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Background - Previous studies suggest that the beneficial health effects of a diet rich in whole grains could be a result of the individual fibres found in the grain. The present study aimed to investigate the influence of a diet high in either wheat fibre (as an example of an insoluble fibre) or inulin (a nondigestible carbohydrate) on markers of cardiovascular disease. Methods - Ten male participants classified as at higher risk of cardiovascular disease [mean (SD) body mass index 30.2 (3) kg m−2, mean (SD) waist circumference 106.4 (7) cm, mean (SD) age 39.8 (9) years] were recruited to a randomised, controlled, cross-over study comparing the consumption of bespoke bread rolls containing either inulin, wheat germ or refined grain (control) (15 g day−1) for 4 weeks with a 4-week washout period between each regime. At the end of each regime, participants underwent an oral glucose tolerance test (OGTT), measures of pulse wave velocity (PWV), 24-h ambulatory blood pressure (AMBP), plasma lipid status and markers of glucose control. Results - There was no difference in measures of glucose control, lipid status, 24-h AMBP or PWV after the intervention periods and no changes compared to baseline. There was no significant difference between OGTT glucose and insulin time profiles; however, there was a significant difference in area under the curves between the wheat fibre and control interventions when comparing change from baseline (control +10.2%, inulin +4.3%, wheat fibre −2.5%; P = 0.03). Conclusions - Only limited differences between the interventions were identified, perhaps as a consequence of the amount of fibre used and intervention length. The wheat germ intervention resulted in a significant reduction in glucose area under the curve, suggesting that this fibre may aid glucose control.

Loss of appetite is frequently observed during ageing, termed the ‘anorexia of ageing’. Ageing is associated with the inability to appropriately increase food intake after under-eating in the short- and long-term. Older people also report lower feelings of hunger and increased feelings of satiety and fullness. Gastrointestinal peptide hormones are a major part of the appetite regulatory system and are released in response to nutritional stimuli. They can be classified as: anorexigenic (satiety) [e.g. peptide tyrosine tyrosine (PYY), glucagon-like peptide-1, pancreatic polypeptide, oxyntomodulin and cholecystokinin (CCK)] or orexigenic (hunger) (e.g. ghrelin). Although the control of appetite is not fully understood, it is clear that these hormones play an important role, and may influence the development and treatment of obesity and under-nutrition. The literature shows a consistent finding that there is a loss of appetite in those aged over 65 years, although how this loss is mediated is not yet clear. Some evidence suggests that with advancing age there is an increase in satiety hormones, such as CCK and PYY, and a decrease in the hunger hormone, ghrelin. However, not all studies agree, emphasising the need for more in-depth research to clarify age-related changes. This knowledge will enable us to develop therapies to help prevent under-nutrition during ageing. This review explores how age influences gastrointestinal appetite hormones in humans, as well as how this may contribute to the development of age-related malnutrition.

Background: This study investigated differences in weight loss outcomes in obese women with Type 2 diabetes (T2D) compared to those without T2D attending a 6-month dietetic led 'Lifestyle' intervention. In those who had failed to reach weight loss goals using the 'Lifestyle' approach, the study further examined the effect on weight loss with the addition of sibutramine (Reductil®, Abbott Laboratories, USA) over a 6-month period. Methods: The study comprised a case-control analysis of data from 38 obese female patients (18 with T2D) from the 'Lifestyle' and 'Pharmacotherapy' clinics attending a tertiary hospital in the UK. Results; In the 'Lifestyle' treatment groups, those with T2D lost significantly less body weight than those without T2D [5.26kg (4.54%) versus 9.89kg (9.55%), respectively]. For subjects who had failed to lose weight via the 'Lifestyle' intervention, the addition of sibutramine resulted in a similar weight loss compared to their pair-matched 'Lifestyle' only 'successful' counterparts (9.66% versus 9.55%). Conclusions: Not all obese women, and those with T2D in particular, will derive benefit from 'Lifestyle' advice and those who are resistant to this treatment approach may be assisted by pharmacotherapy. Dietitians can play a role in identifying those individuals who may benefit from the use of pharmacotherapy.

Background/Aims Obesity has become a global epidemic, and a major preventable cause of morbidity and mortality. Management strategies and treatment protocols are however poorly developed and evaluated. The aim of the Counterweight Programme is to develop an evidence-based model for the management of obesity in primary care. Methods The Counterweight Programme is based on the theoretical model of Evidence-Based Quality Assessment aimed at improving the management of obese adults (18-75 years) in primary care. The model consists of four phases: (1) practice audit and needs assessment, (2) practice support and training, (3) practice nurse-led patient intervention, and (4) evaluation. Patient intervention consisted of screening and treatment pathways incorporating evidence-based approaches, including patient-centred goal setting, prescribed eating plans, a group programme, physical activity and behavioural approaches, anti-obesity medication and weight maintenance strategies. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation. Eighty practices were recruited of which 18 practices were randomized to act as controls and receive deferred intervention 2 years after the initial audit. Results By February 2004, 58 of the 62 (93.5%) intervention practices had been trained to run the intervention programme, 47 (75.8%) practices were active in implementing the model and 1256 patients had been recruited (74% female, 26% male, mean age 50.6 years, SD 14). At baseline, 75% of patients had at one or more co-morbidity, and the mean body mass index (BMI) was 36.9 kg/m(2) (SD 5.4). Of the 1256 patients recruited, 91% received one of the core lifestyle interventions in the first 12 months. For all patients followed up at 12 months, 34% achieved a clinical meaningful weight loss of 5% or more. A total of 51% of patients were classed as compliant in that they attended the required level of appointments in 3, 6, and 12 months. For fully compliant patients, weight loss improved with 43% achieving a weight loss of 5% or more at 12 months. Conclusion The Counterweight Programme is an evidence-based weight management model which is feasible to implement in primary care.

Aims We have previously shown that although a postal questionnaire based on the stages of change model (SCQ) failed to distinguish outpatients most likely to lose weight, it appeared to influence attendance rates. We therefore audited attendance upon receiving a pre-appointment SCQ in the post and compared this to previous standard practice in 1996. Methodology and results Seventy-eight obese outpatients (BMI 36.7 ± 6.7 kg m–2, age 43 ± 15 years) (mean ± SD) were included. Twenty-nine per cent of patients failed to return an SCQ and were not sent an appointment and therefore did not block dietetic time. Eleven per cent returned an SCQ but did not attend (DNA) visit 1, whilst 21% attended visit 1 but DNA visit 2. Thirty-nine per cent attended both appointments and lost a significant amount of weight (105 ± 23 vs. 103.2 ± 23 kg, P

Background Many patients require nutritional intervention to help treat and/or prevent malnutrition. Nursing staff play a key role in identifying malnourished patients. To improve the management of artificial nutritional support, the Hammersmith Hospital NHS Trust has produced guidelines. This audit aimed to assess the need and adequacy of these guidelines and to examine any additional information required. Methods The dietetic department and nursing practice group developed a questionnaire. A total of 260 questionnaires were distributed by dietitians, 10 copies of the questionnaire to nurses on 26 wards. The completed forms were returned by internal post or collected the dietitian. Results The response rate was 29%. All 77 nurses who responded felt there was a need for nutrition literature. Seventy-three per cent of nurses were aware that the guidelines existed; however, referral to the resource was poor. Requests for additional information encompassed tube feeding and catering information. To provide this information, 84% requested a nutrition tutorial, 81% a preprinted care plan and 96% a ward manual specific to their speciality. Conclusions All nurses who were surveyed requested nutrition information. The current guidelines already reflect the requested information, but usage is poor. We aim to improve access and awareness by the hospital intranet, nutrition education and induction programme. The next update will cover gaps identified and additional requirements outside the guidelines remit will be discussed with the nursing practice group.

Summary Background: The transtheoretical model of behaviour change the ‘Stages of Change’ by Prochaska & Di Clemente (1982) has been advocated for enhancing dietary counselling. It has been suggested that understanding where people are in the stages of change model could lead to targeting of advice and improved outcome of dietetic management such as weight loss in the obese and reduced did not attend rates. This study assessed whether a six-question staging model of the stages of change could predict which patients are most likely to not attend an appointment and predict those who will lose weight. Methods: Prior to the start of their dietetic interview, obese outpatients completed a simple ‘stages of change questionnaire’ (SCQ). This assessed where the patient was in the stage of change cycle, motivation to lose weight, how easy they thought this would be and attendance rate. Patients who did not attend were sent a SCQ in the post. Results: There were no significant differences in SCQ scores at visit one, between patients attending twice (group 1) and those who did not attend their second appointment (group 2). By visit two, 72% of group 1 who were in the action or maintenance stage of the cycle had lost 1.5±2.4% body weight, and were more optimistic and committed to doing so. There was no correlation between percentage weight loss and the first SCQ score in group 1 (r=0.05, P=0.73). It is of interest that no subject in group 3, i.e. those who did not attend both appointments, returned any of the SCQs after the first mailing and only 17% of this group returned one after a reminder was sent. Conclusion: Evidence from this study would suggest that the stages of change model does not distinguish between which patients will not attend a second appointment or lose weight. However, it may help identify motivated patients if used as a postal screening tool.

Summary Introduction: Malnutrition has been estimated to cost the NHS £266 million a year because malnourished patients have longer hospital stays and increased morbidity. Malnutrition is particularly common in the elderly. Most attempts to reverse malnutrition in this group have used liquid supplements but the results have been disappointing; even under surveillance, ill older patients often do not take enough supplements to improve their nutritional status. In routine clinical practice the situation is worse because poor nutrition is often not recognized and compliance with supplements is low. Another approach is needed. Objective: To describe the protocol of The Feeding Support Trial which aims to examine whether health care assistants, trained to provide support with all aspects of feeding, can make a significant impact on nutritional intake and whether this improves outcome. Design: A randomized control trial designed to determine whether feeding support increases nutritional intake leads to measurable changes in nutritional status (body mass index, arm circumference, serum albumin) and leads to improved outcome (infection rate, Barthel score, length of stay and readmission rate). Setting: Three elderly medicine wards at Hammersmith Hospitals NHS Trust. The study commenced in June 1998. Subjects: The trial aims to recruit 1500 subjects (750 in each group).

This paper presents the results of a 3-month survey of tube feeding and parenteral nutrition in hospital in-patients, undertaken to provide information for the development of guidelines by the Hospitals Nutritional Advisory Group and a baseline for future monitoring. This represents the first steps in the audit cycle. The results highlighted the following problems. 1 Total parenteral nutrition is often continued after bowel sounds have returned. 2 Enteral tube feeding is often instituted for only a very short period of time and may be of little nutritional benefit to the patient. 3 Significantly lower amounts of energy and nitrogen are received by the patients in the enterally tube-fed group than is indicated by their estimated energy and nitrogen requirements. 4 The medical staff noted the start of feeding in 60% of the case notes, however, the aims of feeding and the reason for commencing feeding were never documented. Nutritional aims were defined in the case notes by dietitians for all tube-fed and 18 of the 20 patients who were parenterally fed.

A patient with a pancreatic tumour suffered severe diarrhoea as a result of abnormal secretions of vasoactive intestinal polypeptide. Initial elemental feeding and continued nutritional support improved her nutritional status. The patient currently supports her nutritional needs from a normal diet.

Clinical outcome audit was carried out on two groups of obese out-patients for a 3-month follow-up period. In the first audit group of 35 patients (A1), energy intake was prescribed by diet history, whereas in the second audit group of 27 patients (A2) energy intake was prescribed from an estimate of individual energy requirements based on age, sex, and activity. There was no significant difference in age or initial BMI between the two groups and the failure-to-attend rate was the same in each group. Patients in Group A2 received a significantly higher energy prescription (P

This case study illustrates the effect a carcinoid tumour may have on the patients nutritional status and demonstrates the effectiveness of nutritional support. It highlights the role of overnight nasogastric feeding and supplementary feeding in improving nutritional status and the effect of palliative therapy in helping a young patient with advanced carcinoid tumour return to a normal life.

This study assesses the effect of the introduction of a food and health policy on the nutritional intake of hospitalized patients. Subjects were selected from three clinical areas: ante-natal, orthopaedics and care of the elderly. The nutrient intake of 81 patients was measured by one-day weighed-food intakes before the introduction of the Food and Health Policy, and again on 89 different patients after its introduction. Patients recorded any food and beverages consumed in addition to that supplied by the hospital. The introduction of the Food and Health Policy had no deleterious effects on energy and protein intake. The percentage contribution of fat to the total energy intake was significantly lower after the introduction of the Food and Health Policy (P

A clinical audit was carried out to assess the effects of providing a pre-treatment information pack on attendance rates and weight loss in obese patients referred to the dietitians. No improvement in either attendance rates or treatment outcome was seen during the period when this pack was provided, compared to a similar period when only an appointment date was given.

A study was performed to assess the reproducibility of upper-arm anthropometry using two observers with subjects of differing body mass. Subjects were divided into four groups according to their body mass index: Group 1: 20-25-30