prompt over-eating. Physician ability to respond to these feelings and to ameliorate the stresses and factors associated with them may help improve physician overweight, and in turn, patient weight loss. References Abramson, E.E. and Stinson, S.G. (1977), ‘‘Boredom and eating in obese and non-obese individuals’’, Addict Behav, Vol. 2, pp. 181-5. Backer, E.L., Lebsack, J.A., Van Tonder, R.J. and Crabtree, B.F. (2000), ‘‘The value of pharmaceutical representative visits and medication samples in community-based family practices’’, J Fam Pract. Vol. 49 No. 9, pp. 811-16. Brink, P.J., Ferguson, K. and Sharma, A. (1999), ‘‘Childhood memories about food: the Successful Dieters Project’’, J Child Adolesc Psychiatr Nurs, Vol. 12, pp. 17-25. Dallman, M.F., Pecoraro, N., Akana, S.F., La Fleur, S.E., Gomez, F., Houshyar, H. et al. (2003), ‘‘Chronic stress and obesity: a new view of comfort food’’, Proc Natl Acad Sci USA, Vol. 100, pp. 11696-701.
Foreyt, J.P. and Goodrick, G.K. (1993), ‘‘Evidence for success of behavior modification in weight loss and control’’, Ann Intern Med, Vol. 119 No. 7 Pt 2, pp. 698-701. French, S.A., Harnack, L. and Jeffery, R.W. (2000), ‘‘Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates’’, Int J Obes Relat Metab Disord, Vol. 24, pp. 1353-9. Guthri, J.F., Lin, B.H. and Frazao, E. (2002), ‘‘Role of food prepared away from home in the American diet, 1977-78 vs 1994-96: changes and consequences’’, Journal of Nutrition Education and Behavior, Vol. 34, pp. 140-150. Hash, R.B., Munna, R.K., Vogel, R.L. and Bason, J.J. (2003), ‘‘Does physician weight affect perception of health advice?’’, Prev Med, Vol. 36, pp. 41-44. Hjemdahl, P. (2002), ‘‘Stress and the metabolic syndrome: an interesting but Enigmatic association’’, Circulation, Vol. 106, pp. 2634-6. Kassirer, J.P. (2001), ‘‘Free meals from the pharmaceutical industry’’, JAMA, Vol. 285, pp. 164-6. La Puma, J., Szapary, P. and Maki, K.C. (2004a), ‘‘Eating out, snacking frequency and diet choices among overweight physicians’’, Chicago Medicine, Vol. 107 No. 15, pp. 32-33. La Puma, J., Szapary, P. and Maki, K.C. (2004b), ‘‘Physicians’ personal intake and prescription of weight loss products: are we practicing what we preach?’’, Arch Intern Med, Apr 12, Vol. 164 No. 7, pp. 806-7. La Puma, J., Szapary, P. and Maki, K.C. (2004c), ‘‘Physicians recommendations for and personal use of low-fat and low-carbohydrate diets’’, Int J Obes Relat Metab Disord, Nov 09 [Epub ahead of print]. Laitinen, J., Ek, E. and Sovio, U. (2002), ‘‘Stress-related eating and drinking behavior and body mass index and predictors of this behavior’’, Prev Med, Vol. 34, pp. 29-39. Lurie, N., Rich, E.C., Simpson, D.E., Meyer, J., Schiedermayer, D.L., Goodman, J.L., McKinney, W.P. (1991), ‘‘Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff’’, J Gen Intern Med, Vol. 6 No. 2, pp. 181. McMenamin, S., Schmittdiel, J., Halpin, H.A., et al. (2004), ‘‘Health promotion in physician organizations: Results from a national study’’, Amer Jrnl Prev Med, Vol. 26 No. 4, pp. 259-64. Schumaker, J.F., Krejci, R.C., Small, L. and Sargent, R.G. (1985), ‘‘Experience of loneliness by obese individuals’’, Psychol Rep, Vol. 57, pp. 1147-54. Wyshak, G., Lamb, G.A., Lawrence, R.S. and Curran, W.J. (1980), ‘‘A profile of the healthpromoting behaviors of physicians and lawyers’’, N Engl J Med, Vol. 303, pp. 104-107. Young, J.S. (2004), ‘‘Physician health and lifestyle’’, JAMA, Vol. 291 No. 5, pp. 632.
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Modern diets converging: the move to low GI/GR diets Shane Landon
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Accredited Practicing Dietitian, Sydney, Australia Abstract Purpose – An abundance of diets advocating various different ways of losing weight have been covered in the media. This article aims to examine the latest trends and to look at how the nutrition message needs to be incorporated for effective and healthy weight management. Design/methodology/approach – The approach taken is to summarise the current diets trends and their nutritional profile. Findings – The issue of carbohydrates is a current hot topic with UK consumers. The Atkins diet started the current interest in the health properties of carbohydrates. This concept has evolved and led to a strong focus on the type of carbohydrate and its effect on blood glucose levels (glycaemic index, glycaemic response and glycaemic load). Originality/value – This review offers an evaluation on the benefits and limitations of the glycaemic concept from an Australian health professional’s viewpoint. Keywords Carbohydrates, Weight (mass), Metabolic diseases, Diet Paper type Viewpoint
Introduction Over the years, how we eat has been highly susceptible to the latest trend or diet concept that may or may not be supported by mainstream nutritional science. Often popularised via diet books and the media it seems that the public has an insatiable appetite for the quickest, newest means of delivering a diet related health benefit (usually weight loss). The recent Atkins phenomenon that swept through the USA and to a lesser extent, impacted the UK and Australia, clearly demonstrates that the consumer public remains vulnerable to a catchy diet message. What is particularly fascinating is the fact that the Atkins juggernaut played out against a backdrop of unprecedented nutrition knowledge. Nutrition science and investigation has undergone a virtual explosion of interest in the last decade. Yet, as the experts in food, health and nutrition we were relative spectators (at least initially) when it came to balancing some of the inappropriate nutrition messages contained within the Atkins regime. It begs the question, what’s next? Is there a new trend emerging and if so, does it have any nutritional merit? Is it a balanced message that fits within accepted nutritional science? Are we ready for it?
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 320-323 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625511
Health and food The connection between what we eat and our health is firmly established and it seems that this trend will only grow into the future. In its 2004 global food and beverage report What’s Hot around the Globe, A.C. Nielsen identified ‘‘a continued focus on health’’ as one of three key trends driving growth within food and beverage categories. So, in terms of reinforcing the idea that ‘‘we are what we eat’’ in all its various and more contemporary forms, health professionals have played a significant and important role. However, as we move forward, what may be less certain is the nature and delivery of ‘‘health’’ when it comes to food and beverage products. Perhaps the
Atkins movement can be illustrative and point the way in terms of health professionals actively participating and perhaps even guiding the next, inevitable diet trend? Atkins as a case study In common with many of its predecessors, the Atkins regime promised quick results, minimal dietary change (other than to eat more of the foods many nutritionists advised against!), plenty of testimonials, a minimal focus on physical activity and wrapped the entire message in a form of science. A classic ‘‘magic bullet’’ regime. No wonder it encouraged massive trial across the globe. But was there anything positive about the Atkins dietary approach? Is there anything we can learn? The answer is unequivocally yes. Regardless of health professional protestations about the diet’s lack of nutritional balance, the frequency with which weight loss occurred (albeit in many cases short term) demanded more vigorous investigation. There was something going on which required a scientific explanation. Although the wheels of science can turn slowly, it is now clear that relative to a more traditional low fat, kilojoule controlled diet, a lower carbohydrate regime is able to initiate weight loss – at least for the first six months. As uncomfortable as it may be, health professionals may need to accommodate the notion that there are a number of dietary approaches for weight loss – one of which includes lower carbohydrate intakes. So, the Atkins legacy may be, at least in part, an acceptance and perhaps adoption by health professionals of a number of dietary methodologies to achieve weight loss. The other substantial benefit is greater scientific interest in the metabolic fate and influence of various forms of carbohydrate (along with protein). However, Atkins alone cannot lay claim to being the only reason the public at large were reviewing the place of carbohydrates in the diet. Carbohydrates under the microscope The Atkins diet machine did not operate alone in terms of raising public awareness about the role and place of carbohydrates. In tandem, the concept of Glycaemic Index (GI) was gaining momentum and with it, the way in which carbohydrate foods can impact health. The convergence of the low carbohydrate diet trend of Atkins with the glycaemic index has resulted in the emergence of the ‘‘carbohydrate conscious consumer’’. Many consumers now approach carbohydrate foods in a similar fashion to the way they choose different types of fat. They are looking for ‘‘good carbs’’ and are wary of carbohydrate foods they perceive as less healthy. This creates challenges for health professionals and the food industry alike. In the case of health professionals, it is vital that we place carbohydrates into an appropriate dietary context and facilitate a balanced perspective in regard to the important role carbohydrates play in the diet. Food manufacturers on the other hand are now faced with the challenge of controlling and or reducing carbohydrate content to deliver products that release glucose into the bloodstream in a controlled fashion. Understanding GI’s strengths and weaknesses In order to meet the challenges that a ‘‘carbohydrate conscious consumer’’ poses, health professionals and the food industry need to appreciate and understand not only the strengths of GI but also its limitations.
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GI strengths Originally developed by Professor David Jenkins in Canada as a ranking tool for various forms of carbohydrate, the GI concept has been honed and popularised in Australia by Professor Jennie Brand-Miller and colleagues. The application of GI has shown good results in terms of glycaemic control for people with diabetes such that its clinical application has received support and is now widely used in diabetes management. Over time, the broader health implications of elevated blood glucose in non-diabetic individuals has gathered interest. Evidence is accumulating for a role for GI in weight management. Metabolic syndrome, a cluster of disorders characterised by raised insulin levels (linked to the glucose concentrations in the blood stream), elevated blood fats and obesity is a growing problem – particularly in developed economies like Australia and the UK. The importance of controlling blood glucose as both a preventative measure as well as part of clinical management has seen the concept of GI broadened to a wider population than just those with diabetes. Measuring glycaemic index Designed primarily as a laboratory measure, the GI measures the blood glucose profile of a standard amount of ‘‘available carbohydrate’’ in the test food (usually 50 g but may be 25 g) consumed by a human subject. Over the next two to three hours the blood is sampled and the glucose content measured and plotted. The results are then compared to that subject’s glucose response to 50 g of the reference CHO – usually glucose. Foods with a high GI release glucose rapidly into the blood stream, while foods with a low GI value release at a slower rate. Levels for GI include: .
High GI: Over 70
.
Medium GI: 56-69 inclusive
.
Low GI: 55 or less
GI weaknesses It is well known that the GI of a food can change when it is consumed with other foods – as part of a mixed meal. Indeed, a number of factors can influence the GI namely: .
type of starch;
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cooking and processing;
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presence of protein;
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amount of fat;
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acidity of the food.
However, there is another limitation to GI that health professionals need to be aware of – one which poses a significant challenge to food manufacturers. GI only compares a set 50 g portion of the ‘‘available carbohydrate’’ of the test food to glucose, but fails to take into account unavailable carbohydrate – like various forms of dietary fibre that may either be naturally present or added to a food. As a result, a broader concept called Glycaemic Response (GR) has evolved which considers the impact on blood glucose of an entire food – as eaten. Importantly, GR takes into account all forms of carbohydrate. The distinction between these two concepts is important for health professionals to understand as the strict application of
GI can result in a somewhat narrow perspective as to the true impact of a food on glucose release.
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As a dietitian, I prefer the glycaemic response as it is more representative of how foods are actually eaten and accounts for all forms of carbohydrate – available and unavailable.
GI vs GR Example: white bread with or without added resistant starch (RS). A commercial form of resistant starch (Hi-maize) that delivers up to 60 per cent dietary fibre (unavailable carbohydrate) is increasingly being used in a range of food products e.g. bread and breakfast cereals. This type of RS has the ‘‘functionality of flour’’ without taste or texture change. White bread with 20 per cent of the flour replaced with RS results in a 45 per cent reduction in glycaemic response compared to bread without Hi-maize. However, if the glycaemic index of these two forms of bread (with or without added RS) were measured, there would be no difference. The GI only measures ‘‘available carbohydrate’’ so the RS is not taken into account. Conclusions GI/GR – just another trend? Although there has been a large amount of public, and increasingly commercial interest in the concept of GI (witness Tesco’s recent introduction of its own GI guide plus labelling its products with a GI value), the body of credible science suggests that the principle of managing the release of glucose into the blood stream (whether this be measured via GI or GR) is here to stay. However, like all such developments, the GI needs to be kept in perspective. Tips for health professionals: . low glycaemic foods provide health benefits, in particular for diabetes; .
although more evidence is required, low glycaemic foods may also improve satiety and thereby weight control;
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GI is only one means of assessing the value of a food (some high fat, high sugar ‘‘treat foods’’ have a low GI);
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glycaemic response (GR) of the entire food may be more beneficial than GI for assessing the impact of resistant starch and dietary fibre added to foods on glucose release;
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the GI can vary when consumed as part of a mixed meal.
Further reading A.C. Nielsen (2004), What’s Hot around the Globe, A.C. Nielsen, New York, NY. Brand-Miller, J.C. et al. (2002), The New Glucose Revolution, 3rd ed. Brand-Miller, J.C. et al. (2002) ‘‘Glycaemic index and obesity’’, American Journal of Clinical Nutrition, Vol. 76, pp. 281S-85S. Jenkins, D.J.A. et al. (2002), ‘‘Glycaemic index: overview of implications in health and disease’’, American Journal of Clinical Nutrition, Vol. 76, pp. 266S-73S. Noakes, M. and Clifton, P.M. (2004), ‘‘Weight loss, diet composition and cardiovascular risk’’, Current Opinion in Lipidology, Vol. 15, pp. 31-5. Willett, W., Manson, J. and Liu, S. (2002), ‘‘Glycaemic index, glycaemic load, and risk of type 2 diabetes’’, American Journal of Clinical Nutrition, Vol. 76, pp. 274S-80S.
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Low levels of cholesterol/ saturated fat index (CSI) in a Japanese–Brazilian diet
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Elizabeth Aparecida Ferraz da Silva Torres, Geni Rodrigues Sampaio, Cla´udia Moreira Nery Castellucci, Edeli Simioni de Abreu and Marly Augusto Cardoso Department of Nutrition, School of Public Health, University of Sa˜o Paulo, Sa˜o Paulo, Brazil Abstract Purpose – Differences in dietary patterns constitute a major component of the environmental changes experienced by immigrant populations, and have been associated with several diseases with contrasting prevalence rates in the USA and Japan. The Japanese preparations present very colorful dishes, with a wide variety of vegetables with little or no cooking, which preserves the nutritive value of vitamins. The present study was carried out to determine the cholesterol/saturated fat index (CSI) levels of some Japanese dishes using the following equation, developed to calculate the ratio between cholesterol and dietary saturated fatty acids: CSI = (1.01 saturated fatty acids in g) + (0.05 cholesterol in mg). Design/methodology/approach – Fifteen Japanese recipes consumed by Japanese immigrants in Sa˜o Paulo (Brazil) were prepared and analyzed for chemical composition by AOAC methods, for fatty acids profile (gas chromatography) and cholesterol (colorimetric method). Findings – Total lipid content (g/100 g) ranged from 0.10 to 16.40, with mean ± SD values of 2.83 ± 4.10. Cholesterol (mg/100 g) ranged from 0 to 166.5, with mean values of 36.90 ± 45.61. CSI values ranged from 0.0 to 9.87, with mean values of 2.76 ± 3.19. Orginality/value – The habitual intake of Japanese foods available in Sa˜o Paulo could be useful to achieve a limit of 30 per day for dietary CSI. Keywords Japan, Brazil, Diet, Fats, Food products Paper type Research paper
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 324-329 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625520
Introduction The burden of cardiovascular diseases is rapidly increasing in developing countries. Previous studies carried out in order to clarify the influence of dietary lipids on nutrition and human diseases have linked high blood cholesterol levels to arteriosclerosis and other cardiovascular diseases. It has been observed that the reduced levels of blood cholesterol are associated with lower intake of total lipids, saturated fatty acids (mainly myristic and palmitic varieties), and higher intake of polyunsaturated fats such as linoleic acid (Katen et al., 1997). Cardiovascular diseases (CVD) are the ones that kill the most in the US. Several risk factors have been identified, including uncontrollable ones that cannot be modified or controlled by diets or medicines. The incidence of CVD increases with age and is higher in men. There is a tendency to recommend a lower intakes of lipids to prevent such diseases. Recent studies have shown that the quality of lipids in foods is more important than their quantity. Moreover, small portions of highly unsaturated lipids may have more adverse effects than fats that are less unsaturated if they are oxidized. Research supported by CAPES, CNPq and FAPESP (scholarships and grant in aid). To the Postgraduate Program in Applied Human Nutrition (PRONUT/USP).
Many researchers have studied the role of dietary lipids in hypercholesterolemia and their atherogenic effect. Fetcher et al. (1967) developed a food table based on their effects in serum levels of cholesterol. The values were obtained with a regression equation developed by Keys (1965). This equation and others, such as Hegsted’s equation (1965), were derived from studies on the metabolism of dietary lipids (saturated fat/cholesterol) performed on humans. Keys’ equation was modified by Whyte and Havenstein (1976) including saturated and polyunsaturated fats in the contents of food cholesterol (Mattson et al., 1972). This was done because cholesterol had to have more weight in the mathematical equation. In 1979, this latter revised equation was used by Zilversmit, who proposed the cholesterol index for foods: CI = 1.01 = (S 0.5P) = 0.05C (where S = saturated fatty acids in g, P = polyunsaturated fatty acids in g, and C = Cholesterol in mg (Zilversmit, 1979). These regression equations were developed in order to show the absolute effect of individual food servings on serum cholesterol. As researchers have increasingly focused their attention on the role of diet in chronic diseases, epidemiology is becoming central to the field of nutritional sciences. Comparisons of morbidity profiles among people of Japanese ancestry living in Hawaii and on the mainland US with those observed among US Caucasians and Japanese in Japan have provided valuable clues about the role of environmental factors in the etiology of cancers and other diseases. As a whole, morbidity patterns in immigrants tend to be intermediate between those observed in Japan and in the US as exemplified by the incidence of cerebrovascular and coronary heart disease and some cancers. Differences in dietary patterns constitute a major component of the environmental changes experienced by immigrant populations, and have been associated with several diseases with contrasting prevalence rates in the US and Japan. The Japanese preparations present very colorful dishes, with a wide variety of vegetables with little or no cooking, which preserves the nutritive value of vitamins. In the present study we determined the energetic values and lipid ratios (cholesterol, saturated and unsaturated fatty acids levels) present in preparations usually consumed by Japanese immigrants in the City of Sa˜o Paulo. Material and methods Fifteen Japanese recipes (Nishime, Kare, Rice with Natto, Tofu, Miso, Konnhaku, Soya Milk, Mazegohan, Yakisoba, Sushi, Norimaki, Tempura, Chikuwa, Anko-Mochi, Manju), usually consumed by Japanese immigrants in Sa˜o Paulo city (Brazil), were prepared and analyzed in triplicate (Table I). Each sample underwent the following analyses: .
Moisture, ash and protein contents were determined as described by AOAC (1990) and IAL (1985). Nitrogen in meat was determined by the Kjeldahl method, whereby the sample is digested by oxidation with boiling sulfuric acid with copper as a catalyst, and the produced ammonium is liberated as ammonia, which is titrated with hydrochloric acid after distillation, and using a conversion factor of 6.25 (Association of Official Analytical Chemists, 1990).
.
Carbohydrates and Energetic Values (EV): Determined by difference; the values obtained were employed in the energetic value calculation, in which the ATWATER coefficients were used (Watt and Merril, 1963).
.
Lipids – Total lipids were determined using the dry column methodology suggested by Marmer and Maxwell (1981), who consider this method to be
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Table I. Cholesterol saturated indexes (CSI) and energetic values (in kcal/kJ) of the foods analyzed in this study
a viable alternative to extraction using chloroform, methanol, and water. The beakers employed were previously stove dried for 12 hours at 105 and then cooled in a desiccator and weighed. Ten milliliters of the dry column extract were transferred to the beaker and evaporated under nitrogen. The extract was then placed in a stove at 105 C and, after 3 hours, it was cooled in a desiccator and weighed on an analytical balance. .
Total fatty acids (FA) – lipids were submitted to cold saponification and methylation with BF3 in methanol (Morrison and Smith, 1964). FA were determined by gas chromatography with a GC Chrompack CP9002 apparatus equipped with a split injector at a 100:1 ratio, FID and a capillary column of fused silica CP-SIL 88 (50 m; 0.25 mm and 0.25 mm). C17:0 was used as the internal standard (SIGMA1 ) and the quantitative external standards were from SIGMA1 Fatty acid methyl ester mixture # 189-19. Normalizing area and the identification-performed the quantification of the FA by comparison of the corrected retention time between standards and samples.
.
Cholesterol – The non-saponifiable lipids were analyzed by the colorimetric method of Bohac et al. (1988), which yields results similar to those obtained by gas chromatography, with the advantage of being less costly. The lipids were extracted and determined by the technique of Marmer and Maxwell (1981). Three milliliters of extract taken from each sample were evaporated under nitrogen. After drying, the samples were saponified by the addition of 10 ml of a 12 per cent potassium hydroxide (KOH) solution in ethanol and subjected to an 80 C water bath with agitation for 15 minutes. They were then promptly cooled by the addition of 5 ml of distilled demineralized water followed by double extraction with 10 ml of hexane. Four-milliliter aliquots of the hexane were taken and dried under a nitrogen (N2) flow. Six milliliters of a saturated solution of ferrous sulfate in glacial acetic acid were added, as well as 2 ml of concentrated sulfuric acid (H2SO4). The samples thus treated were read with a Coleman-295 spectrophotometer at 490 nm. The calibration curve was constructed based on 50-, 100-, 150-, and 200-mg solutions, subjecting the SIGMA1 C-8253 standard
Japanese dishes (per 100g)
Lipid (g)
Cholesterol (mg)
CSI
Kcal
KJ
Nishime Kare Rice with natto Tofu Misso Konnyaku Soy milk Mazegohan Yakisoba Sushi Norimaki Tempura Chikuwa Anko-Mochi Manju
3.40 3.30 2.50 1.30 4.90 0.10 0.10 1.90 4.80 0.40 0.20 16.40 0.10 0.10 2.10
166.50 37.90 37.90 8.60 62.30 0.00 0.00 70.20 46.10 0.00 0.00 77.80 0.00 0.00 47.30
9.87 3.15 2.53 0.82 4.31 0.00 0.00 4.49 3.45 0.00 0.00 8.78 0.00 0.00 3.26
74.50 91.50 153.70 45.50 108.10 9.60 26.50 82.00 76.80 89.80 77.10 166.80 78.20 192.20 175.60
311.70 382.84 643.08 190.37 452.29 40,17 110.88 343.09 321.33 375.72 322.59 488.69 327.19 804.16 734.71
cholesterol concentrations to the saponification and color development stages. A 10 to 40 mg gradient was achieved at the end of the process. .
Calculation of the Cholesterol Indexes CSI and CI: the formulas proposed by Zilversmit (1979) were used to calculate the accepted cholesterol indexes: CI = 1.01 + (S 0.5P) + 0.05C (where S = saturated fatty acids in g, P = polyunsaturated fatty acids in g, and C = cholesterol in mg), and in Connor et al. (1986): CSI = (1.01 saturated fats in g) = (0.05 cholesterol in mg) were used.
Descriptive statistical analyses were performed using the SPSS software 10.0. Results and discussion Table I shows the contents (g/100 g) of total lipids, ranging from 0.10 to 16.40, with mean ± SD values of 2.83 ± 4.10. Total cholesterol (mg/100 g) ranged from 0 to 166.5 mg/100 g, with mean values of 36.90 ± 45.61. The mean total energy values (in kcal/100 g and kJ/100 g, respectively) for all recipes were 92.53/387.14 (50.43/210.99), ranging from 9.60/40.17 to 192.20/804.16. CSI values ranged from 0.0 to 9.87, with mean values of 2.76 ± 3.19. Comparing these results with previous finds of selected foods consumed in the city of Sa˜o Paulo, such as fast foods and fried preparations (Torres, 2000), Japanese recipes had very low values for all parameters studied (Torres, 2000). Connor et al. (1989) proposed the CSI for evaluating or planning low-fat diets. Since the CSI varies as a function of the contents of dietary cholesterol and saturated fat, its values vary according to the total energetic values and lipid composition of the diet. For example, the CSI of a typical American diet is 31 for 1,200 kcal/5,020 kJ, 51 for 2,000 kcal/8,368 kJ, and 69 for 2,800 kcal/11,715 kJ. CSIs are also different in isocaloric diets with different lipid contents. Connor et al. (1989) provided a table containing important foods and their respective CSI values for usual diet. The CSI per 1000 Kcal, which did not include polyunsaturated fat, correlated well (r = 0.78) with mortality from ischaemic heart disease in men aged 55 to 64 from 40 countries. Torres-Schow et al. (1999) used the CSI to compare the atherogenic potential of diets consumed by Asiatics and Hispanics living in California and their parents. The authors suggested that the descendants of both Asiatics and Hispanics have been acquiring American eating habits. Bowman et al. (1998), assessing the health eating index (HEI) of American diets, reported that low-income African-Americans had the poorest eating habits. However, the HEI assessment does not consider the CSI to adjust for different lipid contents of the diets. Another investigation reported the correlation between demographic variables (race/ethnicity, age, gender, and educational level) and the consumption of specific foods contributing to the atherogenic potential of a diet (Melnik et al., 1993). The authors observed a strong influence of education and race on eating habits, suggesting that more attention should be devoted to public health education programs on how to avoid atherogenic diets. When studying CSIs and CVDs in 40 countries, Artaud-Wild et al. (1993) could not achieve a CSI-based explanation for the discrepancy between Finland and France data. A possible cause for the French paradox was the fact that, although both countries showed similar CSIs, the lower coronary mortality rate for France than Finland was probably associated with a more balanced diet, with more fruits and vegetables.
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As recommended by Mitchell et al. (1996), developed and validated cards containing CSIs of foods can be used for self-monitoring among patients on low-fat diets. In Brazil, the regular intake of some available Japanese foods could be used to reach the goal of the upper CSI limit of 30 per day. Japanese recipes could also be helpful to balance normal and low-fat diets for special purposes.
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Conclusion Japanese diet dishes showed very low energetic values and CSI levels, suggesting that they could used as an alternative not to exceed an CSI limit of 30 per day. References AOAC (1990), Official Methods of Analysis 15th ed., AOAC, Washington DC. Artaud-Wild, S.M., Connor, S.L., Sexton, G. and Connor, W.E. (1993), ‘‘Differences in coronary mortality can be explained by differences in cholesterol and saturated fat intakes in 40 countries but not in France and Finland: a paradox’’, Circulation, Vol. 88 No. 7, pp. 2771-9. Bohac, C.E., Rhee, K.S., Cross, H.R. and Ono, K. (1988), ‘‘Assessment of methodologies for colorimetric cholesterol assay of meats’’, Journal of Food Science, Vol. 53, pp. 1642-93. Bowman, A.S., Lino, M., Gerrior, A.S. and Basiotis, P.P. (1998), ‘‘The healthy eating index 1994-1996’’, USDA – Center for Nutrition Policy and Promotion CNPP-5, July, USDA Washington, DC. Connor, S.L., Gustafson, J.R., Artaud-Wild, S.M., Favell, D.P., Classick-Kohn, C.J., Hatcher, L.F. and Connor, W.E. (1986), ‘‘The cholesterol/saturated-fat index: an indication of the hypercholesterolemic and atherogenic potential of food’’, The Lancet, May, pp. 1229-32. Connor, S.L., Gustafson, J.R., Artaud-Wild, S.M., Favell, D.P., Classick-Kohn, C.J., Hatcher, L.F. and Connor, W.E. (1989), ‘‘The cholesterol-saturated fat index for coronary prevention: Background, use, and a comprehensive table of foods’’, Journal of the American Dietetic Association, Vol. 89, pp. 807-16. Fetcher, E.S., Foster, N., Anderson, J.T., Grande, F. and Keys, A. (1967), ‘‘Quantitative estimation of diets to control serum cholesterol’’, American Journal of Clinical Nutrition, Vol. 20, pp. 475-92. Hegsted, D.M., Mcgandy, R.B., Meyers, M.I. and Stare, F.J. (1965), ‘‘Quantitative effects of dietary fat on serum cholesterol in men’’, American Journal of Clinical Nutrition, Vol. 17, pp. 281-95. IAL (1985), Normas analı´ticas do Instituto Adolfo Lutz, 3a ed. Sa˜o Paulo. Vol. 1. Katen, M.B., Grundy, S.M. and Willett, W.C. (1997), ‘‘Beyond low-fat diets’’, Clinical Diabetes, Vol. 337, pp. 563-6. Keys, A., Andersen J.T. and Grande, F. (1965), ‘‘Serum cholesterol responses to changes in the diet. Iodine value of dietary fat vs 2S-P’’, Metabolism, Vol. 14, pp. 747-58. Marmer, W.N. and Maxwell, R.J. (1981), ‘‘Dry column method for the quantitative extraction and simultaneous class separation of lipids from muscle tissue’’, Lipids, Vol. 16, pp. 365-71. Mattson, F.H., Erickson, B.A. and Kligman, A.M. (1972), ‘‘Effect of dietary cholesterol on serum cholesterol in man’’, American Journal of Clinical Nutrition, Vol. 25, pp. 589-94. Melnik, S.S., Stein, T.A., Zansky, A.D., Maylahn, C. and Bash, C.E. (1993), ‘‘Age, sex, educational attainment, and race/ethnicity in relation to consumption of specific foods contributing to the atherogenic potential of diet’’, Preventive Medicine, Vol. 22 No. 2, pp. 203-18. Mitchell, D.T., Korslund, M.K., Brewer, B.K. and Novascone, M.A. (1996), ‘‘Development and validation of the cholesterol-saturated fat index (CSI) scorecard: a dietary self-monitoring tool’’, Journal of the American Dietetic Association, Vol. 96 No. 2, pp.132-6.
Morrison, W.R. and Smith, L.M. (1964), ‘‘Preparation of fat (fatty?) acid methyl esters and dimethylacetals from lipids with boron fluoride-methanol’’, Journal of Lipid Research, Vol. 5, pp. 600-08. Torres EAFS. (2000), Teor de lipı´deos em alimentos e sua importaˆncia na nutric¸a˜o, Tese de Livre Doceˆncia-Faculdade de Sau´de Pu´blica da USP, Sa˜o Paulo. Torres-Schow, R.M., Suen, S. Yeh, J.L. and Tam, C.F. (1999), ‘‘A comparison of atherogenic potential of diets between Asian and Hispanic college students and their parents’’, Nutrition Research, Vol. 19 No. 4, pp. 555-68. Watt, B.K., Merrill, A.L. (1963), ‘‘Composition of foods, raw processed and prepared’’, Agriculture Handbook n 8, US Department of Agriculture, Washington DC. Whyte, H.M. and Havenstein, N. (1976), ‘‘A perspective view of dieting to lower the blood cholesterol in man’’, American Journal of Clinical Nutrition, Vol. 29, pp. 784-96. Zilversmit, D.B. (1979), ‘‘Cholesterol index of foods’’, Journal of the American Dietetic Association, Vol. 74, pp. 562-5.
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Diet, lifestyle factors and symptoms of premenstrual syndrome Katie L. Oliver and G. Jill Davies
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The Academy of Sport, Physical Activity and Wellbeing at the London South Bank University, London, UK Abstract Purpose – The aim of this study is to investigate the prevalence of appetite-related, emotional and physical symptoms in a group of menstruating females. Design/methodology/approach – A total of 20 Caucasian females, aged 17-24 years, completed a specifically designed menstruation symptoms diary for one cycle length. Findings – The findings of the study indicate that changes in appetite and physical and emotional symptoms accord with hormonal changes in the premenstrual and bleed phases of the cycle. Research limitations/implications – The implication of using a daily diary to identify symptoms demonstrates a record of the individuals’ perceptions of their symptoms and is therefore only subjective. The prevalence of appetite-related symptoms was reported in the diaries but the quantity of food and drink consumed, and therefore energy intake could not be established for any of the endocrine phases. Originality/value – Conducted on a very small scale this study can be considered as being a pilot for a more rigorous investigation into the understanding of diet in the identification and management of premenstrual syndrome. Keywords Emotional dissonance, Women, Body systems and organs Paper type Research paper
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 330-336 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625539
Introduction Premenstrual syndrome can be defined as ‘‘a group of physical and mental changes, which begin anything between two and 14 days before menstruation’’ (Dalton, 1999). During women‘s reproductive years it is very common to experience symptoms of premenstrual syndrome. It has been estimated that ‘‘90 per cent of women have experienced at least one symptom, with around 30 per cent having rated their symptoms as being moderate’’ (Korzekwa and Steiner, 1999) The symptoms experienced vary in their nature, severity and duration and can be grouped in four categories; physical, emotional, appetite and sexual behaviour. These symptoms are thought to be due to the changes in the female hormone levels and therefore the endocrine stages of the menstrual cycle (see Figure 1). The endocrinological phases can be defined as menstruation, proliferative, ovulation and secretory. Menstruation is frequently described as the beginning of the cycle, with the menstrual bleed occurring during this time. Levels of both oestrogen and progesterone are at their lowest. The endometrial lining of the uterus from the previous cycle is shed with the loss of blood. This phase of the cycle usually lasts between five and seven days. The proliferative phase commences when bleeding has ceased, and is the start of the underlying endometrial cells in the uterus undergoing proliferation and growth. This co-insides with increases in oestrogen levels and this hormone stimulates growth of the secretory glands and blood vessels that permeate the thickening endometrium. This leads to the next stage of ovulation, which may be defined as the point in the cycle when an ovum is released. The last stage of the endocrine cycle is the secretory phase.
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Figure 1. Changing hormone levels in the menstrual cycle
This progesterone dominant phase allows for the glands in the uterus to secrete large supplies of nutrients such as glycogen, for the maintenance of the endometrium, and therefore possible implantation by the fertilised ovum. The aims of the present study were to investigate the prevalence of appetite-related, emotional and physical symptoms in a group of menstruating females. Subjects Ethical approval was obtained from London South Bank University Ethics Committee, through the undergraduate programme scheme. Caucasian female participants were recruited from Bedfordshire. This area was selected, as it was convenient for the principal investigator. Subjects were aged between 17 and 24 years of age. This specific age group was selected on the basis of Freeman’s (2003) findings that between the ages of twenty and mid-thirties premenstrual syndrome seem to be most severe. Females were informed of the nature of the study and asked to give written informed consent. A screening questionnaire was completed to assess whether each subject met the entry criteria and to obtain background information. Participants were included if they had a body mass index within the range for normal weight, and if they had a regular menstrual cycle. They could not be included if they had been pregnant, been on a diet within the last six months or already seeking help for premenstrual syndrome. Diabetic, anaemic, or patients seeking medical attention for other conditions including hormone replacement therapy and depression were excluded. Methods Background information was obtained regarding the lifestyle choices of the participants, which included the use of an oral contraceptive, the frequency of alcohol
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consumed, whether it was never, occasionally, frequently or excessively and the smoking of cigarettes. A symptoms diary and a medication diary was given to each participant. Subjects were instructed on how to complete both diaries for one menstrual cycle. The design and methods of the symptom diary were adapted from the reviews by Blades, (1996) and Haywood et al. (2002). For each day of the cycle, starting from the first day of menstruation, the prevalence of each symptom (Table I) was determined by indicating in the diary whether or not there were moderate or severe symptoms present. If any form of medication was taken, prescribed or over the counter, it was documented in the diary. The two diaries were collected from each participant at the end of the study. Results Twenty participants were recruited into the study. The mean age of the participants was 20.2 years (range 17-24) and the mean body mass index was 21.2 (range 19.1-24.7). The mean menstrual cycle total length was 28 days (range 24-30). This is in agreement with Dalton (1999) who described this as a typical cycle length. Twelve of the volunteers were using oral contraceptives. 15 per cent of all the participants smoked cigarettes and 90 per cent consumed alcohol on an occasional to frequent basis. The data collected from the medication diaries suggests that the main reasons for medication use were as a result of headaches and period pain experienced during both the secretory and menstruation phases. Figure 2 gives the appetite related symptoms in each endocrinological phase. The majority of symptoms experienced were during the secretory phase (days 17-28) and menstruation (days 1-5). Increased appetite and thirst began to develop in up to 70 per cent of the participants in the secretory phase and then increased to 80 per cent once the menstrual bleed had commenced. A small proportion of participants reported that increased appetite and thirst still remained during the start of the proliferative phase (days 6-13). Minimal symptoms were experienced during ovulation. The carbohydrate cravings reported (Figure 2) showed that during the secretory phase starch-based carbohydrate including pasta, bread, and potatoes were craved by the highest amount of participants. Where as during the bleed the sucrose-based carbohydrate was craved more than in the secretory phase as its value increased by a further 10 per cent.
Table I. Symptoms reported by participants in daily symptom diary
Appetite symptoms
Physical symptoms
Emotional symptoms
Increased appetite Increased thirst Sucrose-based carbohydrate craving Chocolate Confectionery Starch-based carbohydrate craving Pasta Potatoes Bread Crisps Protein craving Fat craving Alcohol craving
Acne Backache Bloated abdomen Breast soreness Constipation Diarrhoea Headache Swollen ankles Weight gain
Anxiety Confusion Crying Depression Insomnia Irritability Mood swings Tension
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Figure 2. Endocrinological phase: appetite symptoms
Physical changes, headache, backache and bloated abdomen, were perceived by 80 per cent of the volunteers and were highly problematic. The figures for both the secretory and menstruation phases were of the same levels, (Figure 3). The proliferative and ovulatory stages were relatively non-problematic and show very few participants feeling any symptoms. The emotional symptoms experienced (Figure 4) indicated how very few of the volunteers were symptom-free during their premenstrual phase. During the secretory phase irritability was the principal emotional feeling, and was experienced by 75 per cent of the participants, with 70 per cent continuing to feel irritable into their menstrual bleed. For 20 per cent the irritability began in ovulation, leaving only the proliferative phase as symptom-free. Crying was also of high prevalence (70 per cent) during the
Figure 3. Endocrinological phase: physical symptoms
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Figure 4. Endocrinological phase: emotional symptoms
secretory phase, but as the participants entered into their menstruation they seemed to feel less tearful but more likely to have mood swings. Discussion From all three of the symptom categories, the symptom‘s duration followed a similar trend becoming prevalent during the secretory phase, and continuing into the menstruation. This suggests that the symptoms experienced can be prolonged for up to two weeks in every menstrual cycle. Some of the participants experienced symptoms during their proliferative phases, implying that potentially women with longer menstrual bleeds may have symptoms extended even longer. During the secretory phase the increased appetite could be due to an increase in energy expenditure, basal body temperature and metabolic rate, which is in accordance with the study reported by Bisdee et al. (1989). The increased appetite poses the question that perhaps menstruating women have a higher energy requirement at this time. In view of the reported increased thirst during both the secretory and menstruating phases, body temperature may have been higher, leading to more perspiration and the need to consume more fluid to prevent dehydration. Preference for sucrose-based carbohydrate during the bleed was in contrast to the study by Davies et al. (1993) who identified that it was in the secretory phase that sucrose-based carbohydrate particularly cakes, sweets, and chocolate were opted for by the participants. The physical symptoms identified, including headache, backache and bloated abdomen, during both the secretory and menstruation phases are possibly associated with water retention and pressure intensity throughout the body. This is consistent with findings by Dalton (1999), which established that water accumulation within the body could lead to abdominal bloating as well as increases behind the eyes and inside the skull leading to an increase in pressure and the commencement of headaches. Water can also accumulate in the muscles and joints, initiating back ache and other rheumatic pains.
The emotional symptoms appear to be linked to the physical and appetite-related changes. The irritability felt by participants could be due to the headaches and backaches reported, as well as the bloating abdomen making women perceive themselves as unattractive and feel unhappy. These trends can be understood to be viable for sufferers of premenstrual syndrome and in accordance with the study by Rapkin (2003). This study stated that reduced serotonin neurotransmission during the secretory phase of the menstrual cycle can lead to changes in mood, especially feelings of irritability, self-depreciation, and mood swings. The changes in female hormones across the cycle attribute to the symptoms identified. This is especially true of the changes in progesterone levels throughout each of the endocrine phases, particularly when in its highest quantity during the secretory phase (Figure 1). All of the symptoms experienced by the participants, especially the appetite-related symptoms, are in accordance with the findings by Dalton (1999). The body’s need to consume more calories, particularly carbohydrate, during the secretory phase is due to requirements to maintain blood-sugar levels. If they are not maintained then progesterone receptors cannot bind to the progesterone molecules and a drop in blood glucose level occurs. This decrease causes the release of adrenaline, which moves sugar from the cells into the blood. As water replaces it in the cell, the cell swells up causing water retention throughout the body and general weight gain. The sudden release of adrenaline causes feelings of irritability and anxiety. Thus, when carbohydrate is then consumed, mood levels rise and therefore the symptom of mood swings is determined. Therefore, maintaining energy intake in the form of carbohydrates allows for the other problematic symptoms identified in this study to be alleviated, thus making diet fundamental to treatment and management of premenstrual syndrome. The use of medication reported was for common problems. Period pain is prevalent during the beginning of menstruation and therefore it is reasonable that women sought to relieve themselves from this problematic pain. The use of painkillers for headaches reported by the participants suggests that their symptoms were severe enough that they needed to take medication to alleviate them. The participation of contraceptive pill users in this investigation was realistic of the population in the United Kingdom at this age range. It has been identified in a study by Korzekwa and Steiner (1999) that premenstrual syndrome occurs in cycles where ovulation is not always present, as sufficient endocrine cyclicity remains. The use of a daily symptom diary ensured that day-to-day alterations, both physically and behaviourally could be monitored closely. However this method does have its limitations. A previous study by Jas (1994) concluded that cyclicity disappears when symptoms diaries are completed daily. Although this could be feasible it was not confirmed in this investigation. Conclusion The results from this study suggest that symptoms of premenstrual syndrome are very much apparent in women of a young age group. The symptoms experienced by the majority of participants showed that they start in the secretory phase and continue into menstruation leaving very few symptom-free days each cycle. Using the results from each symptom category allows for management of the condition primarily through diet and lifestyle adaptation to ensure that normal daily activities can take place no matter what stage of the menstrual cycle a woman is.
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References Bisdee, J.T., James, P.T. and Shaw, M.A. (1989), ‘‘Changes in energy expenditure during the menstrual cycle’’, British Journal of Nutrition, Vol. 61, pp. 187-99. Blades, M. (1996), ‘‘Applied consumer science- Pre-menstrual syndrome and nutritional advice’’, Nutrition & Food Science, Vol. 26 No. 6, pp. i-viii. Dalton, K. (1999) The PMS Bible, Vermilion, London. Davies, G.J., Collins, A.L. and Mead, J.J. (1993), ‘‘Bowel habit and dietary fibre intake before and during menstruation’’, Journal of the Royal Society of Health, Vol. 113 No. 2, pp. 64-7. Freeman, E.W. (2003), ‘‘Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis’’, Psychoneuroendocrinology, Vol. 28, pp. 25-37. Haywood, A., Slade, P. and King, H. (2002), ‘‘Assessing the assessment measures for menstrual cycle symptoms-a guide for researchers and clinicians’’, Journal of Psychosomatic Research, Vol. 52, pp. 223-37. Jas, P. (1994), ‘‘The menstrual cycle, mood and appetite’’, Nutrition & Food Science, Vol. 24 No. 2, pp. 23-25. Korzekwa, M.I. and Steiner, M. (1999), ‘‘Assessment and treatment of premenstrual syndromes’’, Primary Care update for Obstetrics/Gynaecology, Vol. 6, pp. 153-62. Rapkin, A. (2003), ‘‘A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder’’, Psychoneuroendocrinology, Vol. 28, pp. 39-53.
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Nutritional profiling vs guideline daily amounts as a means of helping consumers make appropriate food choices
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Gaynor Bussell Nutrition Manager, Food and Drink Federation, London, UK Abstract Purpose – To distinguish between the use of Guideline Daily Amounts (GDAs) for labelling purposes and traffic-light labelling and to demonstrate the advantages of GDAs over traffic lights. Design/methodology/approach – The advantages of GDAs are laid out along with the disadvantages of traffic-light labelling. Findings – The background to the development of GDAs and the FSA traffic light scheme, currently being consumer tested, is explained. The Food and Drink Federation recommend that GDAs will be of more value to consumers as opposed to traffic lights, as the GDA system will help individuals to build up a balanced diet which is appropriate for them. However, education on how to use GDAs will be vital, and this is already under way. Practical implications – A traffic-light system is a very simplistic subjective approach to signpost labelling and makes it hard to convey the true nutritional value of a food. For this reason it may mislead consumers. GDAs are more objective and will help inform and educate consumers on how to eat a balanced diet. Originality/value – The paper seeks to lay out the concept of GDAs and why it is a labelling concept that will help consumers with their diet. It should be of interest to those working in the food industry, health professionals, food and health academics and anyone who communicates messages about food and health or indeed consumes packaged food. Keywords Food products, Nutrition, Labelling, Diet Paper type Conceptual paper
Introduction Nutrient profiling now has a new meaning. In the old sense, the nutrient profile of a food referred to the nutrients that were present in the food, possibly qualified by their quantity. However, today nutrient profiling has a new meaning. Popularised by the Food Standards Agency, nutrient profiling now refers to the judgement which is made about the relative ‘‘healthfulness’’ of a food, with usually little else revealed about its nutritional composition. Recently FSA have added a twist to the plot by claiming that some systems used to define a food as ‘‘healthy’’ or ‘‘less healthy’’ is actually called ‘‘categorising’’. The terminology perhaps demands some clarification, but for the purposes of this document, nutrient profiling is deemed to be any system which attempts to judge the ‘‘healthfulness’’ of a food. An example of such a judgement would be if a red, amber or green ‘‘traffic light’’ was to be put on the front of food packaging suggesting to consumers that they could eat that food in plentiful amounts (green), in moderation (amber) or sparingly (red). The Public Health White Paper (Department of Health, 2004b) and its subsequent Food and Health Action Plan (Department of Health, 2004a) states that government ‘‘aims to have introduced a system that could be used as a standard basis for signposting foods’’. It has become clear that FSA will deliver such a system and it, and the Department of Health, believe that some kind of a nutrient profiling/categorising
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scheme will deliver such a ‘‘signpost’’. This is seen as the best means of offering consumers ‘‘simple labelling signposts to help them make informed and healthier food choices’’ (Food Standards Agency, 2004b). FSA has defined nutrient profiling as ‘‘the science of categorising foods according to their nutrient composition’’ (Food Standards Agency, 2005b). The Food and Drink Federation believes that to define this meaning of nutrient profiling as a ‘‘science’’ is undermining science. Clearly making a pre-judgement on food is subjective and cannot take into account all consumer needs. Many of these shortfalls could be overcome by use of Guideline Daily Amounts (GDAs). The GDA scheme is a ready-reckoner tool that can help readers of labels compare how much of a certain nutrient they are eating from that particular food with recommendations by nutrition professionals. Background Nutrient profiling for labelling purposes has been proposed, and sometimes tried, for a number of years and in a number of countries (Stockley, 2003). There has been no real evaluation done of any of the schemes introduced (British Nutrition Foundation, 2005). What little evaluation has been done seems to indicate that profiling schemes have not had the desired effect in changing people’s dietary habits for the better (Larson and Lissner, 1996). Currently in the UK, Co-op and Sainsbury’s are the only companies using nutrient profiling for labelling purposes. Co-op are using the Coronary Prevention Group scheme (Black and Rayner, 1992), developed in 1991. This scheme assigns the nutrients in the nutritional labelling panel as high, medium or low. Sainsbury’s have their ‘‘Wheel of Health’’ which does give GDAs but have also used a profiling (or categorising) scheme to assign a traffic light colour to each nutrient. A year ago Tesco’s announced that they would come out with traffic light labelling. However having conducted consumer testing, they decided against traffic lights and have not used any profiling scheme. Instead they have highlighted GDAs on the front of pack as well as the GDA panel on the back of pack (BBC News, 2005). Most of the major retailers have been labelling back of packs with GDAs since they were developed by the Institute of Grocery Distribution (IGD) in 1998 (Institute of Grocery Distribution, 1998). In the summer of 2004 a historic decision was made to relook at GDAs so that they could be updated and used by the whole of the food chain: food manufacturers, retailers and the hospitality industry. The first meeting took place in September 2004. Work has been continuing in earnest with representatives of the food chain and some key academics attending two groups under the auspices of the IGD. The first is a technical working group developing a range of GDA nutritional values for males, females, and children covering a range of ages. A technical rationale paper has now been distributed widely to the academic community and to industry members for comment. The results of the consultation will be analysed to see if any changes or developments are necessary to the GDA values. The second group, on communications, has been looking at how the GDA information might appear on a label and how information on the GDA concept could be disseminated to the whole food chain, consumers, health professionals, and the media. GDA format testing will undergo both qualitative and quantitative consumer research and it is hoped the GDA blueprint will be available for use by the autumn, with the communication roll out also under-way by then.
So what are GDAs? GDAs are a concept developed by the Institute of Grocery Distribution (IGD), and are derived from the Estimated Average Requirements (EARs) for energy for men and women aged between 19-50, of normal weight and fitness. The fat and saturates GDAs are based on the dietary reference values for these nutrients published by the Department of Health (Department for Health, 1991). Figures for salt are based on the 6 g per day recommendation made by COMA (Department of Health, 1994) then later Scientific Advisory Committee on Nutrition (SACN) in 2002 (SACN, 2003). Figures for children are proposed to be similarly based on the COMA and SACN guidelines as appropriate. GDAs are intended as guidance to help UK consumers in their understanding of their recommended daily consumption of energy (calories), fat and saturates and a base against which the content of individual foods can be compared. Currently the GDA declaration is voluntary and is not covered by any EU directive or UK law (see Table I).
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Why has industry gone for GDAs? In its Food and Health Manifesto (Food and Drink Manifesto, 2004), FDF makes the following commitment: More informative labelling FDF members are committed to working constructively with Government and other stakeholders to ensure the availability of clearer nutritional information under revised EU provisions.
Chicken and vegetable bake Nutrition information Per 350 g serving
Typical values
Per 100 g
Energy – kJ – kcal Protein (g) Carbohydrate (g) of which sugars (g) Fat (g) of which saturates (g) Fibre (g) Sodium* (g) Equivalent as salt (g)
480 115 9.5 8.6 3.5 4.6 2.0 1.5 0.3 0.8
1,680 405 33.3 30.1 12.3 16.1 7.0 5.3 1.1 2.8
Per 350 g serving
GDA
405 17.1 7.0 2.8
2,000 70 20 6
Calories (kcal) Fat (g) Saturated fat (g) Salt (g)
Notes: The above table is based on the established GDA values and does not include the values that are currently being finalised. Also the final agreed format of the GDA table might be different (for example it may have GDAs for males and females separately and may also show the percentage GDA). GDA tables will always carry a strap-line that explains how to use the table, who it is appropriate for and how some people’s needs may vary.
Table I. Example of a back of pack label showing GDAs
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Meanwhile FDF will encourage its members to provide on pack where practicable: .
full nutritional information as defined in current EU legislation even where this is not legally necessary
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salt equivalence as well as the legally required sodium information
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GDAs to provide a simple ‘‘ready-reckoner’’.
The commitment to use GDAs is so strong amongst most major manufacturers that several have already started using them in advance of the IGD programme. Some manufacturers have said that once the IGD figures are finalised that they will use these. However, their early use does not distract from their value as a means of conveying objective information about the nutritional value of a particular food. Advantages of labelling Guideline Daily Amounts .
Consumers can see at a glance what their average dietary requirements are, and use this information to help them plan their meal, and see how it fits into a balanced diet.
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Consumers may already be familiar with the concept of GDAs, as some manufacturers and retailers already feature them on-label. In fact, research by IGD’s consumer information group (November 2004) has indicated that consumer awareness of GDAs is high, with 72 per cent of consumers claiming to have seen them (Institute of Grocery Distribution, 2004).
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Although average GDA figures would be labelled on pack, they could point to further information which could be located off pack, relating to differing consumer needs (e.g. to reflect different dietary requirements of very active teen males, or elderly, inactive females and specific GDAs for a variety of children’s ages). On this supplementary information, detail could be expanded to include GDAs on a wide range of nutrients and micronutrients.
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Unlike most profiling or categorising schemes currently being looked at, GDAs take into account the portion size of the food. The profiling/categorising options being considered by FSA are based on per 100 g of food, so that the system quickly becomes unrealistic for foods where a portion size tends to be much smaller or larger than this. Neither does profiling take into account the frequency of consumption of various foods. GDAs allow people to see exactly how much of their daily intake a portion of a particular food will provide and they can quickly get a feel of how many calories, fat, salt etc. they are consuming. Portion size and frequency of consumption both undoubtedly influence the overall amount of food consumed, and are thought to contribute to obesity and cause an imbalance in the diet (Matthiessen et al., 2003).
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Because the GDA label indicates the portion size, this can also act as a guide to a consumer and may help people to avoid serving themselves a larger portion size than is suggested!
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Although a GDA scheme – like any other new labelling scheme – would require backing by consumer education, this would actually provide opportunity to encourage consumers to eat a varied balanced diet. A subjective profiling scheme would also require education back-up, but such a scheme would not directly be
teaching consumers about eating a variety of foods in the right proportions appropriate to their needs. What would a profiled labelling scheme look like? There are several ways of using profiling to indicate subjective information about the healthfulness of a food. These include an overall single traffic light, or a selection of nutrients could be assigned a traffic light so that the label would carry several traffic lights (these two schemes are currently being consumer tested by FSA). Such a scheme could also involve placing high, medium or low in the nutritional panel next to each nutrient (such as currently being used by Co-op). FSA has called the use of a front of pack indication about a food as a ‘‘signpost’’. Figure 1 shows examples of a single and a multiple signpost which are being considered for consumer testing by FSA (Food Standards Agency, 2005a).
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Why is such a scheme not the preferred option for FDF .
A scheme based on a profiling scheme, would give a very narrow ‘‘picture’’ about that food; does not help educate consumers about balanced eating, moderation or appropriate portion sizes. Thus it is misleading to the consumer. It would not give the consumer information about the adequacy of their diet over time, or address the importance of physical activity.
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It is hard to develop a simple ‘‘signpost’’ which can give appropriate information to an individual person. For example, a profiling scheme that classifies energy dense foods as ‘‘less healthy’’, may not be sending the ‘‘signpost message’’ appropriate for an active adolescent boy with a high energy requirement. Similarly it does not distinguish between fat spreads that are more appropriate for people with high blood cholesterol – a substantial percentage of the population.
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If a food product were to bear just one red traffic light, a consumer’s instant reaction would be that that food is not healthy: a red traffic-light means ‘‘STOP’’. Indeed, FSA’s provisional qualitative consumer research showed that some consumers would interpret a red traffic light as ‘‘stop, don’t eat it!’’ (Food Standards Agency, 2004a) If this were to be the end result, it may have serious consequences for the availability of many of the food and drink products provided by the industry, but yet still not encourage individuals to consume a balanced diet made up from a wide range of foods. It is far more likely that individuals who really do need to take care of their diets will carry on as before and take no notice of any over-simplistic and potentially patronising ‘‘signposting’’ scheme.
Figure 1.
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A signposting scheme based on a nutrient profiling model would never be transparent to the average consumer, because of its objectivity, and may be difficult to understand by the average consumer. The scheme will therefore be, at best, misleading. A particular food (such as a fortified breakfast cereal) may be a very good source of iron, or folic acid, suitable inter alia for women, yet it could end up carrying a red traffic light.
342
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If a food carries multiple traffic lights (i.e. a traffic light coding for each designated nutrient), it will probably carry the range of colours. In this case, how will a consumer know ‘‘at a glance’’ whether that particular food is a ‘‘healthy choice’’ or not? Such a scheme will not reflect the balance of the overall nutritional value of a food and there will be no account taken of the positive micronutrients or of the fruit and vegetable and omega three content of that food. In addition, if this multiple signpost contained any red coloured traffic lights, consumers would be likely to view that particular food negatively.
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It is inappropriate to put a ‘‘distilled’’ version of a full nutritional label that is based on a profiling scheme, on the front of the pack. Such a limited ‘‘flash’’ of information is likely to be subjective and may mislead the consumer. Consumers want simple, consistent objective information to help them choose an appropriate diet. However it is irresponsible to frighten consumers away from eating certain foods, irrespective of the amount normally eaten, especially as there is already confusion regarding what constitutes a healthy balanced diet.
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A simple front of pack signposting scheme based on a profiling scheme may deter the consumer from trying to understand the more objective and legally prescribed information on the back. Consumers do not always need to absorb all the nutrition information about the food they buy in the store. They can plan their dietary intake by looking at a label in the home setting and thus take on board a much fuller picture about a particular food by reading the back nutrition panel.
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In addition many food and drink products are linked to other sources of information such as company websites and consumer helplines. Furthermore, as the majority of processed foods would end up as being equivalent to amber or red, any impact of such a scheme would soon be lost as consumers, who today clearly wish to purchase convenience products, would simply ignore any form of front of pack ‘‘warning’’.
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FSA has acknowledged that if a signposting scheme, based on a profiling scheme, is to be used on front of pack, it would need to educate consumers about it. FDF agree that any scheme will have to be underpinned by a very substantial education programme. It is all the more important therefore to include the wider elements of labelling and the information which it currently delivers to consumers in any scheme. FDF has long expressed willingness to work with government on food and health issues. In fact, in May 2004, the food chain and advertising industries wrote to the Prime Minister pledging our commitment to participate in a government-led campaign of public education on healthy eating and healthy lifestyles.
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Finally, there is currently much innovation being carried out by the food industry to bring down levels of fat, salt and sugar. However, despite this some manufacturers for technical or consumer acceptance reasons just cannot bring down levels of certain nutrients beyond a certain point. When this point is
checked against proposed schemes for assigning the traffic light colours it is found that lowering nutrient levels does not take the product down from a red to an amber or from an amber to a green. Hence there is little incentive to bother at all as reformulation will not allow the product to improve its traffic light profile. References BBC News Online (2005), Tesco Rejects Traffic Light Label, available at: http://news.bbc.co.uk/1/ hi/uk/4484195.stm (accessed 26 April 2005). Black, A. and Rayner, M. (1992), Just Read the Label: Understanding Nutrition Information in Numeric, Verbal and Graphic Forms, HMSO, London. British Nutrition Foundation (2005), BNF Response to FSA Consultation on Nutrient Profiling, available at: www.nutrition.org.uk/upload/BNF%20Response%20to%20Nutrient%20 Profiling1.pdf (accessed 2 February 2005). Department of Health (1991), Dietary Reference Values for Food Energy and Nutrients for the United Kingdom, HMSO, London. Department of Health (1994), Nutritional Aspects of Cardiovascular Disease, HMSO, London. Department of Health (2004a), Choosing a Better Diet: A Food and Health Action Plan, Department of Health, London. Department of Health (2004b), Choosing Health: Making Healthier Choices Easier, Department of Health, London. Food Standards Agency (2004a), Agency Research Suggests People Believe Signposting would Make Healthier Eating Easier, available at: www.food.gov.uk/news/pressreleases/2004/ nov/signpostpress (accessed 25 November 2004). Food Standards Agency (2004b), Signposts Make Healthier Eating Easier, available at: www.food.gov.uk/news/newsarchive/2004/nov/signposting (accessed 25 November 2004). Food Standards Agency (2005a), Food Standards Agency Launches Next Phase of Signposting Research, available at: http://www.food.gov.uk/news/pressreleases/2005/may/signpostfinal (accessed 18 May 2005). Food Standards Agency (2005b), ‘‘FSA academic workshop to discuss its nutrient profiling model’’, 25 February, personal communication. Institute of Grocery Distribution (1998), Voluntary Nutrition Labelling Guidelines to Benefit the Consumer (01.02): IGD, available at: www.igd.com/CIR.asp?menuid=36&cirid=78. Institute of Grocery Distribution (2004), Nutrition Labelling – the Consumers’ Choice, available at: www.igd.com/cir.asp?cirid=1303&search=1 (accessed 15 November 2004). Larson, I. and Lissner, L. (1996), ‘‘The ‘green keyhole’ nutritional campaign in Sweden: do women with more knowledge have better dietary practices’’, European Journal of Clinical Nutrition, Vol. 50, pp. 323-28. Matthiessen, J. et al. (2003), ‘‘Size makes a difference’’, Public Health Nutrition, Vol. 6 No. 1, pp. 65-72. SACN (2003), Salt and Health, TSO, Food Standards Agency and Department of Health, London. Stockley, L. (2003), Nutrition Profiles for Foods to Which Nutrients Could Be Added, or on which Health Claims Could Be Made, Food Standards Agency, London. Further reading Food and Drink Federation (2004), FDF Food and Health Manifesto, available at: www.fdf.org.uk/ manifesto.
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Functional foods and nutraceuticals in the management of obesity Gursevak S. Kasbia
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Behavioural and Metabolic Research Unit, Monfort Hospital, Ottawa, Ontario, Canada Abstract Purpose – With a global increase in the prevalence of obesity, nutrition and exercise play a key role in its prevention and treatment. Natural product (nutraceutical) interventions are currently being investigated on a large-scale basis as potential treatments for obesity and weight management. This paper aims to examine current research on nutraceuticals and their role in the management of obesity and body composition. This paper will focus specifically on nutraceuticals, which are plant-based, which may aid in preventing/treating the metabolic syndrome. Those that will be discussed include conjugated linoleic acid (CLA), capsaicin, Momordica Charantia (MC) and Psyllium fibre. Design/methodology/approach – Recent empirical evidence has suggested that the utilization of such nutraceuticals to treat human cases of the metabolic syndrome may indeed be warranted. By examining various databases and conducting literature searches the following herbs and food additives were found to be of significant importance within this realm of food science. More importantly, emphasis was placed on research which used the randomized placebo control design. Findings – Whilst many of the nutraceuticals already have widespread usage, dosage and utilization have still not been critically examined in research literature. Many studies have focused solely on animal research, while others have implemented these nutraceuticals in controlled human trials. Research limitations/implications – Whilst many journal articles met rigorous scientific standards, international research in this area has also revealed that, language barriers may exist. The field of clinical nutraceutical research is rel atively new in North America, and thus much information is still available in the East but barriers still exist with respect to knowledge of certain herbs. Practical implications – Clinical nutritionists as well as physicians must gain knowledge of nutraceutical usage as well as availability. With recent marketing of products online, issues of safety should also be raised with respect to clinical treatment. Some products may have contra-indicatory properties and thus further investigation with nutraceuticals and significant interactions with physician supervised treatment should also be evaluated in future research. Originality/value – To date few papers have evaluated nutraceutical usage specifically clinical usage and, furthermore, the implications that some may have on obesity and treatment of the metabolic syndrome. Filling this gap in the literature may allow other researchers, clinicians and physicians to learn more about nutraceuticals. Keywords Obesity, Diabetes, Metabolic diseases, Nutrition Paper type Literature review
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 344-352 # Emerald Group Publishing Limited 0034-6659 DOI 10.1108/00346650510625557
Introduction Obesity and the metabolic syndrome continue to plague the world at an alarming rate. In recent years it has been reported that obesity and its metabolic complications will cause both substantial socio-economic and physical burden on society respectively (Laing, 2002). Furthermore if left untreated diabetes, hypertension, dyslipidemia and others more severe conditions will increase (Wild et al., 2004). The abundance of refined The author thanks the Centre National de Franc¸ais en Sante´ (CNFS) for providing a working grant, as well as supervisors for their full support of the research, and last but not least the author’s family.
and fast food diets (Brownell, 2004), as well as declining rates of exercise play a key role in energy balance. Unfortunately, many are not getting enough physical activity and are eating larger more calorically dense portions of food, thus leading to the substantial global increased prevalence of obesity. With a substantial increase in obesity, has come a pro-pharmacological approach to the treatment of obesity. One such approach however, has many undesired side-effects. Various surgical procedures have also been developed to aid the loss of weight to health levels in patients suffering from obesity. A nutritional based intervention is being haled as an inexpensive alternative to the aid weight loss, and weight management (Swinburn et al., 2004). This paper will examine the role of natural product intervention (nutraceuticals) that can be used in conjunction with dietary manipulation, which in turn may aid an individual’s ability to achieve effective weight loss, while maintaining key vitamins and mineral composition. This paper will focus specifically on nutraceuticals, which are plant based products that may aid in preventing/treating the metabolic syndrome. Those that will be discussed include conjugated linoleic acid (CLA), capsaicin, Momordica Charantia (MC) and psyllium fibre. Hypertension, diabetes and cardiovascular can strongly be linked to obesity (El-Atat et al., 2004). Due to the complex nature of this disease, a wide variety of treatment strategies may be implemented. Surgical procedures may provide short term gains for many patients, and pharmacotherapy may be a mainstream approach to the treatment of such a disease. However, that being said the shear expenses that patients must endure may leave many who suffer from this condition to rely on conventional methods such as diet and exercise. With respect to the dense caloric diets of the average North American (Brownell, 2004), nutritional modification of dietary intake seems to be a very logical and practical approach to the control/treatment of obesity. With respect to obesity specific herbal or nutritional extracts supplemented into the diets of many may improve conditions such as insulin resistance, which eventually if untreated leads to diabetes (Reaven, 1999). Natural products which may be used to treat obesity include the usage of Psyllium fibre, Capsaicin, and conjugated linoleic acid (CLA) and more recently the potential for Momordica Charantia (MC). These in combination with the lowering of saturated fats, and exercise intervention (Dao et al., 2004) may hold the key to the treatment of the metabolic syndrome which is plaguing much of the world today. Nutraceutical intervention A nutraceutical can be defined as: A nutraceutical is a product isolated or purified from foods that is generally sold in medicinal forms not usually associated with food. A nutraceutical is demonstrated to have a physiological benefit or provide protection against chronic disease (Wolfe, 2002).
It is estimated that by 2005 Canadians will spend an estimated one billion dollars annually on such products, to help aid chronic conditions such as arthritis, diabetes and hypertension (Wolfe, 2002). Nutraceutical usage in the United States and Europe is also increasing, with expenditures reaching as much as 25 to 30 billion dollars annually (not including raw foods that are not marketed as functional). Popularity of nutraceutical and functional food usage in Europe and North American has increased substantially (Anon, 2001). Currently products such as psyllium fiber and polyunsaturated fatty acids (PUFA’s) have been tested for clinical usage. Some have even been added to cereal products and are now even recommended by the medical community to be used in conjunction with treatment plans for a variety of diseases
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including arthritis, atherosclerosis, and now even obesity. Common products used in the healthcare setting include the usage of poly unsaturated fatty acids (PUFA’s) including CLA. Other substances that may be used in the treatment of the metabolic syndrome include Capsaicin and Momordica Charantia Linn (MC). Conjugated linoleic acid CLA is found primarily in the seeds of flax, and nut oils, as well as fish, and more readily in poultry eggs (Azain, 2004). This product has been rigorously researched due to the fact that it has a multitude of health benefits. The amelioration of LDL/HDL concentrations in blood is one of the main beneficial actions of such a product. This may be accomplished by lowering plasma triacylglycerol via the decrease of VLDL/ apolipoprotein B production (Chan et al., 2003). Recent research has also indicated that supplementation of this CLA reduced fat mass of obese individuals (Blankson et al., 2000). CLA is very sensitive to temperature change and should not be used in the cooking of meals. Rather it should be administered in its original state in salad dressings or taken as a therapeutic dosage. In one specific study, multiple dosages were experimented with, which included placebo (9 g olive oil), and dosages of up to 6.8 g of CLA. A reduction of fat mass was observed to be significant with the 3.4 g ( p = 0.05) and 6.8 g ( p = 0.02) group respectively. However, it should be noted that no greater amount of fat mass was noticed when the dosage was higher than 3.4 g respectively (Blankson et al., 2000). The mechanisms surrounding weight loss are still under investigation. However, what is known is that these specific types of oils have been found to manipulate the genetic expression of certain adipocytokines, which may ultimately modify their proliferation or differentiation. These factors include CCAAT/ enhancer binding protein, peroxisome proliferator activated receptor (PPARy), and other adipose-specific genes (Azain, 2004). Another physiological explanation may actually lie in the hormone melatonin. Melatonin (MLT) actually controls circadian rhythm in the human body. As such, when CLA, MLT and eicosapentanoic acid (EPA) were administered to rodents, it was observed that fatty acid uptake was inhibited (Dauchy et al., 2003). As well, cyclic amp (c-amp) was inhibited this would allow for fat to be used as a primary source of energy. Thus, it would appear that CLA combined with melatonin may have a major impact on weight reduction in animal species, and also may hold a similar function in humans. CLA may also have a substantial effect on the development of insulin resistance which occurs in conjunction with obesity. In a recent study it has been shown that adding CLA to a high fat diet fed to rodents actually prevented the onset of obesity induced muscle insulin resistance (Lavigne et al., 2001). However, what may be problematic is that there have been few clinical evaluations on humans (Dyck, 2000). Thus it is important to further explore the mechanisms and evaluate further weight loss in humans. Capsaicin Commonly known as the pungently active ingredient of cayenne chilli peppers, this potent substance is very effective in countering obesity. It has been observed that Capsaicin may increase energy expenditure under certain circumstances (Doucet and Tremblay, 1997). The mechanism for the increase in energy expenditure can be explained by its influence on the sympathetic nervous systems (SNS) of mammals. While this may not seem a likely manner to increase energy expenditure, such a response has been linked to increases in the potential for the mobilization of bodily fat stores. It also seems to increase core body temperature which may impact satiety via
the thermic effect of food (TEF). As well it has been seen that Capsaicin increases energy expenditure via augmented oxygen consumption and thereby may also impact metabolic rate (Masuda et al., 2003). As a result, if used in a long term intervention increased energy expenditure may favour fat oxidation. At the molecular level, capsaicin has been observed to impact uncoupling proteins (Masuda et al., 2003), whereby UCP1 and UCP3 are up regulated. UCP1 has been associated with brown adipose tissue (BAT) because it has been suggested that UCP1 may contribute to thermo genesis after the activation of the sympathetic nervous system (SNS) in BAT. Capsiate, an active analogue of capsaicin, has also been shown to increase oxygen consumption after ingestion (Masuda et al., 2003), and thus suppression of body fat accumulation. Metabolic rate increases in this study were also noted, as was an increase in mRNA levels of UCP1 in white adipose tissue (WAT) found primarily in humans. This has also been suggested as the potential mechanism responsible for increased energy expenditure which may occur as a result of capsiate ingestion. When combined with diet research has shown that it can be a key appetite regulator, as well as a significant factor in the control of energy balance in obesity (Yoshioka et al., 2001). However since capsiate is also associated with activating the central nervous system, including heart rate, and also in very high doses may affect those who suffer from gastroesophageal reflux disease (GERD) dosage should be monitored in patients with cardiac problems, and or GERD respectively (Wahlqvist and Wattanapenpaiboon, 2001). Momordica charantia (MC) This vegetable is found in Southeast Asia, and in sub-tropical areas of South and Central America respectively. The active agents within MC contain both anti-viral and anti-diabetic properties. Insulin sensitivity has been a major co-factor implicated in the development of the metabolic syndrome. MC has been shown in clinical studies done on streptozotocin (STZ) induced diabetic rats to decrease islet cell necrosis, and repair cells that were damaged (Ahmed et al., 1998). It has been observed that increased adiposity has been linked with insulin resistance (Reaven, 1999). This prolonged state of insulin resistance often leads to damage in pancreatic islet cells, which may be related to inflammatory factors released by adipocytokines such as tumor necrosis factor (TNf ) (Hotamisligil, 2003). As well, resistance may form due to interference with cellular insulin receptors by specific adipocytokines released in excessive amounts while in the obese state (Ruan and Lodish, 2003). This may help explain the ensuing hyperinsulinemia that occurs before the onset of diabetes. Thus MC seems of particular interest in that it also serves to protect islets that are functional. What is noteworthy of mentioning is that MC, has been implicated in the reduction of adiposity in mice (Matsuda et al., 1999; Tian et al., 2004), lowering lipoprotein levels (Jayasooriya et al., 2000; Senanayake et al., 2004), and as well lowering blood glucose in STZ induced rats (Karunanayake et al., 1990; Miura et al., 2004; Platel and Srinivasan, 1995) and human participants as well (Leatherdale et al., 1981). Hepatic enzymes responsible for the breakdown of lipids such as gluthionine S-transferase have also been observed to normalized, as a result of Momordica treatment (Tennekoon et al., 1994). As well cytochrome P-450 seems to be increased, which when defective has been implicated with hypertryglyceridemia (Irizar et al., 1995). Central obesity tends to also develop in patients with a defective P-450 gene (Baghaei et al., 2003). Clinically effective dosages range between 20 mg/kg (Virdi et al., 2003) body weight to 50 mg/kg (Welihinda et al., 1986). In fact in STZ rats it was observed that MC worked just as effectively as the oral
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hypoglycemic glibenclamide. This vegetable combined with exercise has also been observed to increase insulin sensitivity (Miura et al., 2004). Further testing with human participants is required before this supplement can be used to treat insulin resistance. However, the potential of such a herb provides a novel direction of therapeutic usage of nutraceuticals as preventative measures to counter growing rates of obesity.
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Psyllium fiber Psyllium fiber is extracted from the husks of its seeds. This type of fiber has been shown to be more effective than traditional fibers used in the North American diet. It has been implicated in the reduction of low density lipoprotein levels in humans (Roberts et al., 1994). In one particular study, phone interviews and follow-ups combined with psyllium fiber intake led to a significant reduction in cholesterol and triacylglycerol levels in patients suffering from cardiovascular disease (Kris-Etherton et al., 2002). Psyllium fiber has also been found in combination type therapies whereby differing types are also included when administered to patients. Minolest is a mixture of psyllium fiber and guar gum, and was administered in a randomized placebo control study. Patients who received Minolest, revealed improvement of overall cholesterol and LDL levels as compared to the placebo group (Tai et al., 1999). Another clinical study has indicated that doses of 5.2 g were effective in a clinical cohort of men with type II diabetes. The group receiving psyllium fiber showed significant improvement in glucose and lipid values. Furthermore it was observed that serum LDL levels were 8.9 per cent ( p < 0.05), and 13.0 per cent ( p < 0.07) lower as compared with the placebo group. The mechanism of action may occur because it has been observed that psyllium fiber allows for an increase in gastric transient time. Fiber may expand in the intestinal tract and as a result the body may feel more satiated. Furthermore, if combined with a balanced diet this may aid in metabolism and increased ability to absorb vitamins and minerals necessary to energy balance and regulation (Rigaud et al., 1998). With respect to glucose metabolism it has been observed that psyllium fiber decreases the rate glucose of absorption. This would be due to the fact that psyllium fiber has a lower glycemic index, which has been found to decrease postprandial insulin and glycemic response. Decreases in gastric emptying may also act as the means by which psyllium depresses appetite (Bergmann et al., 1992). The world health organization (WHO) has indicated that rates of obesity in pediatric and adolescent patients are very alarming (Rugg, 2004). Psyllium has been shown to reduce adiposity, and improve glucose homeostasis in pediatric and adolescent patients suffering from obesity. Therefore, intervention in the form of dietary modification would seem a very simple and safe way to intervene as a clinical practitioner in these particular cases (Moreno et al., 2003). Psyllium fiber has also be shown to work with the current pharmaceutical Orlistat1 to limit the number of side effects suffered by patients (Cavaliere et al., 2001). Practically speaking, studies have suggested that this ingredient can be added to the staple diets of North Americans, which may reduce conditions such as hypercholestoremia (Davidson et al., 1996), and overall cholesterol levels (Olson et al., 1997). Examination of current literature would indicate that anywhere between 5 and 10 g of psyllium fiber could be used in a nutritional based intervention. The FDA guidelines have suggested 1.78 g per serving (four servings daily), which has been proven to have validity in the prevention of cardiovascular disease (Jenkins et al., 2002). Some contraindications if too much is used include inhibition of difficulties in iron absorption, as well as certain minerals including vitamin B12.
Conclusion It is clearly evident that with the billions of dollars being spent on surgical procedures, and costly drug intervention, that a nutraceutical based approach seems logical, less invasive and relatively inexpensive. In the modern era of processed and fast foods, sedentary lifestyles, and increasing rates of chronic preventable diseases, physicians and clinical nutritionists should be encourage to further knowledge with regard to safe alternatives available to treat the metabolic syndrome. With the rising costs of health care, prevention and intervention with nutrition seem to offer a practical means of preventing further upward global trends in obesity currently being experienced. Whilst many may be skeptical of such an approach, more clinical evidence is revealing that this may be a safe method to the treatment of obesity. It is fair to say that more research is required in this area, with respect to human clinical intervention. Currently nutraceuticals are gaining popularity in North America and Europe, which would indicate that many are receptive to the approach of prevention and treatment through optimizing nutrition. The nutraceuticals mentioned in this article have been clinically evaluated and some have been added to the staple diet of populations. However, the medical community must also keep up to date with recent trends of nutraceutical usage, and regulatory bodies must ensure that clinical evaluations occur before being marketed to a population. Optimizing health with the inclusion of nutraceuticals, will allow for more individuals to be able to control their obesity, and decrease the burden that it may place on them physically, socially and psychologically. Therefore, obesity is not limited to being treated in only one manner; rather it is now being treated via a multidisciplinary approach. Diet, exercise, nutritional awareness and a sound psychological state of being provide an excellent environment by which this disease will one day be controlled. References Ahmed, I., Adeghate, E., Sharma, A.K., Pallot, D.J. and Singh, J. (1998), ‘‘Effects of Momordica charantia fruit juice on islet morphology in the pancreas of the streptozotocin-diabetic rat’’, Diabetes Res Clin Pract, Vol. 40 No. 3, pp. 145-51. Anon (2001), ‘‘Pharmacognosy in the 21st century’’, J Pharm Pharmacol, Vol. 53 No. 2, pp. 135-48. Azain, M.J. (2004), ‘‘Role of fatty acids in adipocyte growth and development’’, J Anim Sci, Vol. 82 No. 3, pp. 916-24. Baghaei, F., Rosmond, R., Westberg, L., Hellstrand, M., Eriksson, E., Holm, G. et al. (2003), ‘‘The CYP19 gene and associations with androgens and abdominal obesity in premenopausal women’’, Obes Res, Vol. 11 No. 4, pp. 578-85. Bergmann, J.F., Chassany, O., Petit, A., Triki, R., Caulin, C. and Segrestaa, J.M. (1992), ‘‘Correlation between echographic gastric emptying and appetite: influence of psyllium’’, Gut, Vol. 33 No. 8, pp. 1042-43. Blankson, H., Stakkestad, J. A., Fagertun, H., Thom, E., Wadstein, J. and Gudmundsen, O. (2000), ‘‘Conjugated linoleic acid reduces body fat mass in overweight and obese humans’’, J Nutr, Vol. 130 No. 12, pp. 2943-48. Brownell, K.D. (2004), ‘‘Fast food and obesity in children’’, Pediatrics, Vol. 113 No. 1 Pt 1, p. 132. Cavaliere, H., Floriano, I. and Medeiros-Neto, G. (2001), ‘‘Gastrointestinal side effects of orlistat may be prevented by concomitant prescription of natural fibers (psyllium mucilloid)’’, Int J Obes Relat Metab Disord, Vol. 25 No. 7, pp. 1095-99. Chan, D.C., Watts, G.F., Mori, T.A., Barrett, P.H., Redgrave, T.G. and Beilin, L.J. (2003), ‘‘Randomized controlled trial of the effect of n-3 fatty acid supplementation on the
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Matsuda, H., Li, Y., Yamahara, J. and Yoshikawa, M. (1999), ‘‘Inhibition of gastric emptying by triterpene saponin, momordin Ic, in mice: roles of blood glucose, capsaicinsensitive sensory nerves, and central nervous system’’, J Pharmacol Exp Ther, Vol. 289 No. 2, pp. 729-34. Miura, T., Itoh, Y., Iwamoto, N., Kato, M. and Ishida, T. (2004), ‘‘Suppressive activity of the fruit of Momordica charantia with exercise on blood glucose in type 2 diabetic mice’’, Biol Pharm Bull, Vol. 27 No. 2, pp. 248-50. Moreno, L.A., Tresaco, B., Bueno, G., Fleta, J., Rodriguez, G., Garagorri, J.M. et al. (2003), ‘‘Psyllium fibre and the metabolic control of obese children and adolescents’’, J Physiol Biochem, Vol. 59 No. 3, pp. 235-42. Olson, B.H., Anderson, S.M., Becker, M.P., Anderson, J.W., Hunninghake, D.B., Jenkins, D.J. et al. (1997), ‘‘Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: results of a meta-analysis’’, J Nutr, Vol. 127 No. 10, pp. 1973-80. Platel, K. and Srinivasan, K. (1995), ‘‘Effect of dietary intake of freeze dried bitter gourd (Momordica charantia) in streptozotocin induced diabetic rats’’, Nahrung, Vol. 39 No. 4, pp. 262-68. Reaven, G.M. (1999), ‘‘Insulin resistance: a chicken that has come to roost’’, Ann N Y Acad Sci, Vol. 892, pp. 45-57. Rigaud, D., Paycha, F., Meulemans, A., Merrouche, M. and Mignon, M. (1998), ‘‘Effect of psyllium on gastric emptying, hunger feeling and food intake in normal volunteers: a double blind study’’, Eur J Clin Nutr, Vol. 52 No. 4, pp. 239-45. Roberts, D.C., Truswell, A.S., Bencke, A., Dewar, H.M. and Farmakalidis, E. (1994), ‘‘The cholesterol-lowering effect of a breakfast cereal containing psyllium fibre’’, Med J Aust, Vol. 161 No. 11-12, pp. 660-64. Ruan, H. and Lodish, H.F. (2003), ‘‘Insulin resistance in adipose tissue: direct and indirect effects of tumor necrosis factor-alpha’’, Cytokine Growth Factor Rev, Vol. 14 No. 5, pp. 447-55. Rugg, K. (2004), ‘‘Childhood obesity: its incidence, consequences and prevention’’, Nurs Times, Vol. 100 No. 3, pp. 28-30. Senanayake, G.V., Maruyama, M., Shibuya, K., Sakono, M., Fukuda, N., Morishita, T. et al. (2004), ‘‘The effects of bitter melon (Momordica charantia) on serum and liver triglyceride levels in rats’’, J Ethnopharmacol, Vol. 91 No. 2-3, pp. 257-62. Swinburn, B.A., Caterson, I., Seidell, J.C. and James, W.P. (2004), ‘‘Diet, nutrition and the prevention of excess weight gain and obesity’’, Public Health Nutr, Vol. 7 No. 1A, pp. 123-46. Tai, E.S., Fok, A.C., Chu, R. and Tan, C.E. (1999), ‘‘A study to assess the effect of dietary supplementation with soluble fibre (Minolest) on lipid levels in normal subjects with hypercholesterolaemia’’, Ann Acad Med Singapore, Vol. 28 No. 2, pp. 209-13. Tennekoon, K.H., Jeevathayaparan, S., Angunawala, P., Karunanayake, E.H. and Jayasinghe, K.S. (1994), ‘‘Effect of Momordica charantia on key hepatic enzymes’’, J Ethnopharmacol, Vol. 44 No. 2, pp. 93-7. Tian, W.X., Li, L.C., Wu, X.D. and Chen, C.C. (2004), ‘‘Weight reduction by Chinese medicinal herbs may be related to inhibition of fatty acid synthase’’, Life Sci, Vol. 74 No. 19, pp. 2389-99. Virdi, J., Sivakami, S., Shahani, S., Suthar, A.C., Banavalikar, M.M. and Biyani, M.K. (2003), ‘‘Antihyperglycemic effects of three extracts from Momordica charantia’’, J Ethnopharmacol, Vol. 88 No. 1, pp. 107-11. Wahlqvist, M.L. and Wattanapenpaiboon, N. (2001), ‘‘Hot foods-unexpected help with energy balance?’’, Lancet, Vol. 358 No. 9279, pp. 348-49.
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The potential role of peanuts in the prevention of obesity
The prevention of obesity
Jennette Higgs Consultant Nutritionist and Media Specialist for the American Peanut Council; Freelance Public Health Nutritionist and Sports Dietitian, Food To Fit, Northamptonshire, UK
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Abstract Purpose – To provide an overview of recent research that collectively demonstrates the potential for peanuts as an aid to weight management. Design/methodology/approach – Research on nuts and their effects on health has been plentiful in recent years. This short literature review focuses principally on that research relevant to peanuts. Findings – Epidemiological and intervention studies have provided useful information on the beneficial effects of nuts, including peanuts in relation to weight management and obesity. This has served to overturn the perception that peanuts, due to their fat content, should not be included in weight loss diets. Furthermore, that, for effective weight management, a moderate fat diet, that includes peanuts, may be more effective for both cardiovascular health and weight management. Research limitations/implications – More definitive research to directly assess the effects of peanuts on energy balance and body weight is recommended to ascertain optimal quantities of peanuts that can be included in diets for both weight loss and weight maintenance. Plausible explanations for the absence of expected weight gain with regular nut consumption are reported and further research to explore these theories will be reassuring. Practical implications – Inclusion of daily 1oz(30 g) handfuls of peanuts within a moderate fat diet can be recommended as a useful means not only to improve diet quality but also to assist with weight management, due to their satiating effects. Originality/value – This paper will be useful to health professionals and educators by highlighting how a convenient snack food, peanuts can play a beneficial role within a healthy diet for both cardiovascular protection and weight management. Keywords Nuts (food), Weight (mass), Obesity Paper type Literature review
Introduction Peanuts were traditionally viewed as useful nutritionally but fell from favour as a consequence of general negative concerns about fat. Despite reductions in fat intakes (Hoare et al., 2004), levels of obesity have dramatically increased by over 400 per cent in the UK over the last 25 years, more so than in most European countries, (House of Commons Health Committee, 2004). The apparent failure of low fat diets to control weight has encouraged debate regarding the ideal percentage of macronutrients in the diet that can assist weight control (Willett, 1998). The emphasis on low fat, weight loss diets (<30 per cent energy from fat) has often precluded nuts from recommendation, regardless of their nutrient density. The beneficial effects of unsaturated fats are now well documented (Willett, 2001). Epidemiological studies have confirmed that consuming nuts, a snack food, at least five times per week may contribute to protecting against cardiovascular disease (CVD), type two diabetes and more recently gallbladder disease (Hu et al., 1998; Jiang et al., The author would like to thank Mrs Kathryn Styles for her contribution to the preparation of this paper.
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2002; Tsai et al., 2004). Nuts do not appear to have a detrimental effect on glucose homeostasis and hence may offer protection against insulin resistance (Garca-Lorda et al., 2003). Several intervention studies in normal, hyperlipidaemic and diabetic subjects have demonstrated the cholesterol-lowering effects of groundnuts (legume peanuts) and tree nuts, when consumed regularly at a level of 1oz or more, (GarcaLorda et al., 2003; Alper and Mattes, 2003). Fat weight loss Given that obesity in itself is a risk factor for CVD and that the type of fat consumed is more important than the total amount of fat, as a risk for chronic diseases (Khor, 2004), it would be useful to be able to recommend peanuts within weight management diets. Prospective cohort studies have shown that nut consumption can be cardioprotective in both lean and obese individuals (Sabate´, 2003). Pelkman et al. (2004) explored the effects of altering the energy profile of a diet on cardiovascular health in 52 healthy, overweight and obese men and women, assigned to a low fat diet (18.3 per cent of energy), or a moderate fat, high monounsaturated fat (MUFA) diet (32.8 per cent). Both experimental diets were low in saturated fat (7 per cent). Half of the fat from the moderate fat diet came from peanuts, peanut butter and peanut oil. Weight loss was regulated and did not differ between the groups, although significant changes to lipid profiles were observed. Both groups’ total cholesterol, LDL cholesterol and triacylglycerol levels reduced significantly. However, consuming the low fat diet also significantly reduced protective HDL levels, by 12 per cent, whereas those on the moderate fat diet maintained their HDL levels even during the weight maintenance phase. Thus a moderate fat diet, containing a large proportion of fat from peanuts can achieve good weight loss (2 lb/wk), whilst also benefiting cardiovascular health. Whereas following the typical low fat diet may adversely effect CVD risk, even in response to weight loss, since reduced HDL levels, whilst following a low fat diet, have been shown in both long and short term studies. McManus et al. (2001) compared success rates of the typical low fat diet with a Mediterranean-style, moderate fat diet (high in MUFAs provided by nuts, peanuts, peanut butter, avocados and olive oil). Three times as many people were able to stick to the Mediterranean-style, moderate fat diet vs the low fat diet and they were able to keep off a significant amount of their lost weight for up to two-and-a-half years, whereas the low fat group had regained some of their initial weight loss by 18 months. The authors attribute the success of the moderate fat diet to the greater palatability and variety afforded by the daily inclusion of foods such as peanuts and olive oil that would be prohibited on a typical low fat diet. Nuts and weight Epidemiological data and nut – feeding studies have highlighted the fact that regular nut consumption is not associated with increased body mass index (BMI), both in freefeeding and more controlled diet situations. Hu et al. (1999) showed statistically significant negative associations between nut consumption and BMI in 31,200 people. Schroder et al. (2004) studied 3,162 Spanish adults and showed that those who were more adherent to a traditional Mediterranean diet, which includes nuts, had statistically lower BMIs. US Government food survey data from 1994-96 has been used to show that both nut eaters and, more specifically peanuts eaters had lower BMIs than non nut and peanut eaters (Sabate´, 2003; Griel et al., 2004). Furthermore, BMI did not change with increasing peanut consumption, despite the fact that almost a third of the
peanut consumers were eating more than two, or more than three handfuls of peanuts per day. Interestingly energy intakes were significantly higher for peanut consumers and possible explanations for this will be explored later. Supplementation studies using separately, peanuts, walnuts, almonds, pistachios, macadamia and pecans illustrate overwhelmingly that short-term consumption of moderate to large amounts of nuts has shown no increase in body weight (Sabate´, 2003; St-Onge, 2005). Sabate´ (2003) reviewed the evidence and concluded that free living people on self selected diets that included frequent consumption of nuts were unlikely to have a higher BMI as a consequence. Griel et al. (2004) has demonstrated that the regular peanut consumers had better diet quality overall, having higher intakes of vitamin E and folate, magnesium, zinc, iron, monounsaturated fat and dietary fibre, and lower intakes of cholesterol. Additionally, Talcott et al. (2005) has shown that peanuts are as rich in antioxidants as many fruits, in particular vitamin E and the polyphenol, p-coumaric acid, which has been shown to block lipid peroxidation and reduce cholesterol levels. McManus et al. (2001) also showed that following a moderate fat, weight loss diet (that included peanuts and olive oil) significantly increased intake of vegetables and fibre by one portion per day, whereas, those people following the low fat diet decreased their intake. Thus the use of moderate fat, high MUFA diets, that allow inclusion of peanuts and a greater variety of food, can improve diet quality both directly and indirectly. Low fat weight reducing diets, particularly for women can be restrictive to the point that nutrient adequacy cannot always be guaranteed and micronutrient supplements are often recommended as insurance (Thomas, 2001). Why peanuts do not cause weight gain Explanations for why peanuts and tree nuts are not associated with increased BMI can help us to appreciate their potential for weight management. The high satiety effects of nuts – due to their energy and protein dense, high fibre nature, coupled with their low glycaemic index (GI) is perhaps the most plausible explanation for the absence of weight gain on diets containing peanuts (Alper and Mattes, 2002; Sabate´, 2003). O’Byrne et al. (1997) found that where subjects were given peanuts as a substitute for other sources of fat, in a low fat diet, despite being told to maintain their normal weight, subjects gradually lost 3 kg weight over a six-month period. Research into the satiating effects of peanuts has illustrated that 90 g (500 kcal) peanut snacks not only suppress hunger for 2.5 hours, compared to half an hour for other typical snacks such as rice cakes (Kirkmeyer and Mattes, 2000); but when eaten in addition to the normal diet 500 kcal peanut snacks do not cause the predicted weight gain as subjects compensate and eat less of other foods (Alper and Mattes, 2002). Similarly 54-78 per cent of the extra energy supplied by almonds in a six month supplementation study was compensated for by reductions in other foods (Fraser et al., 2002). New research has also shown that 300 kcal peanut snacks suppress hunger and reduce plasma glucose levels when consumed either as a snack or with a meal (Devitt and Mattes, 2005). Nuts are a rich source of dietary fibre, mainly in the insoluble form and dietary fibre is inversely related to obesity and BMI, independent of fat intake (Megias-Rangil et al., 2004; Slavin, 2005; Liu et al., 2003). Diets based on foods with a low GI are proving effective for weight loss in addition to cardiovascular health (Brand-Miller, 2005). Nuts have a low GI and peanuts, at 14, have one of the lowest GIs of all nuts (Henry, 2005). There appears to have been a reluctance to enthusiastically recommend nuts within low GI diets for weight loss, perhaps due to the precedence given to low fat foods, even
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within low GI diets. Ebbeling et al. (2005) has now shown that an ad libitum lowglycaemic load, moderate fat diet (which included nuts) may be more efficacious than a conventional, energy-restricted, low-fat diet in reducing cardiovascular disease risk and achieving effective weight loss. Increased satiation, due to the inclusion of low GI foods, such as nuts, with consequent dietary compensation would explain how an ad libitum diet could achieve effective weight loss, when traditionally one of the factors causing diets to fail is poor dietary restraint. (McManus et al., 2001; Anderson et al., 2001). The high protein and high unsaturated fat nature of peanuts may also contribute to the lack of weight gain associated with peanut consumption. Diet-induced thermogenesis is up to three times higher with protein than isocaloric amounts of carbohydrate or fat. Johnston (2005) has explored the role of protein in protecting against weight gain due to it’s thermic effects and increased satiety and recommends this as one strategy for effective weight management. A high polyunsaturated to saturated fat ratio increases resting energy expenditure and diet induced thermogenesis since unsaturated fats are preferentially oxidised (Sabate´, 2003; Alper and Mattes, 2002). A 30 week (11 weeks baseline and washout periods), cross over intervention study of 15 normal body weight adults looked at the effects on energy balance of altering the fat content of the diet by adding peanuts to their diet (505 ± 118 kcal/day). During the 19 weeks of regular peanut consumption resting energy expenditure increased by 11 per cent compared to baseline and there was no significant change in physical activity levels during the study that could account for this (Alper and Mattes, 2002). Faecal fat loss due to incomplete digestion and absorption of nuts may result in a loss of available energy. As long ago as 1980, it was shown that whole peanuts are incompletely absorbed with the undigested dietary fat appearing in stools. Similar findings have also been shown for studies using pecan nuts and almonds (Alper and Mattes, 2002; Sabate´, 2003). Possible explanations for the inverse relation between nut consumption and BMI found in epidemiological data are reverse causation and higher energy expenditure. Unlike lean people, obese people may tend not to eat nuts as they perceive that they are high in fat (Sabate´, 2003). This may be partly true, although the results seen in intervention studies with nuts demonstrate that other factors must account for the lack of weight gain associated with daily nut intakes. Results from both the Nurses Health Study (Hu et al., 1998) and Physicans’ Health Study (Albert et al., 2002) suggest that nut consumption is associated with more frequent exercise, although results from experimental studies do not support this. No increase in physical activity was shown in subjects supplementing their diet with almonds for six months, even though they lost weight (Fraser et al., 2002). Conclusion More definitive research to directly assess the effects of nuts on energy balance and body weight is still required, however, peanuts have already been shown to contribute to effective weight loss when consumed daily as part of moderate fat, high MUFA, Mediterranean-style diets. Such diets are also relatively low GI. The research reviewed here illustrates the potential for regular moderate portions of peanuts, along with other nuts to play an important part in moderate fat, low GI diets that can be effective for both weight loss and CVD health. Given the crisis concerning obesity and type two
diabetes, it is perhaps time to try new dietary approaches that may be more sustainable and practical in our fast food society. References Albert, C.M., Gaziano, J.M., Willett, W.C. and Manson, J.E. (2002), ‘‘Nut consumption and decreased risk of sudden death in the physicians’ health study’’, Archives Internal Medicine, Vol. 162, 24 June, pp. 1382-7. Alper, C.M. and Mattes, R.D. (2002), ‘‘Effects of chronic peanut consumption on energy balance and hedonics’’, International Journal of Obesity, Vol. 26, pp. 1129-37. Alper, C.M. and Mattes, R.D. (2003), ‘‘Peanut consumption improves indices of cardiovascular disease risk in healthy adults’’, Journal of the American College of Nutrition, Vol. 22 No. 2, pp. 133-41. Anderson, J.W., Konz, E.C., Frederich, R.C. and Wood, C.L. (2001), ‘‘Long-term weight-loss maintenance: a meta-analysis of US studies’’, American Journal of Clinical Nutrition, Vol. 74, pp. 579-84. Brand-Miller, J. (2005), ‘‘Optimising the cardiovascular outcomes of weight loss’’, American Journal of Clinical Nutrition, Vol. 81, pp. 949-50. Devitt, A.A. and Mattes, R.D. (2005), ‘‘Effects of peanuts ingested with a meal or as a snack on subjective hunger ratings and plasma glucose in healthy adults’’, Program/Abstract # 849.11, paper presented at Experimental Biology 2005. Ebbeling, C.B., Leidig, M.M., Sinclair, K.B., Seger-Shippee, L.G., Feldman, H.A. and Ludwig, D.S. (2005), ‘‘Effects of an ad libitum low-glycemic load diet on cardiovascular disease risk factors in obese young adults’’, American Journal of Clinical Nutrition, Vol. 81 No. 5, pp. 976-82. Fraser, G.E., Bennett, H.W., Jaceldo, K.B. and Sabate´, J. (2002), ‘‘Effect on body weight of a free 76 kilojoule (320 calorie) daily supplement of almonds for six months’’, Journal of the American College of Nutrition, Vol. 21, pp. 275-83. Garca-Lorda, P., Megias Rangil, I. and Salas-Salvado, J. (2003), ‘‘Nut consumption, body weight and insulin resistance’’, European Journal of Clinical Nutrition, Vol. 57 (suppl 1), 8S-11S. Griel, A.E., Eissenstat, B., Juturu, V., Hsieh, G. and Kris-Etherton, P.M. (2004), ‘‘Improved diet quality with peanut consumption’’, Journal of the American College of Nutrition, Vol. 23, pp. 660-8. Henry, J. (2005), personal communication. Hoare, J., Henderson, L., Bates, C.J., Prentice, A., Birch, M., Swan, G. and Farron, M. (2004), The National Diet & Nutrition Survey: Adults Aged 19 to 64 Years Summary Report. TSO, London. House of Commons Health Committee (2004). Obesity. Third Report of Session 2003-4, May, The Stationery Office Limited, London, available at www.parliament.the-stationery-office. co.uk/pa/cm200304/cmselect/cmhealth/23/23.pdf Hu, F.B. and Stampfer, M.J. (1999), ‘‘Nut consumption and risk of coronary heart disease: a review of epidemiologic evidence’’, Curr Atheroscler Rep, Vol. 3, pp. 204-9. Hu, F.B., Stampfer, M.J., Manson, J.A.E., Rimm, E.B., Colditz, G.A., Rosner, B.A., Speizer, F.E., Hennekens, C.H. and Willett, W.C. (1998), ‘‘Frequent nut consumption and risk of coronary heart disease in woman: prospective cohort study’’, British Medical Journal, Vol. 317, pp. 1341-5. Jiang, R., Manson, J.E., Stampfer, M.J., Liu, S., Willett, W.C. and Hu, F.B., (2002), ‘‘A prospective study of nut consumption and risk of type II diabetes in women’’, Journal of the American Medical Association, Vol. 288, pp. 2554-60.
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Johnston, C.S. (2005), ‘‘Strategies for healthy weight loss: from vitamin C to the glycemic response’’, Journal of the American College of Nutrition, Vol. 24, No. 3, pp. 158-65. Khor, G.L. (2004), ‘‘Dietary fat quality: a nutritional epidemiologist’s view’’, Asia Pac J Clin Nutr, Vol. 13 (suppl), 22S. Kirkmeyer, S.V. and Mattes, R.D. (2000), ‘‘Effects of food attributes on hunger and food intake’’, International Journal of Obesity, Vol. 59, pp. 103-11. Liu, S., Willett, W.C., Manson, J.A.E., Hu, F.B., Rosner, B. and Colditz, G. (2003), ‘‘Relation between changes in intakes of dietary fiber and grain products and changes in weight and development of obesity among middle-aged women’’, American Journal of Clinical Nutrition, Vol. 78, pp. 920-7. McManus, K., Antinoro, L. and Sacks, F. (2001), ‘‘A randomised controlled trial of a moderate fat, low-energy diet with a low fat, low-energy diet for weight loss in overweight adults’’, International Journal of Obesity, Vol. 25, pp. 1503-11. Megias-Rangil, I., Garcia-Lorda, P., Torres-Moreno, M., Bullo, M. and Salas-Salvado, J. (2004), ‘‘Nutrient content and health effects of nuts’’, Arch Latinoam Nutr, Vol. 54, pp. 83-6. O’Byrne, D.J., Knauft, D.A. and Shireman, R.B. (1997), ‘‘Low fat-monounsaturated rich diets containing high-oleic peanuts improve serum lipoprotein profiles’’, Lipids, Vol. 32, pp. 687-95. Pelkman, C.L., Fishell, V.K., Maddox, D.H., Pearson, T.A., Mauger, D.T. and Kris-Etherton, P.M. (2004), ‘‘Effects of moderate-fat (from monounsaturated fat) and low-fat weight-loss diets on the serum lipid profile in overweight and obese men and women’’, American Journal of Clinical Nutrition, Vol. 79, pp. 204-14. Sabate´, J. (2003), ‘‘Nut consumption and body weight’’, American Journal of Clinical Nutrition, Vol. 78, pp. 647-50. Schroder, H., Marrugat, J., Vila, J., Covas, M.I. and Elosua, R. (2004), ‘‘Adherence to the traditional mediterranean diet is inversely associated with body mass index and obesity in a Spanish population’’, J. Nutr., Vol. 134, pp. 3355-61. Slavin, J.L. (2005), ‘‘Dietary fiber and body weight’’, Nutrition, Vol. 21, pp. 411-8. St-Onge, M.P. (2005), ‘‘Dietary fats, teas, dairy, and nuts: potential functional foods for weight control?’’, American Journal of Clinical Nutrition, Vol. 81, pp. 7-15. Talcott, S.T., Passeretti, S., Duncan, C.E. and Gorbet, D.W. (2005), ‘‘Polyphenolic content and sensory properties of normal and high oleic acid peanuts’’, Journal of Food Chemistry, Vol. 90, pp. 379-88. Thomas, B. (2001), Manual of Dietetic Practice, 3rd ed., Blackwell Science, Oxford, p. 468. Tsai, C.J., Leitzmann, M.F., Hu, F.B., Willett, W.C. and Giovannucci, E.L. (2004), ‘‘Frequent nut consumption and decreased risk of cholecystectomy in women’’, American Journal of Clinical Nutrition, Vol. 80, pp. 76–81. Willett, W.C. (1998), ‘‘Is dietary fat a major determinant of body fat?’’, American Journal of Clinical Nutrition, Vol. 67 (Suppl.), pp. 556S-62S. Willett, W.C. (2001), Eat, Drink, and Be Healthy, Simon and Schuster, New York, NY. Further Reading Jenkins, D.J., Wolever, T.M., Taylor, R.H., Barker, H., Fielden, H., Baldwin, J.M., Bowling, A.C., Newman, H.C., Jenkins, A.L. and Goff, D.V. (1981), ‘‘Glycemic index of foods: a physiological basis for carbohydrate exchange’’, American Journal of Clinical Nutrition, Vol. 34, pp. 362-6. Ma, Y., Olendzki, B., Chiriboga, D., Hebert, J.R., Li, Y., Li, W., Campbell, M.J., Gendreau, K. and Ockene, I.S. (2005), ‘‘Association between dietary carbohydrates and body weight’’, American Journal of Epidemiology, Vol. 161, pp. 359-67.
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Waist to height ratio and the Ashwell1 shape chart could predict the health risks of obesity in adults and children in all ethnic groups
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Margaret Ashwell OBE Ashwell Associates, Ashwell, UK and Visiting Research Fellow, Oxford Brookes University, Oxford, UK Abstract Purpose – To outline the benefits of the ratio of the waist to height ratio (WHTR) and its graphical representation in the Ashwell1 shape chart for the assessment of the health risks of obesity. To show that it has potential to be used in all ethnic groups and in adults and children. Design/methodology/approach – A review of the benefits and limitations of the use of some different anthropometric measures to assess the health risks of obesity. Those covered are the body mass index (BMI), the waist to hip ratio (WHR), the waist circumference (WC) and the waist to height ratio (WHTR). Findings – Waist to Height Ratio (WHTR) has the potential to be globally applicable to different ethnic populations and to children as well as adults. Further validation, particularly of the suggested boundary values of 0.5 and 0.6, as used within the Ashwell1 shape chart to indicate different levels of risk, is required. Originality/value – This is the first paper to summarise the accumulating evidence for the benefits of using WHTR and the Ashwell1 shape chart to assess health risk. Keywords Obesity, Measurement, Health education, Health and safety Paper type Viewpoint
Introduction The health risks of excess body fat for adults have traditionally been associated with inappropriate weights for height. Tables of such weights for different frame sizes were originally derived from insurance data. Various indices based on weight and height were then suggested as correlates of total body fat, but the Body Mass Index - BMI (weight in kilograms divided by the square of the height in metres) became the most widely accepted. Since the early 1980s, John Garrow’s classic chart based on BMI has been used extensively to assess the health risks of obesity (Garrow, 1981). Healthy weight for height was defined in UK as a BMI between 20 and 25, overweight as more than 25 and less than 30, and obesity as BMI=30 and over. Even the USA has now adopted the same BMI categories as the rest of the world. BMI has served us well as a proxy for obesity for many years, but it has always been recognised that it does not differentiate between the over-muscled and the over-fat. But there is another problem with BMI. Even in the over-fat, it is only a proxy for total fat in the body and it does not distinguish between individuals with different types of fat distribution. Jean Vague (1956) first pointed out in the 1940s and 50s that people with a ‘‘central’’ type of fat distribution (android shape) were at greater health risk than those whose fat was deposited ‘‘peripherally’’ (gynoid shape). However, it has only been in the last
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decade that there has been a consensus view that health risks (predominantly cardiovascular disease (CVD) and diabetes) can be determined as much by the relative distribution of the excess fat as by its total amount. And only very recently has there been any media interest in the ‘‘unhealthy apple shape’’ and the ‘‘healthy pear shape’’. The use of imaging techniques such as Computed Tomography (CT) (Ashwell et al., 1985) and Magnetic Resonance Imaging (MRI) (Seidell et al., 1990) has subsequently indicated that the ‘‘unhealthy apple shape’’ is associated with a preferential deposition of fat in the internal, visceral fat depots rather than the external, subcutaneous fat depots. Relative fat distribution can be measured by the ratio of waist circumference to hip circumference (WHR). This was shown to be a good predictor of health risk and was popular for many years (Bjorntorp, 1988). However, although very useful for risk assessment, WHR is not helpful in a risk management in a public health context because both waist and hip can decrease with weight reduction and so the ratio of WHR changes very little. So, attention then shifted to the use of waist circumference alone as a possible replacement for BMI. Jean-Pierre Despres and his colleagues (Despres et al., 1990; Despres, 2001) produced exciting results from the Quebec Cardiovascular Study which show that waist circumference alone is much better than BMI for predicting not only the traditional metabolic complications of excess fat (hypertension, CVD and NIDDM) but also the newer very important risk factors or ‘‘markers’’ for these complications (high insulin, high Apoprotein B, increased concentration of small dense lipoprotein particles; glucose intolerance, high triglycerides, low HDL cholesterol, high cholesterol to HDL ratio, insulin resistance and altered haemostatic variables). Using Despres’ analogy of an iceberg, measuring BMI only allows you to see the tip of the iceberg when it is too late, but measuring waist circumference can tell you much more about the countless dangers that lurk beneath the surface. So then you have time to avoid a serious collision – real preventive medicine! Not surprisingly, the simple measurement of waist circumference has been suggested as a good proxy measure for body fat distribution and subsequent health risk (Han et al., 1995). Unfortunately several cut off or boundary values for waist circumference have been proposed and these have had different values for men and women and, sometimes, for different age groups (Zhu et al., 2005). Furthermore, most of these cut-off values would indicate a higher proportion of the UK population at risk than those who would currently be considered at risk on the basis of BMI! Furthermore, a report from Japan showed the difference of metabolic risks between people of similar waist circumference with different heights. (Hsieh and Yoshinaga, 1999) So how can the simple measure of waist circumference be used satisfactorily in a public health context? Use of ratio of the waist circumference to height (WHTR) The ratio of the waist circumference to height (WHTR) was originally proposed more or less simultaneously in Japan (Hsieh and Yoshinaga, 1995a, b) and UK (Ashwell et al., 1996) (Cox et al., 1996) as a way of assessing shape and monitoring risk reduction. Both research groups suggested that WHTR values above 0.5 should indicate increased risk. The UK group also suggested that values above 0.6 indicate substantially increased risk (Ashwell, 1997). Since then, studies in Taiwan have also demonstrated the superiority of WHTR over other anthropometric indices for the prediction of metabolic risks (Lin et al., 2002) (Lyu et al., 2003). Further research in other populations to determine optimal boundary values for WHTR has indicated that whtr = 0.5 is the
simplest value that corresponds to more precise boundary values in both sexes (Lin et al., 2002; Bertsias et al., 2003). Prospective studies (Cox and Whichelow, 1996) showed that both waist circumference and WHTR are better than BMI at predicting CHD deaths and all-cause mortality. WHTR is a slightly better predictor than waist circumference alone. This is probably because there is a positive association between waist and height in global populations of mixed ethnicity which include a wide range of heights. It is also possible that the independent negative association between height and mortality contributes to the predictive powers of WHTR. One advantage of using WHTR over waist circumference in a public health context is that boundary values can be set which are the same for men and women. A second advantage of these suggested boundary values, which have been derived from UK (Ashwell et al., 1996), Japanese (Hsieh and Yoshinaga, 1995a, b) and Chinese (Ho et al., 2003) populations completely independently, is that the estimated size (but not the members) of the population at risk is similar to that estimated by BMI. Furthermore, the proportion of men at risk using WHTR is greater than the proportion of women at risk, reflecting the greater propensity for men to store visceral fat.
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The Ashwell1 shape chart The third, and maybe the most important advantage is that WHTR (unlike waist circumference) can be converted into a ‘‘consumer-friendly chart. This is very similar to that used for BMI but with the important difference that The Ashwell1 shape chart (Ashwell, 1995) requires the user to match their waist measurement against their height rather than their weight (see Figure 1)
Figure 1.
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Adults Some UK data allowed us (Ashwell, 1998) to demonstrate the important new Public Health message that the use of waist circumference in the Ashwell 1 Shape Chart would convey compared with the traditional BMI Chart. The BMI Chart would classify 21 per cent of the European women in the Newcastle Heart Study (Patel et al., 1999) and 15 per cent of men as obese or high risk, whereas The Ashwell1 shape chart would classify 15 per cent of men, but only 11 per cent of women as high risk. In other words, using The Ashwell1 shape chart would focus attention and resources on the ‘‘appleshaped’’ men and women and it would make it clear that the ‘‘pear-shaped’’ women have less health risks than their ‘‘apple shaped’’ counterparts. Ethnic groups Recent research, mainly from Asian countries, has shown that even in populations with low rates of obesity and moderate BMIs such as Japan (Hsieh et al., 2000a, b; Hsieh et al., 2003; Hsieh and Muto, 2005) and China (Ho et al., 2003) (Patel et al., 1999), the measurement of WHTR can be an important early indicator of lifestyle related disorders and could be an important public health approach to preventing diabetes and CHD. Children An exciting thought for the future is that WHTR may allow the same boundary value for children and adults. There is now growing evidence that WHTR can be used to predict risk in children (Savva et al., 2000) (Hara et al., 2002) (Kahn et al., 2005). Since the height and waist circumference of children increases continually as they age, the same boundary value (WHTR=0.5) could be used to indicate increased risk across all age groups (McCarthy and Ashwell, 2002) (McCarthy and Ashwell, 2003). Conclusion In conclusion, the use of WHTR and the Ashwell1 shape chart could be an important new public health tool which has global applicability for adults and children (Ashwell and Hsieh, 2005). Further validation, particularly of the suggested boundary values of 0.5 and 0.6 to indicate different levels of risk, is urgently required. References Ashwell, M. (1995), ‘‘A new shape chart for assessing the risks of obesity’’, Proc Nutr Soc, Vol. 54, pp. 86A. Ashwell, M. (1997), ‘‘The Ashwell Shape Chart - a new millennium approach to communicate the metabolic risks of obesity’’, Obesity Research, Vol. 5, pp. 45S. Ashwell, M. (1998), ‘‘The Ashwell Shape Chart - a public health approach to the metabolic risks of obesity’’, International Journal of Obesity, Vol. 22 (Supplement 3), pp. S213. Ashwell, M. and Hsieh, S.D. (2005), ‘‘Six reasons why the waist to height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message for the prevention of obesity’’, International Journal of Food Science and Nutrition. Ashwell, M.A., Cole, T.J. and Dixon, A.K. (1985), ‘‘Obesity: new insight into anthropometric classification of fat distribution shown by computed tomography’’, Br. Med. J., Vol. 290, pp. 1692-4.
Ashwell, M.A., LeJeune, S.R.E. and McPherson, K. (1996), ‘‘Ratio of waist circumference to height may be better indicator of need for weight management’’, British Medical Journal, Vol. 312, pp. 377. Bertsias, G., Mammas, I., Linardakis, M. and Kafatos, A. (2003), ‘‘Overweight and obesity in relation to cardiovascular disease risk factors among medical students in Crete, Greece’’, BMC Public Health, Vol. 3 No. 1, pp. 3. Bjorntorp, P. (1988), ‘‘The associations between obesity, adipose tissue distribution and disease’’, Acta Med Scand, Vol. 723, pp. 121-34. Cox, B.D. and Whichelow, M. (1996), ‘‘Ratio of waist circumference to height is better predictor of death than body mass index’’, Bmj, Vol. 313 No. 7070, pp. 1487. Cox, B.D., Whichelow, M.J., Ashwell, M.A. and Prevost, A.T. (1996), ‘‘Comparison of anthropometric indices as predictors of mortality in British adults’’, International Journal of Obesity, Vol. 20 (suppl 4), pp. 141. Despres, J., Moorjani, S., Lupien, P.J., Tremblay, A., Nadeau, A. and Bouchard, C. (1990), ‘‘Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease’’, Arteriosclerosis, Vol. 10 No. 4, pp. 497-511. Despres, J.P. (2001), ‘‘Health consequences of visceral obesity’’, Ann Med, Vol. 33 No. 8, pp. 534-41. Garrow, J.S. (1981), Treat Obesity Seriously – A Clinical Manual, Churchill Livingstone, Edinburgh. Han, T.S., van Leer, E.M., Seidell, J.C. and Lean, M.E.J. (1995), ‘‘Waist circumference action levels in the identification of cardiovascular risk factors: prevalence study in a random sample’’, British Medical Journal, Vol. 311, pp. 1401-5. Hara, M., Saitou, E., Iwata, F., Okada, T. and Harada, K. (2002), ‘‘Waist-to-height ratio is the best predictor of cardiovascular disease risk factors in Japanese schoolchildren’’, J Atheroscler Thromb, Vol. 9 No. 3, pp. 127-32. Ho, S.Y., Lam, T.H. and Janus, E.D. (2003), ‘‘Waist to stature ratio is more strongly associated with cardiovascular risk factors than other simple anthropometric indices’’, Ann Epidemiol, Vol. 13 No. 10, pp. 683-91. Hsieh, S. and Yoshinaga, H. (1999), ‘‘Do people with similar waist circumference share similar health risks irrespective of height?’’, Tohoku J exp Med, Vol. 188, pp. 55-60. Hsieh, S.D. and Muto, T. (2005), ‘‘The superiority of waist-to-height ratio as an anthropometric index to evaluate clustering of coronary risk factors among non-obese men and women’’, Prev Med, Vol. 40 No. 2, pp. 216-20. Hsieh, S.D. and Yoshinaga, H. (1995a), ‘‘Abdominal fat distribution and coronary heart disease risk factors in men - waist/height ratio as a simple and useful predictor’’, International Journal of Obesity, Vol. 19, pp. 585-9. Hsieh, S.D. and Yoshinaga, H. (1995b), ‘‘Waist/height ratio as a simple and useful predictor of coronary heart disease risk factors in women’’, Japanese Society of Internal Medicine, Vol. 34, pp. 1147-52. Hsieh, S.D., Yoshinaga, H. and Muto, T. (2003), ‘‘Waist-to-height ratio, a simple and practical index for assessing central fat distribution and metabolic risk in Japanese men and women’’, Int J Obes Relat Metab Disord, Vol. 27 No. 5, pp. 610-6. Hsieh, S.D., Yoshinaga, H., Muto, T. and Sakurai, Y. (2000a), ‘‘Anthropometric obesity indices in relation to age and gender in Japanese adults’’, Tohoku J Exp Med, Vol. 191 No. 2, pp. 79-84. Hsieh, S.D., Yoshinaga, H., Muto, T., Sakurai, Y. and Kosaka, K. (2000b), ‘‘Health risks among Japanese men with moderate body mass index’’, Int J Obes Relat Metab Disord, Vol. 24 No. 3, pp. 358-62.
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Kahn, H.S., Imperatore, G. and Cheng, Y.J. (2005). ‘‘A population-based comparison of BMI percentiles and waist-to-height ratio for identifying cardiovascular risk in youth’’, J Pediatr, Vol. 146 No. 4, pp. 482-8. Lin, W.Y., Lee, L.T., Chen, C.Y., Lo, H., Hsia, H.H., Liu, I.L., Lin, R.S., Shau, W.Y. and Huang, K.C. (2002), ‘‘Optimal cut-off values for obesity: using simple anthropometric indices to predict cardiovascular risk factors in Taiwan’’, Int J Obes Relat Metab Disord, Vol. 26 No. 9, pp. 1232-8. Lyu, L.C., Hsu, C.Y., Yeh, C.Y., Lee, M.S., Huang, S.H. and Chen, C.L. (2003), ‘‘A case-control study of the association of diet and obesity with gout in Taiwan’’, Am J Clin Nutr, Vol. 78 No. 4, pp. 690-701. McCarthy, H. and Ashwell, M. (2002), ‘‘Waist:height ratios in British children aged 5-16 years: a suggestion for a simple public health message-keep your waist circumference to less than half your height’’, Proc Nutr Soc Vol. 61, pp. 116A. McCarthy, H. and Ashwell, M. (2003), ‘‘Trends in waist:height ratios in British chlidren aged 11-16 over a two-decade period’’, Proc Nutr Soc Vol. 62, pp. 46A. Patel, S., Unwin, N., Bhopal, R., White, M., Harland, J., Ayis, S.A., Watson, W. and Alberti, K.G. (1999), ‘‘A comparison of proxy measures of abdominal obesity in Chinese, European and South Asian adults’’, Diabet Med, Vol. 16 No. 10, pp. 853-60. Savva, S.C., Tornaritis, M., Savva, M.E., Kourides, Y., Panagi, A., Silikiotou, N., Georgiou, C. and Kafatos, A. (2000), ‘‘Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index’’, Int J Obes Relat Metab Disord, Vol. 24 No. 11, pp. 1453-8. Seidell, J.C., Bakker, C.J.G. and van der Kooy, K. (1990), ‘‘Imaging techniques for measuring adipose tissue distribution - a comparison between computed tomography and I.S.T magnetic resonance’’, Am. J. Clin. Nutr., Vol. 51, pp. 953-7. Vague, J. (1956), ‘‘The degree of masculine differentiation of obesities: a factor determining predisposition to diabetes, atherosclerosis, gout and uric calculous disease.’’ Am. J. Clin Nutr., Vol. 4, pp. 20. Zhu, S., Heymsfield, S.B., Toyoshima, H., Wang, Z., Pietrobelli, A. and Heshka, S. (2005), ‘‘Raceethnicity-specific waist circumference cutoffs for identifying cardiovascular disease risk factors’’, Am J Clin Nutr, Vol. 81 No. 2, pp. 409-15.
Food facts HCA National Day of Choice, 12 May 2005, delivering choice enhancing patient mealtimes On the National Day of Choice the Hospital Caterers’ Association (HCA) called for Hospitals to make changes to the services they deliver, changes that provide patients with choices, choices that make a real difference. For patients to have real choice, transparency about what is available needs to exist, patients need to be empowered and supported to exercise choice, accordingly, rather than extending choice hospitals may look at supporting patients to make choices. For further information on this National event please visit the HCA website: www.hospitalcaterers.org
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Is vegetarianism as healthy as it is beefed up to be? National vegetarian week ran between 23-27 May and, according to The British Dietetic Association, meat-eaters could have some lessons to learn from vegetarians. Registered dietitian, Dr Frankie Phillips, spokesperson for the British Dietetic Association, and author of a new authoritative review of vegetarianism and health says: Following a vegetarian diet does not automatically mean being healthier. Vegetarians and meat-eaters alike need to make suitable dietary and lifestyle choices. So many attributes of being vegetarian or vegan seem to be able to influence health, for example, they tend to be leaner, more active, and less likely to smoke than their meat- eating counterparts. This makes it difficult to untangle the web of factors in the vegetarian diet and lifestyle that may have an impact on health. But it seems that vegetarians, and especially vegans, have lower rates of heart disease, and associated risk factors such as lower blood cholesterol levels.
School meals An extra £3220m over three years is to be spent on improving school meals in England – as TV chef Jamie Oliver’s campaign on the issue reaches a climax. At least 50p, up from the current 37p, will be spent on each primary school lunch and 60p in secondary schools. Presenting a petition signed by 271,677 people to No 10, Mr Oliver said it was a shame it took a film to get changes. But education secretary Ruth Kelly insisted she had been planning to improve school lunches anyway. There is also £360m to set up a new school food trust, which will advise schools and parents on nutritional standards and help them devise healthy menus. Grants, to go via local education authorities, involve ‘‘new’’ money from Department for education and skills reserves. In his Channel 4 series, Jamie Oliver has been scathing about the existing quality of many school dinners – revitalising a public debate on the issue. He was appalled to find the London borough of Greenwich was spending only 37p per child per day on primary school lunches. The nutritional guidance for schools is to be advisory from this autumn and mandatory from September 2006. Parents will also get advice on nutritional standards. It will become part of school inspections and could mean some foodstuffs being banned from schools. Nutritional standards were introduced in 2003 for schools in Scotland.
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Milk for schools Stephanie M Spiers, Chair, Milk for Schools, PO Box 412, Stafford ST16 9TF, Tel./Fax: 01785 248345, www.milkforschools.org.uk It is a Registered Charity and provides information on all aspects of milk. Schools toolkit On 30 March, the Department of Health launched the exciting new food in schools toolkit. The toolkit is designed to support, guide and inspire schools in taking a ‘‘wholeschool’’ approach to healthy eating and drinking with the help of key learnings from the over 300 schools who took part in the pilots. The launch of the toolkit was part of a wider announcement by the Education Secretary of State where schools are being encouraged to spend at least 50p per child on food ingredients. From September and over the next three years, schools and local education authorities will be supported in transforming school meals with healthy food, prepared fresh on the premises by trained school cooks, which will follow tough minimum nutrition standards underpinned by Ofsted inspection. The action to improve school food including the launch of the food in schools toolkit are part of the Government’s commitment to deliver the aims set out in the Public Health White Paper Choosing Health – making healthy choices easier (November, 2004) and choosing a better diet: a food and health action plan (March, 2005) to reduce the amount of fat, salt and sugar in children’s food and to increase consumption of fruit and vegetables and other essential nutrients. The toolkit consists of guidance, advice, case studies and templates brought to life by interactive elements such as a ‘‘Food Audit’’, to help schools create customised solutions, and a ‘‘Virtual Day’’, which follows a day in the life of a student. It covers healthier breakfast clubs, healthier cookery clubs, healthier lunch boxes, growing clubs, dining room environment, water provision, healthier tuck shops and healthy vending machines. Resource and print centres give access to reference materials, Downloadable posters, template questionnaires, booklets and presentations. A create area allows these to be adapted to suit individual schools’ needs and local community concerns and issues. The toolkit can help schools work towards the healthy eating component of the Healthy Schools Programme and links in to the Government’s Healthy Living Blueprint and to other work to improve school food such as the school fruit and vegetable scheme and school meals. The toolkit is available online – www.foodinschools.org – or in printed form from your local healthy schools coordinator or by calling 08701 555 455 or emailing
[email protected]. Ask for item code 267050. National men’s health week 2005 The week focussed on men and weight. For further information visit website: www.menshealthforum.org.uk IPSI BGD conferences All IPSI BGD conferences are non-profit. They bring together the elite of the world science; so far, we have had seven Nobel Laureates speaking at the opening ceremonies. The conferences always take place in some of the most attractive places of the world.
All those who come to IPSI conferences once, always love to come back (because of the unique professional quality and the extremely creative atmosphere); lists of past participants are on the web, as well as details of future conferences. These conferences are in line with the newest recommendations of the US National Science Foundation and of the EU research sponsoring agencies, to stress multidisciplinary, interdisciplinary, and transdisciplinary research. The speakers and activities at the conferences truly support this type of scientific interaction. Prof. V. Milutinovic, Chairman, IPSI BGD Conferences Research conducted by Mori and commissioned by Water UK Research conducted by Mori and commissioned by Water UK in September 2004, showed that 65 per cent of the 16-34 age group, 62 per cent of 35-54 age group and 46 per cent of people aged 55+ thought they should be drinking a minimum of seven glasses of water a day. This is a positive result, however only 18 per cent of people actually drank seven or more glasses of water a day. The challenge for the water industry and its stakeholders is to increase the awareness of the health benefits of water in the public arena and improve the amount of water consumed by individuals. For further information visit website: www.water.org.uk Lifescape Lifescape is a training and coaching company. It has a strong background in employee wellbeing – in particular putting together and delivering packages and products that combine the best elements of employee assistance programmes, training and other wellbeing interventions, including stress management. For further information:
[email protected] ‘‘Managing food waste in the NHS’’ NHS Estates document Managing Food Waste in the NHS was published in March 2005 and placed on the NHS Estates website. Healthful vending in schools More schools are taking responsibility for providing a good quality, nutritionally sound school meals service and developing their own food and nutrition policies, as part of a whole school approach to food and health. It is clear that any vending operation must be a consistent and appropriate part of this new framework. Vending is a very useful tool and a highly visible component of a school’s food provision and should be used to enhance healthy eating practices. This can be a reality, provided the vending operation is appropriately managed from the top. The Health Education Trust (HET) has played the lead role in advocating a rational position for healthful school vending for some years now. HET has conducted pilot studies within schools on behalf of food standards agency (FSA), dept. of health (DH) and The Welsh Assembly Government. Following this work, HET has been instrumental in the development of a series of practical guidance for schools on both food and drinks vending. The following are now available: (1) The Drinks Vending Toolkit funded by the FSA. (2) The DH/DFES food in schools toolkit, on both food and drinks vending provides valuable practical guidance for schools wishing to address their school vending policy.
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HET is presently developing practical guidelines for schools to assist them in making decisions about vending that will enhance their food and nutrition policies. These guidelines will be available in conjunction with guidelines for vending operators produced by the automatic vending association (AVA). HET exhibited the latest healthful schools vending opportunities at AVEX (The International Vending Exhibition) at Earls Court. Latest news added to the Health Education Trusts website on vending in schools. For further information visit website: www.healthedtrust.com NuGO is an EU-funded network of excellence NuGO is an EU-funded network of excellence shaping the new discipline of nutrigenomics. NuGO started in January 2004 and is received funding for six years. At inception the Network comprised of 22 partner organisations; 13 universities, eight research institutes and one SME. For further information visit website: www.nugo.org You do not have to register but you are welcome to do so if you want to get involved with future NuGO activities. For further information contact: NuGO Communications Manager, Institute of Food Research, Norwich Research Park, Colney, Norwich NR4 7UA, Tel.: +44 (0)1603 255219, E-mail:
[email protected]. Health and safety in the food industry – conference at CCFRA on 26 October 2005 Building on the extremely successful previous conferences, this event provides a blend of both practical and essential information together with appropriate case studies. The conference, organised by CCFRA, supported by the Health and Safety Executive, the Food and Drink Federation and BFAWU, and sponsored by Whittles Solicitors, will also provide an excellent opportunity to network with colleagues who have similar responsibilities. For programme details and to register online visit website: www.campden.co.uk/ training/events2005/cm1.htm Functional foods and nutraceuticals magazine free subscription Functional Foods and Nutraceuticals, The Media Centre, 9 Middle Street, Brighton, East Sussex, BN1 1AL, Tel.: +44 (0) 1273 384282. 6th national nutrition and health conference scientific update and practical tips for professionals a multidisciplinary approach 25-26 November 2005, Kensington, London Your annual update and inspiration on over 20 hot topics relating to: .
Nutrition and fitness to health and disease in everyday practice
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Meet national and international experts and gurus and pick up plenty of advice and resources from the exhibition
Topics include: .
Obesity and weight management; metabolic syndrome; diabetes; CHD; cancer; allergies; immunity; GI debate; physical activity; enteral nutrition; case studies
Who attends? .
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All professionals involved in communicating sound nutrition and health issues, including: dietitians; dietetic assistants; nutritionists; doctors; nurses; public health advisers; 5-a-day co-ordinators; pharmacists; teachers; students; government officials; and health press.
For further information contact: Nutrition and Health Conference, 16 Brownlow Court, Lyttelton Road, London N2 0EA, Tel: 0870 766 3216, E-mail: admin@ nutritionandhealth.co.uk International symposium on the role of soy in preventing and treating chronic disease October 30-November 2, 2005, Chicago, Illinois, USA This international symposium will draw hundreds of researchers and health professionals to discuss the latest findings and possible future collaborations. This is your best opportunity to present your research to an international audience. Tel.: +1-217-359-5401 ext. 132, E-mail:
[email protected], web: www.aocs.org/ meetings/soy Air quality standards in food production areas Air is a potential source of food contaminants, but help is at hand to minimize the risk of contamination via this route. A new edition of CCFRA’s well-established Guidelines on air quality standards for the food industry provides extensive practical guidance for food and construction companies on the installation, monitoring and maintenance of air quality systems to help prevent food contamination and assure product safety. Devised by experts drawn from the food, air handling and research communities, the new edition spans the complete air handling chain from identifying the design and type of system most appropriate to particular food production operations through construction and validation to maintenance, cleaning, monitoring and assessing environmental impact. The guide is one of a series to help technical personnel in the food and construction industries with hygienic aspects of building or refurbishment of food production facilities. The other titles in the series are: Guidelines for the hygienic design, construction and layout of food processing factories; Guidelines for the design and construction of floors for food production areas (second edition); and Guidelines on the design and construction of walls, ceilings and services for food production areas (second edition). Copies of this document are available from Mrs Sue Hocking, CCFRA, Chipping Campden, Glos. GL55 6LD, Tel.: +44(0)1386 842225, Fax: +44(0)1386 842100, E-mail:
[email protected] Venue change offers exhibition new potential Organisers of the Food and Meat Expo and Foodtech 2005 exhibitions are heavily promoting the move to the International Centre in Telford as a very positive factor in attending the show as an exhibitor or, as a visitor. The exhibitions locate together in
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Telford on 7 and 8 September and are designed to provide a new style exhibition experience for participants. The exhibitions are endorsed by 24 leading trade organisations. The English Beef and Lamb Executive (EBLEX) was keen to participate and booked a stand early to ensure a prominent position at Food and Meat Expo. Phil Davies, trade sector manager-marketing at EBLEX explains: We feel the exhibition will offer us a useful way to meet the industry. The launch of our Quality Standard for English beef and lamb has been a great success and we will use this opportunity to inform the trade about the Mark and our ongoing trade promotions, as well as future plans. Of course meeting our trade partners will give them a chance to give us their views, which we want to encourage. The important and respected SOFHT conference will be staged over the two days during the exhibitions and Helen Hyde of the society reported that SOFHT were delighted with the modern and roomy facilities at the Telford International Centre and that everyone involved are really looking forward to the two days when the conference and Foodtech show link up. The Food and Meat Expo also hosts the National Sausage Competition and National Pie and Pasty Competition. These are the biggest craft competitions of their type in the UK staged every two years by the National Federation of Meat and Food Traders. For further information telephone Nicci Griffiths on 01908 613323 or e-mail
[email protected] To visit the show website, go to www.foodshow.co.uk Call for papers For 16 years the International Journal of Health Care Quality Assurance has covered all issues related to quality in healthcare. It provides a forum for the international exchange of theoretical and practical aspects of quality assurance, innovation, management, continuous improvement and performance management in health care. The journal will be of interest to all professionals in health care aiming to develop knowledge about quality assurance and process innovation and their implementation in health care systems. IJHCQA is uniquely placed to cover all recent developments concerning health care quality and clinical governance. The topics addressed are both clinical and non-clinical encouraging the translation of theory and tried and tested approaches into practice. As part of its unique placement, the journal aspires to provide a network for practitioners to improve quality within their own organisation. In particular, the journal encourages new writers to publish their work. The journal explores topics surrounding: .
Successful quality/continuous improvement projects.
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The use of quality tools and models in leadership management development such as the EFQM excellence model, balanced scorecard, quality standards and issues relating to process control, leadership, managing change, pareto analysis, process mapping, theory of constraints. A key principle is the support of management in leadership in bringing about the changes in quality cultures – improving patient care through quality related programmes and/or research.
Articles submitted may be of a theoretical nature, be based on practical experience, provide stimulus for debate, report a case study situation, or report on experimental results. As a guide, articles should be between 3,000 and 6,000 words in length. Please send copies to the Editor in Chief, Robin Gourlay, at
[email protected] or to Keith Hurst at
[email protected] For further information on the journal visit the journal homepage at www.emeraldinsight.com/ijhcqa.htm or contact the Managing Editor, Rachel Murawa, at
[email protected]
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Profitability and health – a recipe for success. 52nd Biscuit, Cake, Chocolate and Confectionery Association, Hilton Birmingham Metropole, 14-15 April 2005. The conference was well attended by those from the food industry. It covered numerous aspects of both general aspects of nutrition such as glycaemic index as well as very specialist areas of ingredients for BCCCA industry. More information can be obtained from the BCCCA on 020 7420 7200, Website www.bccca.org.uk Nutrition through life – professional study day Royal College of Physicians 5 April 2005 The study day was well attended by all sorts of people with an interest in nutrition from dietitians to managers to individuals from self help groups. It covered all aspects of nutrition including: . . . .
Infant nutrition. Paediatric nutrition. Managing obesity. Heart disease.
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Diabetes.
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Nutrition in the elderly. Palliative care.
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The conference papers were all very practical and provided adequate time for discussion. The conference was supported by a small exhibition on foods and services including those for weight loss. More information can be obtained from the organiser on 07949 686866. The 7th London International Eating Disorders Conference, Imperial College London, 4-6 April 2005 The conference attracted both speakers and participants from all over the world. The conference was accompanied by an exhibition with numerous stands on organisations offering support for those suffering from disorders such as bulimia and anorexia. These included: stands on books and publications on eating disorders; various units for those with eating disorder both within the NHS and private medicine as well as a number of support groups whose details are as follows: . .
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Overeaters Anonymous, PO Box 19, Stretford, Manchester M32 9EB The Academy for Eating Disorders – which is dedicated to promoting excellence in research, treatment and prevention of eating disorders www.aedweb.org
Not only was this a world standard conference but there were extremely good opportunities for networking. Mabel Blades
Hazardous waist? New approaches to tackling male weight problems, sponsored by Men’s Health Forum, the Department of Health and the NHS, Savoy Place, London, Monday, 13 June 2005 This was the first national conference on the issue of men and weight. About 300 delegates from all types of backgrounds attended the event. With the event information delegates were sent a pedometer to encourage them to walk part of the way to the event. There were a number of speakers setting the scene as regards male obesity to commence the event. The middle part of the day was devoted to a number of concurrent workshops which covered all types of aspects of male obesity and included such topics as: .
Primary care.
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Community pharmacies.
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Working with boys and teenagers.
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The workplace.
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Male body image.
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Increasing physical activity.
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Media and weight loss.
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Australian gut busters.
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Working with older men.
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Commercial weight loss organisations.
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What men really want.
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Psychological impact of obesity.
There was also a small exhibition of products and organisations related to obesity. These included: (1) Low carbohydrate products www.xcarb.co.uk (2) Men’s Health Forum who provide an independent voice on male health www.menshealthforum.org.uk (3) The Obesity Awareness and Solutions Trust (TOAST) www.toast-uk.org.uk (4) The weight loss surgery information and support charity www.wisinfo.org.uk (5) Obesity and weight management www.weightmanagementcentre.co.uk
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(6) The British Dietetic Association with their weight wise campaign www. bdaweightwise.com. (7) National Obesity Forum www.nationalobesityforum.org.uk (8) Slimming world with their referral scheme www.slimming-on-referral.com (9) Cambridge diet and weight loss www.cambridge-diet.co.uk and weight loss and diabetes www.diabetes.org.uk (10) National Heart Forum www.heartforum.org.uk (11) The Association for the Study of Obesity (ASO) www.aso.org.uk
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The conference concluded with a consensus statement that three quarters of the male population will be overweight by the year 2010 and that this is too many. Five actions were recommended (1) Politicians, policy makers, practitioners, media and the public need to recognise that weight is a male issue too.
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(2) It is important to understand male attitudes and behaviour in relation to weight and weight loss. (3) There must be an investment in male sensitive approaches. (4) Work is essential on weight related issues with boys. (5) A wide ranging strategy on obesity must be developed. At the end of the conference all delegates were presented with a copy of the HGV MAN– Reducing all large sizes; all shapes and colours – the practical guide to healthy living and weight loss by Dr Ian Banks which has been written in the style of the Haynes car workshop manuals in a light hearted and informative guide with lots of cartoons (ISBN 1 84425 183 7). British Nutrition Taskforce Report on Cardiovascular Disease launched 12 April 2005 The new taskforce report has been launched and while it primarily covers CVD it also considers obesity and its effect on CVD risk. The BNF report on obesity is one of the most comprehensive publications on the topic and it is called The Task Force Report, and was originally published in 1999. Obesity (1999, 258 pp; reprinted 2003). Contents include: Health risks of obesity, clinical assessment, epidemiology, aetiology, genetics, critical periods for obesity development, metabolic factors, macronutrient balance, physiological aspects of appetite control, endocrine causes, psychological factors, food preferences, impact of the economic environment and weight variation, prevention, treatment (including physical activity and exercise). The website (www.nutrition.org.uk) provides a detailed overview about what these reports include. Vitafoods International 2005 – Geneva, 10-12 May 2005 Vitafoods International 2005 exhibition was also held at the same time as the Vitafoods conference which is regarded as a global neutriceutical event. Europe’s leading nutraceutical exhibition was a most productive day. On top of the 300 exhibitors, 1000s of products, 28 free seminars were also run. Visit http://www.vitafoods.eu.com/newsletter to see what happened and for information on forthcoming events. HACCP 2006 Seminar and Exhibition, Brooklands, Barnsley, 25 April 2005 The conference addressed the need for caterers to be aware of the Hygiene of Foodstuffs which were adopted and will apply to all food businesses from 1 January 2006. The conference was supported by a small exhibition on hygiene, training and related services. For more information on all aspects of training on food hygiene and nutrition go to www.highfield.co.uk
Community Nutrition Group (CNG) – Annual Conference 25-27 April 2005, the Hayes Conference Centre, Swanwick, Derbyshire The CNG is the Specialist Group of the British Dietetic Association for those dietitians with an interest in community nutrition. For the first time the conference was open to other professions and was attended by a range of others with an interest in nutrition and health. Particular attention was paid to Sustainability and Health and the procurement of local food. Food in Schools was the main theme on the third day of the conference. For more information on all aspects of the CNG go to www.cnguk.org Other issues from the event, which may be of interest are: .
Food fitness – from
[email protected]
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Slimming on referral part of a local obesity strategy for information go to www.slimming-world.com
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Soy and health for information go to www.alprosoya.co.uk
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The Food Commission at www.foodcomm.org.uk
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Food safety with information from www.fdf.org.uk
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The British Heart Foundation who produce a comprehensive range of informative booklets contact them at www.bhf.org.uk
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Healthy vending with information from the Health Education Trust at www.healthedtrust.com and on events on vending from www.alpha.nhs.uk
Refresh – Primary Care Conference and Exhibition, National Exhibition Centre, Birmingham, 5-6 May www.primarycare2005.co.uk This annual conference was well attended by all grades and types of community health staff. Not only is there an excellent exhibition of equipment, medication, products, management tools, training material and books but there is also a series of seminars on nutrition and health. The conference is free to health professionals and can provide an easy and comprehensive update on what is happening in community care. Of interest with obesity the World Cancer Research Fund (WCRF UK) have a range of leaflets to use including ones on obesity – they can be contacted via – www.wcrf-uk.org Hospital Caterers Association (HCA) National Conference 2005, The Grand Hotel, Eastbourne, 21-22 April The Hospital Caterers Association Conference was organised by the South West Thames branch of the HCA and the theme was ‘‘At the heart of health care’’ and the conference was attended by approximately 400 people. Presentations included information on major aspects of catering in the NHS; .
Measures of catering quality and assuring catering quality which included the results of a survey of HCA members.
There were also ample opportunities for networking as well as an interactive debate panel.
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The conference was supported by a large exhibition on food and services. This included one from the British Dietetic Association (BDA) who produce a wealth of materials including those on obesity as well as running a number of campaigns on the topic. The BDA website is www.bda.uk.com The Healthcare Caterers International also had an exhibition stand to provide information on their global alliance of caterers and food service professionals. Learn more about them at www.hciglobal.org More information on the HCA conference can be obtained from the dedicated website www.hospitalcaterers.org
Book reviews Clinical Paediatrics (2nd edition) Edited by Vanessa Shaw and Margaret Lawson for the Paediatric Group of the British Dietetic Association Blackwell Publishing ISBN 0-632-05241-4
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For anyone with an interest in paediatric dietetics this book is essential as it is easy to use as a reference book to solve any problems that may arise. It is easy to use and is written by experts in the field. It comprises of 10 sections each on a specific area. Sections include: . . . .
An introduction Enteral and Parenteral nutrition Preterm and low birth weight nutrition Diseases of organ systems such as the Gastro intestinal tract, liver and pancreas
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Inborn errors of metabolism
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Lipid disorders Peroxisomal diseases such as Refsum’s disease
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Childhood cancers Eating disorders and obesity which provides useful practical information Other conditions requiring nutritional support and advice and includes burns and failure to thrive
There is a useful appendix of specialist products and the manufacturers who make them. For anyone dealing with paediatric nutrition and diet this book is a must for the bookshelf. Mabel Blades
The Allergy Catering Manual This easy to read book provides invaluable information on catering for people with food allergies. It is aimed at caterers and is a brilliant idea for the bookshelf of caterers so that they know what to provide. It is available from Michelle Berriedale-Johnson, Editor – Foods Matter, 5 Lawn Road, London NW3 2XS, Tel: 020 7722 2866, Fax: 020 7722 7685, www.foodsmatter.com, www.allergycateringmanual.com.
Nutrition & Food Science Vol. 35 No. 5, 2005 pp. 377 # Emerald Group Publishing Limited 0034-6659
