Markers of chronic disease in offenders in a high secure correctional centre in Queensland

This study aimed to gauge the presence of markers of chronic disease, as a basis for food and nutrition policy in correctional facilities. One hundred and twenty offenders, recruited from a Queensland Correctional Centre, provided informed consent and completed both dietary interviews and physical measurements. Mean age of the sample was 35.5 ± 12 years (range = 19–77 yrs); mean age of the total population (n = 945) was 32.8 ± 10 years (range = 19–80 yrs). Seventy-nine participants also provided fasting blood samples. The mean body mass index (BMI) was 27 ± 3.5 kg/m2; 72% having a BMI > 25 kg/m2. Thirty-three percent were classified overweight or obese using waist circumference (mean = 92 ± 10 cm). Mean blood pressure measurement was systolic = 130 ± 14 mmHg and diastolic = 73 ± 10 mmHg. Twenty-four percent were classified as hypertensive of whom three were on antihypertensive medication. Eighteen percent had elevated triglycerides, and 40% unfavourable total cholesterol to HDL ratios. Homeostatic Model Assessment (HOMA scores) were calculated from glucose and insulin. Four participants were insulin resistant, two of whom had known diabetes. Metabolic syndrome, based on waist circumference (adjusted for ethnicity), blood lipids, blood pressure and plasma glucose indicated that 25% (n = 20) were classified with metabolic syndrome. Eighty-four percent (n = 120) reported some physical activity each day, with 51 percent participating ≥two times daily. Fifty-four percent reported smoking with an additional 20% having smoked in the past. Findings suggest that waist circumference rather than weight and BMI only should be used in this group to determine weight status. The data suggest that markers of chronic disease are present and that food and nutrition policy must reflect this. Further analysis is being completed to determine relevant policy initiatives.

Ethnic differences in body fat distribution among Asian pre-pubertal children: A cross-sectional multicenter study

Background Ethnic differences in body fat distribution contribute to ethnic differences in cardiovascular morbidities and diabetes. However few data are available on differences in fat distribution in Asian children from various backgrounds. Therefore, the current study aimed to explore ethnic differences in body fat distribution among Asian children from four countries. Methods A total of 758 children aged 8-10 y from China, Lebanon, Malaysia and Thailand were recruited using a non-random purposive sampling approach to enrol children encompassing a wide BMI range. Height, weight, waist circumference (WC), fat mass (FM, derived from total body water [TBW] estimation using the deuterium dilution technique) and skinfold thickness (SFT) at biceps, triceps, subscapular, supraspinale and medial calf were collected. Results After controlling for height and weight, Chinese and Thai children had a significantly higher WC than their Lebanese and Malay counterparts. Chinese and Thais tended to have higher trunk fat deposits than Lebanese and Malays reflected in trunk SFT, trunk/upper extremity ratio or supraspinale/upper extremity ratio after adjustment for age and total body fat. The subscapular/supraspinale skinfold ratio was lower in Chinese and Thais compared with Lebanese and Malays after correcting for trunk SFT. Conclusions Asian pre-pubertal children from different origins vary in body fat distribution. These results indicate the importance of population-specific WC cut-off points or other fat distribution indices to identify the population at risk of obesity-related health problems.

A parent-led family-focused treatment program for overweight children aged 5 to 9 years : The PEACH RCT

OBJECTIVE: To evaluate a healthy lifestyle intervention to reduce adiposity in children aged 5 to 9 years and assess whether adding parenting skills training would enhance this effect. PARTICIPANTS AND METHODS: We conducted a single-blinded randomized controlled trial of prepubertal moderately obese (International Obesity Task Force cut points) children, aged 5 to 9 years. The 6-month program targeted parents as the agents of change for implementing family lifestyle changes. Only parents attended group sessions. We measured BMI and waist z scores and parenting constructs at baseline, 6, 12, 18, 24 months. RESULTS: Participants (n = 169; 56% girls) were randomized to a parenting skills plus healthy lifestyle group (n = 85) or a healthy lifestyle–only group (n = 84). At final 24-month assessment 52 and 54 children remained in the parenting skills plus healthy lifestyle and the healthy lifestyle–only groups respectively. There were reductions (P < .001) in BMI z score (0.26 [95% confidence interval: 0.22–0.30]) and waist z score (0.33 [95% confidence interval: 0.26–0.40]). There was a 10% reduction in z scores from baseline to 6 months that was maintained to 24 months with no additional intervention. Overall, there was no significant group effect. A similar pattern of initial improvement followed by stability was observed for parenting outcomes and no group effect. CONCLUSIONS: Using approaches that specifically target parent behavior, relative weight loss of ∼10% is achievable in moderately obese prepubertal children and can be maintained for 2 years from baseline. These results justify an investment in treatment as an effective secondary obesity-prevention strategy.

Risk of metabolic syndrome among children living in metropolitan Kuala Lumpur: A case control study

Background With the increasing prevalence of childhood obesity, the metabolic syndrome has been studied among children in many countries but not in Malaysia. Hence, this study aimed to compare metabolic risk factors between overweight/obese and normal weight children and to determine the influence of gender and ethnicity on the metabolic syndrome among school children aged 9-12 years in Kuala Lumpur and its metropolitan suburbs. Methods A case control study was conducted among 402 children, comprising 193 normal-weight and 209 overweight/obese. Weight, height, waist circumference (WC) and body composition were measured, and WHO (2007) growth reference was used to categorise children into the two weight groups. Blood pressure (BP) was taken, and blood was drawn after an overnight fast to determine fasting blood glucose (FBG) and full lipid profile, including triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC). International Diabetes Federation (2007) criteria for children were used to identify metabolic syndrome. Results Participants comprised 60.9% (n = 245) Malay, 30.9% (n = 124) Chinese and 8.2% (n = 33) Indian. Overweight/obese children showed significantly poorer biochemical profile, higher body fat percentage and anthropometric characteristics compared to the normal-weight group. Among the metabolic risk factors, WC ≥90th percentile was found to have the highest odds (OR = 189.0; 95%CI 70.8, 504.8), followed by HDL-C≤1.03 mmol/L (OR = 5.0; 95%CI 2.4, 11.1) and high BP (OR = 4.2; 95%CI 1.3, 18.7). Metabolic syndrome was found in 5.3% of the overweight/obese children but none of the normal-weight children (p < 0.01). Overweight/obese children had higher odds (OR = 16.3; 95%CI 2.2, 461.1) of developing the metabolic syndrome compared to normal-weight children. Binary logistic regression showed no significant association between age, gender and family history of communicable diseases with the metabolic syndrome. However, for ethnicity, Indians were found to have higher odds (OR = 5.5; 95%CI 1.5, 20.5) compared to Malays, with Chinese children (OR = 0.3; 95%CI 0.0, 2.7) having the lowest odds. Conclusions We conclude that being overweight or obese poses a greater risk of developing the metabolic syndrome among children. Indian ethnicity is at higher risk compared to their counterparts of the same age. Hence, primary intervention strategies are required to prevent this problem from escalating.

Exercise, appetite and weight management: understanding the compensatory responses in eating behaviour and how they contribute to variability in exercise-induced weight loss

Does exercise promote weight loss? One of the key problems with studies assessing the efficacy of exercise as a method of weight management and obesityis that mean data are presented and the individual variability in response is overlooked. Recent data have highlighted the need to demonstrate and characterise the individual variability in response to exercise. Do people who exercise compensate for the increase in energy expenditure via compensatory increases in hunger and food intake? The authors address the physiological, psychological and behavioural factors potentially involved in the relationship between exercise and appetite, and identify the research questions that remain unanswered. A negative consequence of the phenomena of individual variability and compensatory responses has been the focus on those who lose little weight in response to exercise; this has been used unreasonably as evidence to suggest that exercise is a futile method of controlling weight and managing obesity. Most of the evidence suggests that exercise is useful for improving body composition and health. For example, when exercise-induced mean weight loss is <1.0 kg, significant improvements in aerobic capacity (+6.3 ml/kg/min), systolic (−6.00 mm Hg) and diastolic (−3.9 mm Hg) blood pressure, waist circumference (−3.7 cm) and positive mood still occur. However, people will vary in their responses to exercise; understanding and characterising this variability will help tailor weight loss strategies to suit individuals.

Associations between socioeconomic position, food insecurity and BMI

Introduction: Food insecurity is a social determinant of health and is defined as limited ability to access sufficient amounts of nutritionally adequate or safe food for a healthy and active life. Food insecurity is associated with poor health status and the exacerbation of other health inequalities. This study examined whether an association existed between 1) socioeconomic position (SEP) and food insecurity and 2) food insecurity and weight status. Methods: Data from the 1995 National Nutrition Survey was analysed. A random sample of households (n = 13 858) were asked about dietary habits and food choices. Information about gender, age, BMI, waist circumference, household income and whether the household had run out of money to purchase food in the previous 12 months was obtained and analysed using chi-square and logistic regression. Results: Income was significantly associated with food insecurity; households with lower income were at higher risk of food insecurity. Lower income males were nine times more likely to experience food insecurity and lower income females were three times more likely to experience food insecurity than their higher income counterparts. Food insecurity was significantly associated with body mass index (BMI) among women but not men. Women experiencing food insecurity were at higher risk of overweight/obesity according to BMI and waist circumference measures. Conclusion: Evidence suggests that low income households are at higher risk of food insecurity and women who are food insecure are at higher risk of being overweight or obese. Food insecurity may mediate the association between SEP and BMI.

Does food insecurity contribute to socioeconomic inequalities in BMI?

Introduction: Food insecurity is a social determinant of health and is defined as limited ability to access sufficient amounts of nutritionally adequate or safe food for a healthy and active life. Food insecurity is associated with poor health status and the exacerbation of other health inequalities. This study examined whether an association existed between 1) socioeconomic position (SEP) and food insecurity and 2) food insecurity and weight status. Methods: Data from the 1995 National Nutrition Survey was analysed. A random sample of households (n = 13 858) were asked about dietary habits and food choices. Information about gender, age, BMI, waist circumference, household income and whether the household had run out of money to purchase food in the previous 12 months was obtained and analysed using chi-square and logistic regression. Results: Income was significantly associated with food insecurity; households with lower income were at higher risk of food insecurity. Lower income males were nine times more likely to experience food insecurity and lower income females were three times more likely to experience food insecurity than their higher income counterparts. Food insecurity was significantly associated with body mass index (BMI) among women but not men. Women experiencing food insecurity were at higher risk of overweight/obesity according to BMI and waist circumference measures. Conclusion: Evidence suggests that low income households are at higher risk of food insecurity and women who are food insecure are at higher risk of being overweight or obese. Food insecurity may mediate the association between SEP and BMI.

Malnutrition in a sample of community-dwelling people with Parkinson’s disease

Objective: Malnutrition results in poor health outcomes, and people with Parkinson’s disease may be more at risk of malnutrition. However, the prevalence of malnutrition in Parkinson’s disease is not yet well defined. The aim of this study is to provide an estimate of the extent of malnutrition in community-dwelling people with Parkinson’s disease. Methods: This is a cross-sectional study of people with Parkinson’s disease residing within a 2 hour driving radius of Brisbane, Australia. The Subjective Global Assessment (SGA) and scored Patient Generated Subjective Global Assessment (PG-SGA) were used to assess nutritional status. Body weight, standing or knee height, mid-arm circumference and waist circumference were measured. Results: Nineteen (15%) of the participants were moderately malnourished (SGA-B). The median PG-SGA score of the SGA-B group was 8 (4 – 15), significantly higher than the SGA-A group, U=1860.5,p<.05. The symptoms most influencing intake were loss of appetite, constipation, early satiety and problems swallowing. Conclusions: As with other populations, malnutrition remains under-recognised and undiagnosed in people with Parkinson’s disease. Regular screening of nutritional status in people with Parkinson’s disease by health professionals with whom they have regular contact should occur to identify those who may benefit from further nutrition assessment and intervention.

Pilot study of an individualised early post partum intervention to increase physical activity in women with previous gestational diabetes

Background: Whilst the benefits of physical activity in preventing progression from impaired glucose tolerance to overt diabetes in older adults are well recognised, it is not clear which strategies may prevent progression to overt diabetes in women with recent gestational diabetes. We sought to devise and pilot test a convenient, home based exercise program with telephone support, suited to the early post partum period. Twenty eight women with recent gestational diabetes were enrolled six weeks post partum into a 12 week randomised controlled trial of Usual Care ("UC" Controls (n= 13)) vs. Supported Care ("SC" individualised exercise program with regular telephone support (n= 15)). Findings: Baseline characteristics for the whole cohort at six weeks post partum (Mean ± SD) were Age 33 ± 4 years, Weight 80 ± 20 kg and Body Mass Index (BMI) 30.0 ± 9.7 kg / m2. The primary outcome, planned physical activity, increased by Median (Range) 60 (0-540) mins/wk in the SC group vs. 0 (0-580) mins/wk in the UC group (p = 0.234, Mann Whitney U test). The change in planned physical activity predominantly comprised planned walking. Body weight, BMI, waist circumference, % body fat (measured by bioimpedance), fasting glucose and insulin did not change significantly over time in either group. Conclusions: The intervention designed to increase physical activity in post partum women with previous gestational diabetes was feasible. However, no evidence to suggest that this type of program provides any measurable improvement in metabolic or biometric parameters over a three month post partum follow up was observed.

Nutritional status of Ugandan women living with HIV/AIDS : anthropometry and body composition assessment

Human immunodeficiency virus (HIV) that leads to acquired immune deficiency syndrome (AIDs) reduces immune function, resulting in opportunistic infections and later death. Use of antiretroviral therapy (ART) increases chances of survival, however, with some concerns regarding fat re-distribution (lipodystrophy) which may encompass subcutaneous fat loss (lipoatrophy) and/or fat accumulation (lipohypertrophy), in the same individual. This problem has been linked to Antiretroviral drugs (ARVs), majorly, in the class of protease inhibitors (PIs), in addition to older age and being female. An additional concern is that the problem exists together with the metabolic syndrome, even when nutritional status/ body composition, and lipodystrophy/metabolic syndrome are unclear in Uganda where the use of ARVs is on the increase. In line with the literature, the overall aim of the study was to assess physical characteristics of HIV-infected patients using a comprehensive anthropometric protocol and to predict body composition based on these measurements and other standardised techniques. The other aim was to establish the existence of lipodystrophy, the metabolic syndrome, andassociated risk factors. Thus, three studies were conducted on 211 (88 ART-naïve) HIV-infected, 15-49 year-old women, using a cross-sectional approach, together with a qualitative study of secondary information on patient HIV and medication status. In addition, face-to-face interviews were used to extract information concerning morphological experiences and life style. The study revealed that participants were on average 34.1±7.65 years old, had lived 4.63±4.78 years with HIV infection and had spent 2.8±1.9 years receiving ARVs. Only 8.1% of participants were receiving PIs and 26% of those receiving ART had ever changed drug regimen, 15.5% of whom changed drugs due to lipodystrophy. Study 1 hypothesised that the mean nutritional status and predicted percent body fat values of study participants was within acceptable ranges; different for participants receiving ARVs and the HIV-infected ART-naïve participants and that percent body fat estimated by anthropometric measures (BMI and skinfold thickness) and the BIA technique was not different from that predicted by the deuterium oxide dilution technique. Using the Body Mass Index (BMI), 7.1% of patients were underweight (<18.5 kg/m2) and 46.4% were overweight/obese (≥25.0 kg/m2). Based on waist circumference (WC), approximately 40% of the cohort was characterized as centrally obese. Moreover, the deuterium dilution technique showed that there was no between-group difference in the total body water (TBW), fat mass (FM) and fat-free mass (FFM). However, the technique was the only approach to predict a between-group difference in percent body fat (p = .045), but, with a very small effect (0.021). Older age (β = 0.430, se = 0.089, p = .000), time spent receiving ARVs (β = 0.972, se = 0.089, p = .006), time with the infection (β = 0.551, se = 0.089, p = .000) and receiving ARVs (β = 2.940, se = 1.441, p = .043) were independently associated with percent body fat. Older age was the greatest single predictor of body fat. Furthermore, BMI gave better information than weight alone could; in that, mean percentage body fat per unit BMI (N = 192) was significantly higher in patients receiving treatment (1.11±0.31) vs. the exposed group (0.99±0.38, p = .025). For the assessment of obesity, percent fat measures did not greatly alter the accuracy of BMI as a measure for classifying individuals into the broad categories of underweight, normal and overweight. Briefly, Study 1 revealed that there were more overweight/obese participants than in the general Ugandan population, the problem was associated with ART status and that BMI broader classification categories were maintained when compared with the gold standard technique. Study 2 hypothesized that the presence of lipodystrophy in participants receiving ARVs was not different from that of HIV-infected ART-naïve participants. Results showed that 112 (53.1%) patients had experienced at least one morphological alteration including lipohypertrophy (7.6%), lipoatrophy (10.9%), and mixed alterations (34.6%). The majority of these subjects (90%) were receiving ARVs; in fact, all patients receiving PIs reported lipodystrophy. Period spent receiving ARVs (t209 = 6.739, p = .000), being on ART (χ2 = 94.482, p = .000), receiving PIs (Fisher’s exact χ2 = 113.591, p = .000), recent T4 count (CD4 counts) (t207 = 3.694, p = .000), time with HIV (t125 = 1.915, p = .045), as well as older age (t209 = 2.013, p = .045) were independently associated with lipodystrophy. Receiving ARVs was the greatest predictor of lipodystrophy (p = .000). In other analysis, aside from skinfolds at the subscapular (p = .004), there were no differences with the rest of the skinfold sites and the circumferences between participants with lipodystrophy and those without the problem. Similarly, there was no difference in Waist: Hip ratio (WHR) (p = .186) and Waist: Height ratio (WHtR) (p = .257) among participants with lipodystrophy and those without the problem. Further examination showed that none of the 4.1% patients receiving stavudine (d4T) did experience lipoatrophy. However, 17.9% of patients receiving EFV, a non-nucleoside reverse transcriptase inhibitor (NNRTI) had lipoatrophy. Study 2 findings showed that presence of lipodystrophy in participants receiving ARVs was in fact far higher than that of HIV-infected ART-naïve participants. A final hypothesis was that the prevalence of the metabolic syndrome in participants receiving ARVs was not different from that of HIV-infected ART-naïve participants. Moreover, data showed that many patients (69.2%) lived with at least one feature of the metabolic syndrome based on International Diabetic Federation (IDF, 2006) definition. However, there was no single anthropometric predictor of components of the syndrome, thus, the best anthropometric predictor varied as the component varied. The metabolic syndrome was diagnosed in 15.2% of the subjects, lower than commonly reported in this population, and was similar between the medicated and the exposed groups (χ 21 = 0.018, p = .893). Moreover, the syndrome was associated with older age (p = .031) and percent body fat (p = .012). In addition, participants with the syndrome were heavier according to BMI (p = .000), larger at the waist (p = .000) and abdomen (p = .000), and were at central obesity risk even when hip circumference (p = .000) and height (p = .000) were accounted for. In spite of those associations, results showed that the period with disease (p = .13), CD4 counts (p = .836), receiving ART (p = .442) or PIs (p = .678) were not associated with the metabolic syndrome. While the prevalence of the syndrome was highest amongst the older, larger and fatter participants, WC was the best predictor of the metabolic syndrome (p = .001). Another novel finding was that participants with the metabolic syndrome had greater arm muscle circumference (AMC) (p = .000) and arm muscle area (AMA) (p = .000), but the former was most influential. Accordingly, the easiest and cheapest indicator to assess risk in this study sample was WC should routine laboratory services not be feasible. In addition, the final study illustrated that the prevalence of the metabolic syndrome in participants receiving ARVs was not different from that of HIV-infected ART-naïve participants.

Principal component and linkage analysis of cardiovascular risk traits in the Norfolk isolate

OBJECTIVE(S): An individual's risk of developing cardiovascular disease (CVD) is influenced by genetic factors. This study focussed on mapping genetic loci for CVD-risk traits in a unique population isolate derived from Norfolk Island. METHODS: This investigation focussed on 377 individuals descended from the population founders. Principal component analysis was used to extract orthogonal components from 11 cardiovascular risk traits. Multipoint variance component methods were used to assess genome-wide linkage using SOLAR to the derived factors. A total of 285 of the 377 related individuals were informative for linkage analysis. RESULTS: A total of 4 principal components accounting for 83% of the total variance were derived. Principal component 1 was loaded with body size indicators; principal component 2 with body size, cholesterol and triglyceride levels; principal component 3 with the blood pressures; and principal component 4 with LDL-cholesterol and total cholesterol levels. Suggestive evidence of linkage for principal component 2 (h(2) = 0.35) was observed on chromosome 5q35 (LOD = 1.85; p = 0.0008). While peak regions on chromosome 10p11.2 (LOD = 1.27; p = 0.005) and 12q13 (LOD = 1.63; p = 0.003) were observed to segregate with principal components 1 (h(2) = 0.33) and 4 (h(2) = 0.42), respectively. CONCLUSION(S): This study investigated a number of CVD risk traits in a unique isolated population. Findings support the clustering of CVD risk traits and provide interesting evidence of a region on chromosome 5q35 segregating with weight, waist circumference, HDL-c and total triglyceride levels.

Changes in health profiles of participants in an Australian police department’s Wellness program

Background: Little is known about the health effects of worksite wellness programs on police department staff. Objective: To examine 1-2 year changes in health profiles of participants in the Queensland Police Service’s wellness program. Methods: Participants underwent yearly physical assessments. Health profile data collected during assessments from 2008 to 2012 were included in the analysis. Data Analysis: Repeated-measures ANOVA was used for continuous outcome variables, related-samples Wilcoxon Signed Rank test for non-normally continuous variables, and McNemar’s test for binary variables. Results: Significant changes in physical measures included decreases in waist circumference and percent body fat, and increases in cardiorespiratory fitness and flexibility (p<0.01). Changes in serum cholesterol, haemoglobin, total cholesterol ratios, HDL, LDL and Triglyceride levels were also significant (p<0.01). Conclusion: Participants’ health profiles mostly improved between cycles although most changes were not clinically significant. As this evaluation used a single-group pre-test post-test design, it provides initial indications that wellness programs can benefit staff in police departments.

Isoenergetic replacement of dietary saturated with monounsaturated fat via macadamia nuts enhances endothelial function in overweight subjects

Background & aims: - Excess adiposity (overweight) is one of numerous risk factors for cardiometabolic disease. Most risk reduction strategies for overweight rely on weight loss through dietary energy restriction. However, since the evidence base for long-term successful weight loss interventions is scant, it is important to identify strategies for risk reduction independent of weight loss. The aim of this study was to compare the effects of isoenergetic substitution of dietary saturated fat (SFA) with monounsaturated fat (MUFA) via macadamia nuts on coronary risk compared to usual diet in overweight adults. Methods: - A randomised controlled trial design, maintaining usual energy intake, but manipulating dietary lipid profile in a group of 64 (54 female, 10 male) overweight (BMI > 25), otherwise healthy, subjects. For the intervention group, energy intakes of usual (baseline) diets were calculated from multiple 3 day diet diaries, and SFA was replaced with MUFA (target: 50%E from fat as MUFA) by altering dietary SFA sources and adding macadamia nuts to the diet. Both control and intervention groups received advice on national guidelines for physical activity and adhered to the same protocol for diet diary record keeping and trial consultations. Anthropometric and clinical measures were taken at baseline and at 10 weeks. Results: A significant increase in brachial artery flow-mediated dilation (p < 0.05) was seen in the monounsaturated diet group at week 10 compared to baseline. This corresponded to significant decreases in waist circumference, total cholesterol (p < 0.05), plasma leptin and ICAM-1 (p < 0.01). Conclusions: - In patient subgroups where adherence to dietary energy-reduction is poor, isoenergetic interventions may improve endothelial function and other coronary risk factors without changes in body weight. This trial was registered with the Australia New Zealand Clinical Trial Registry (ACTRN12607000106437).

Malnutrition in Parkinson's disease and an individualised approach to its management

It has been reported that poor nutritional status, in the form of weight loss and resulting body mass index (BMI) changes, is an issue in people with Parkinson's disease (PWP). The symptoms resulting from Parkinson's disease (PD) and the side effects of PD medication have been implicated in the aetiology of nutritional decline. However, the evidence on which these claims are based is, on one hand, contradictory, and on the other, restricted primarily to otherwise healthy PWP. Despite the claims that PWP suffer from poor nutritional status, evidence is lacking to inform nutrition-related care for the management of malnutrition in PWP. The aims of this thesis were to better quantify the extent of poor nutritional status in PWP, determine the important factors differentiating the well-nourished from the malnourished and evaluate the effectiveness of an individualised nutrition intervention on nutritional status. Phase DBS: Nutritional status in people with Parkinson's disease scheduled for deep-brain stimulation surgery The pre-operative rate of malnutrition in a convenience sample of people with Parkinson's disease (PWP) scheduled for deep-brain stimulation (DBS) surgery was determined. Poorly controlled PD symptoms may result in a higher risk of malnutrition in this sub-group of PWP. Fifteen patients (11 male, median age 68.0 (42.0 – 78.0) years, median PD duration 6.75 (0.5 – 24.0) years) participated and data were collected during hospital admission for the DBS surgery. The scored PG-SGA was used to assess nutritional status, anthropometric measures (weight, height, mid-arm circumference, waist circumference, body mass index (BMI)) were taken, and body composition was measured using bioelectrical impedance spectroscopy (BIS). Six (40%) of the participants were malnourished (SGA-B) while 53% reported significant weight loss following diagnosis. BMI was significantly different between SGA-A and SGA-B (25.6 vs 23.0kg/m 2, p<.05). There were no differences in any other variables, including PG-SGA score and the presence of non-motor symptoms. The conclusion was that malnutrition in this group is higher than that in other studies reporting malnutrition in PWP, and it is under-recognised. As poorer surgical outcomes are associated with poorer pre-operative nutritional status in other surgeries, it might be beneficial to identify patients at nutritional risk prior to surgery so that appropriate nutrition interventions can be implemented. Phase I: Nutritional status in community-dwelling adults with Parkinson's disease The rate of malnutrition in community-dwelling adults (>18 years) with Parkinson's disease was determined. One hundred twenty-five PWP (74 male, median age 70.0 (35.0 – 92.0) years, median PD duration 6.0 (0.0 – 31.0) years) participated. The scored PG-SGA was used to assess nutritional status, anthropometric measures (weight, height, mid-arm circumference (MAC), calf circumference, waist circumference, body mass index (BMI)) were taken. Nineteen (15%) of the participants were malnourished (SGA-B). All anthropometric indices were significantly different between SGA-A and SGA-B (BMI 25.9 vs 20.0kg/m2; MAC 29.1 – 25.5cm; waist circumference 95.5 vs 82.5cm; calf circumference 36.5 vs 32.5cm; all p<.05). The PG-SGA score was also significantly lower in the malnourished (2 vs 8, p<.05). The nutrition impact symptoms which differentiated between well-nourished and malnourished were no appetite, constipation, diarrhoea, problems swallowing and feel full quickly. This study concluded that malnutrition in community-dwelling PWP is higher than that documented in community-dwelling elderly (2 – 11%), yet is likely to be under-recognised. Nutrition impact symptoms play a role in reduced intake. Appropriate screening and referral processes should be established for early detection of those at risk. Phase I: Nutrition assessment tools in people with Parkinson's disease There are a number of validated and reliable nutrition screening and assessment tools available for use. None of these tools have been evaluated in PWP. In the sample described above, the use of the World Health Organisation (WHO) cut-off (≤18.5kg/m2), age-specific BMI cut-offs (≤18.5kg/m2 for under 65 years, ≤23.5kg/m2 for 65 years and older) and the revised Mini-Nutritional Assessment short form (MNA-SF) were evaluated as nutrition screening tools. The PG-SGA (including the SGA classification) and the MNA full form were evaluated as nutrition assessment tools using the SGA classification as the gold standard. For screening, the MNA-SF performed the best with sensitivity (Sn) of 94.7% and specificity (Sp) of 78.3%. For assessment, the PG-SGA with a cut-off score of 4 (Sn 100%, Sp 69.8%) performed better than the MNA (Sn 84.2%, Sp 87.7%). As the MNA has been recommended more for use as a nutrition screening tool, the MNA-SF might be more appropriate and take less time to complete. The PG-SGA might be useful to inform and monitor nutrition interventions. Phase I: Predictors of poor nutritional status in people with Parkinson's disease A number of assessments were conducted as part of the Phase I research, including those for the severity of PD motor symptoms, cognitive function, depression, anxiety, non-motor symptoms, constipation, freezing of gait and the ability to carry out activities of daily living. A higher score in all of these assessments indicates greater impairment. In addition, information about medical conditions, medications, age, age at PD diagnosis and living situation was collected. These were compared between those classified as SGA-A and as SGA-B. Regression analysis was used to identify which factors were predictive of malnutrition (SGA-B). Differences between the groups included disease severity (4% more severe SGA-A vs 21% SGA-B, p<.05), activities of daily living score (13 SGA-A vs 18 SGA-B, p<.05), depressive symptom score (8 SGA-A vs 14 SGA-B, p<.05) and gastrointestinal symptoms (4 SGA-A vs 6 SGA-B, p<.05). Significant predictors of malnutrition according to SGA were age at diagnosis (OR 1.09, 95% CI 1.01 – 1.18), amount of dopaminergic medication per kg body weight (mg/kg) (OR 1.17, 95% CI 1.04 – 1.31), more severe motor symptoms (OR 1.10, 95% CI 1.02 – 1.19), less anxiety (OR 0.90, 95% CI 0.82 – 0.98) and more depressive symptoms (OR 1.23, 95% CI 1.07 – 1.41). Significant predictors of a higher PG-SGA score included living alone (β=0.14, 95% CI 0.01 – 0.26), more depressive symptoms (β=0.02, 95% CI 0.01 – 0.02) and more severe motor symptoms (OR 0.01, 95% CI 0.01 – 0.02). More severe disease is associated with malnutrition, and this may be compounded by lack of social support. Phase II: Nutrition intervention Nineteen of the people identified in Phase I as requiring nutrition support were included in Phase II, in which a nutrition intervention was conducted. Nine participants were in the standard care group (SC), which received an information sheet only, and the other 10 participants were in the intervention group (INT), which received individualised nutrition information and weekly follow-up. INT gained 2.2% of starting body weight over the 12 week intervention period resulting in significant increases in weight, BMI, mid-arm circumference and waist circumference. The SC group gained 1% of starting weight over the 12 weeks which did not result in any significant changes in anthropometric indices. Energy and protein intake (18.3kJ/kg vs 3.8kJ/kg and 0.3g/kg vs 0.15g/kg) increased in both groups. The increase in protein intake was only significant in the SC group. The changes in intake, when compared between the groups, were no different. There were no significant changes in any motor or non-motor symptoms or in "off" times or dyskinesias in either group. Aspects of quality of life improved over the 12 weeks as well, especially emotional well-being. This thesis makes a significant contribution to the evidence base for the presence of malnutrition in Parkinson's disease as well as for the identification of those who would potentially benefit from nutrition screening and assessment. The nutrition intervention demonstrated that a traditional high protein, high energy approach to the management of malnutrition resulted in improved nutritional status and anthropometric indices with no effect on the presence of Parkinson's disease symptoms and a positive effect on quality of life.

Validity of dietary questionnaires in Sri Lankan adults and the association of dietary intake with obesity

Traditionally, infectious diseases and under-nutrition have been considered major health problems in Sri Lanka with little attention paid to obesity and associated non-communicable diseases (NCDs). However, the recent Sri Lanka Diabetes and Cardiovascular Study (SLDCS) reported the epidemic level of obesity, diabetes and metabolic syndrome. Moreover, obesity-associated NCDs is the leading cause of death in Sri Lanka and there is an exponential increase in hospitalization due to NCDs adversely affecting the development of the country. Despite Sri Lanka having a very high prevalence of NCDs and associated mortality, little is known about the causative factors for this burden. It is widely believed that the global NCD epidemic is associated with recent lifestyle changes, especially dietary factors. In the absence of sufficient data on dietary habits in Sri Lanka, successful interventions to manage these serious health issues would not be possible. In view of the current situation the dietary survey was undertaken to assess the intakes of energy, macro-nutrients and selected other nutrients with respect to socio demographic characteristics and the nutritional status of Sri Lankan adults especially focusing on obesity. Another aim of this study was to develop and validate a culturally specific food frequency questionnaire (FFQ) to assess dietary risk factors of NCDs in Sri Lankan adults. Data were collected from a subset of the national SLDCS using a multi-stage, stratified, random sampling procedure (n=500). However, data collection in the SLDCS was affected by the prevailing civil war which resulted in no data being collected from Northern and Eastern provinces. To obtain a nationally representative sample, additional subjects (n=100) were later recruited from the two provinces using similar selection criteria. Ethical Approval for this study was obtained from the Ethical Review Committee, Faculty of Medicine, University of Colombo, Sri Lanka and informed consent was obtained from the subjects before data were collected. Dietary data were obtained using the 24-h Dietary Recall (24HDR) method. Subjects were asked to recall all foods and beverages, consumed over the previous 24-hour period. Respondents were probed for the types of foods and food preparation methods. For the FFQ validation study, a 7-day weight diet record (7-d WDR) was used as the reference method. All foods recorded in the 24 HDR were converted into grams and then intake of energy and nutrients were analysed using NutriSurvey 2007 (EBISpro, Germany) which was modified for Sri Lankan food recipes. Socio-demographic details and body weight perception were collected from interviewer-administrated questionnaire. BMI was calculated and overweight (BMI ≥23 kg.m-2), obesity (BMI ≥25 kg.m-2) and abdominal obesity (Men: WC ≥ 90 cm; Women: WC ≥ 80 cm) were categorized according to Asia-pacific anthropometric cut-offs. The SPSS v. 16 for Windows and Minitab v10 were used for statistical analysis purposes. From a total of 600 eligible subjects, 491 (81.8%) participated of whom 34.5% (n=169) were males. Subjects were well distributed among different socio-economic parameters. A total of 312 different food items were recorded and nutritionists grouped similar food items which resulted in a total of 178 items. After performing step-wise multiple regression, 93 foods explained 90% of the variance for total energy intake, carbohydrates, protein, total fat and dietary fibre. Finally, 90 food items and 12 photographs were selected. Seventy-seven subjects completed (response rate = 65%) the FFQ and 7-day WDR. Estimated mean energy intake (SD) from FFQ (1794±398 kcal) and 7DWR (1698±333 kcal, P<0.001) was significantly different due to a significant overestimation of carbohydrate (~10 g/d, P<0.001) and to some extent fat (~5 g/d, NS). Significant positive correlations were found between the FFQ and 7DWR for energy (r = 0.39), carbohydrate (r = 0.47), protein (r = 0.26), fat (r =0.17) and dietary fiber (r = 0.32). Bland-Altman graphs indicated fairly good agreement between methods with no relationship between bias and average intake of each nutrient examined. The findings from the nutrition survey showed on average, Sri Lankan adults consumed over 14 portions of starch/d; moreover, males consumed 5 more portions of cereal than females. Sri Lankan adults consumed on average 3.56 portions of added sugars/d. Moreover, mean daily intake of fruit (0.43) and vegetable (1.73) portions was well below minimum dietary recommendations (fruits 2 portions/d; vegetables 3 portions/d). The total fruit and vegetable intake was 2.16 portions/d. Daily consumption of meat or alternatives was 1.75 portions and the sum of meat and pulses was 2.78 portions/d. Starchy foods were consumed by all participants and over 88% met the minimum daily recommendations. Importantly, nearly 70% of adults exceeded the maximum daily recommendation for starch (11portions/d) and a considerable proportion consumed larger numbers of starch servings daily, particularly men. More than 12% of men consumed over 25 starch servings/d. In contrast to their starch consumption, participants reported very low intakes of other food groups. Only 11.6%, 2.1% and 3.5% of adults consumed the minimum daily recommended servings of vegetables, fruits, and fruits and vegetables combined, respectively. Six out of ten adult Sri Lankans sampled did not consume any fruits. Milk and dairy consumption was extremely low; over a third of the population did not consume any dairy products and less than 1% of adults consumed 2 portions of dairy/d. A quarter of Sri Lankans did not report consumption of meat and pulses. Regarding protein consumption, 36.2% attained the minimum Sri Lankan recommendation for protein; and significantly more men than women achieved the recommendation of ≥3 servings of meat or alternatives daily (men 42.6%, women 32.8%; P<0.05). Over 70% of energy was derived from carbohydrates (Male:72.8±6.4%, Female:73.9±6.7%), followed by fat (Male:19.9±6.1%, Female:18.5±5.7%) and proteins (Male:10.6±2.1%, Female:10.9±5.6%). The average intake of dietary fiber was 21.3 g/day and 16.3 g/day for males and females, respectively. There was a significant difference in nutritional intake related to ethnicities, areas of residence, education levels and BMI categories. Similarly, dietary diversity was significantly associated with several socio-economic parameters among Sri Lankan adults. Adults with BMI ≥25 kg.m-2 and abdominally obese Sri Lankan adults had the highest diet diversity values. Age-adjusted prevalence (95% confidence interval) of overweight, obesity, and abdominal obesity among Sri Lankan adults were 17.1% (13.8-20.7), 28.8% (24.8-33.1), and 30.8% (26.8-35.2), respectively. Men, compared with women, were less overweight, 14.2% (9.4-20.5) versus 18.5% (14.4-23.3), P = 0.03, less obese, 21.0% (14.9-27.7) versus 32.7% (27.6-38.2), P < .05; and less abdominally obese, 11.9% (7.4-17.8) versus 40.6% (35.1-46.2), P < .05. Although, prevalence of obesity has reached to epidemic level body weight misperception was common among Sri Lankan adults. Two-thirds of overweight males and 44.7% of females considered themselves as in "about right weight". Over one third of both male and female obese subjects perceived themselves as "about right weight" or "underweight". Nearly 32% of centrally obese men and women perceived that their waist circumference is about right. People who perceived overweight or very overweight (n = 154) only 63.6% tried to lose their body weight (n = 98), and quarter of adults seek advices from professionals (n = 39). A number of important conclusions can be drawn from this research project. Firstly, the newly developed FFQ is an acceptable tool for assessing the nutrient intake of Sri Lankans and will assist proper categorization of individuals by dietary exposure. Secondly, a substantial proportion of the Sri Lankan population does not consume a varied and balanced diet, which is suggestive of a close association between the nutrition-related NCDs in the country and unhealthy eating habits. Moreover, dietary diversity is positively associated with several socio-demographic characteristics and obesity among Sri Lankan adults. Lastly, although obesity is a major health issue among Sri Lankan adults, body weight misperception was common among underweight, healthy weight, overweight, and obese adults in Sri Lanka. Over 2/3 of overweight and 1/3 of obese Sri Lankan adults believe that they are in "right weight" or "under-weight" categories.