Professional regulation of nutritionists: where are we now?

Waterlow's (1981) Sixth Boyd Orr Lecture on a 'crisis of identity for nutrition' stimulated the Nutrition Society's drive to professionalisation. Twenty-five years on, the Society begins a new stage; first, towards an independent voluntary regulator, and then towards statutory regulation. It is timely to reflect on progress and identify the remaining challenges. The Society has made impressive progress as a voluntary regulator since 1991 when the Institute of Biology opened a register in cooperation with the Institute of Food Science and Technology and the Nutrition Society; the present register is 2.75-fold larger. The Society has specialist standards for course accreditation that enable graduates to apply for direct entry to the register, having met standards of competency in nutrition or public health nutrition. A code of ethics and a statement of professional conduct underpin a functioning system for oversight and governance that protects the public, the hallmark of all professions. Registered nutritionists lay easy claim to a unique science basis for their profession. A scheme for continuing professional development (CPD) started in July 2006, 1 year before a sample audit starts to show the link between CPD and re-registration. The scheme will be piloted in the first year. The critical challenge is the issue of identity. Waterlow (1981) stated that professional registration must lead explicitly and formally to a specific vocation, an occupation that provides services that society requires and one that contributes to the well-being and health of all. The present time may be the last and best chance for nutritionists, as nutrition has a higher priority for government in the UK than ever before. The Society has begun to help in strategic public health workforce planning and development; new and still plastic, it is the ideal locus from which a discipline and a profession can emerge. The CPD scheme will work if it helps nutritionists meet their own needs; more mutual cooperation and consensus about real world standards of performance are needed. Nutritionists need to show how they actually contribute to national health and/or wealth. Then, sustained resources can be advocated for and the support of the voting public and legislators secured, without which it will not be possible to get the legal protection that is desirable for the profession.

Nutritional composition of commonly consumed dishes eaten by the African-Caribbean Community in Manchester, UK: a comparison with those eaten in Jamaica

Few food tables exist for traditional Caribbean foods eaten by the British African-Caribbean (AFC) Community. This paper presents nutritional composition of dishes currently eaten by British AFCs (mainly from Jamaica) compared with the same dishes eaten in Jamaica 10 years previously. Nutritional analysis values for macronutrients were calculated by weighting raw ingredients at every stage of preparation in both sites. These weights were entered into a dietary analysis package "Microdiet". The macronutrient composition (only protein and energy available) was then compared to that obtained 10 years previously in Jamaica. Despite the small number of recipes per dish, between site composition is very similar for energy in both countries with some variation in protein. Fried food varied most probably because of oil dripping. Further work is needed but this small study has provided data for analysing dietary records on these populations (AU)

The Kingston Project: VII. The point prevalence of helminths and parasites, and morbidity in malnourished children failing ambulatory treatment with a high energy supplement and a course of metronidazole - abstract

In a prospective study, 163 moderately malnourished children, living in the slums of Kingston, were followed up for one year. The anthropometric measurements in weight and length in those children receiving a High Energy Supplement (HES), and in wasting in those receiving, additionally, a course of metronidazole (MET) have been previously reported. The point prevalence as assessed by positive stool tests for helminths and parasites of the children treated with metronidazole, and if deemed necessary with mebendazole, increased significantly over the period of one year concurrent with improvement of their nutritional status (chi-2 = 13.57; p < .001). A significant increase was observed in both the supplemented and unsupplemented group (chi-2 = 3.98; p < .05 and chi-2 = 5.31; p < .05 respectively). Children receiving health care (HC) only, or health care and a high energy supplement (HC/HES) failed more than twice (17 per cent) as often the community-based management as those receiving additional metronidazole (HC/MET and HC/HES/MET) (8 per cent). Admissions to hospital for full nutritional and clinical recovery in the HC/HES group were mostly for enteric infections and septicaemia, while children in the MET groups were admitted for respiratory tract infections leading to anorexia. Malnourished children, managed in the community, are less likely to be admitted for failure if a course of metronidazole and mebendazole is given combined with their rehabilitation, using HES. This treatment reduces social and nutritional costs to the child, as well as costs to the public health service (AU)

Dietary patterns and nutrition in pregnancy in Jamaica

During a study of nutrition in pregnancy, the diets of 108 Jamaican pregnant women were assessed by single 24-hour recalls. The women were 16-45 years old, of mixed parity (0-9), attended private (23 percent) and public (77 percent)antenatal clinics and differed in stage of pregnancy at interview. Mean energy intake (2110ñ739 kcal/d) was low, 83 per cent of the average Recommended Dietary Allowance for the Caribbean (CFNI 1976). Most (76 percent) women had low energy and dietary iron (75 percent) intakes. Fewer women had low riboflavin (42 percent) or protein intakes (29 percent). Maternal age, parity, obstetric performance, and unusual cravings influenced maternal nutrition to some extent. Dietary assessments overestimated the risk of maternal malnutrition. (AU)

Parasitism and nutritional status of poor suburban Jamaican toddlers

A survey was conducted on 145 toddlers, 6-36 months of age, in a suburb in Kingston, Jamaica. The aim of the study was to measure the prevalence of and association between parasitism and nutritional status. Forty-two per cent were malnourished (<80 percent of standard weight for age), most commonly (76 percent) in the 12-17 month age group. Thirty-four per cent had one or more parasites, particularly Trichuris trichuria (21 percent) or Ascaris lumbricoides (19 percent). The peak prevalence of parasitism was among the 30-36 month old children (63 percent). Nutritional status did not differ between children with and without parasites. Most of them had light intensities of infection. Therefore, in this sample, there was no association between parasitism and nutritional status (AU)

Urea kinetics in adults with homozygous sickle cell disease

The kinetics of urea metabolism were measured in four adults with homozyguous sickle cell disease (HbSS). On a dietary intake of 1.2 to 2.7g protein /kg/d. A relatively small proportion of the urea was excreted in the urine (40 per cent), with a high fixed rate of hydrolysis in the bowel, 145 mg nitrogen /kg/d. Although 50 per cent of the nitrogen from hydrolysed urea was resynthesized to urea, and a further 10 per cent may have been lost in the stool, it is estimated that 58 mg nitrogen /kg/d was available for synthetic metabolic activity. Urea kinetics in sickle cell disease subjects are markedly different from normals, and this may be a reflection of the metabolic demands for increased red cell synthesis. (AU)

Helminths and nutritional status in Jamaica toddlers - abstract

Malnutrition, ascariasis and trichuriasis are prevalent and co-exist among the poor. However, the nature of the relationship between nutritional status and helminthiasis remains unclear. We therefore compared the prevalence and intensity of infection with Trichuris trichuria and Ascaris lumbricoides in 11 to 25-month-old children in two groups from the same slum communities in Kingston, Jamaica. One group comprised 66 malnourished children (<90 percent weight-for-age) and the other 55 well-nourished children (<90 percent weight-for-age). Both groups of children had similar mean ages, comprised similar proportions of boys and girls and had similar socio-economic status. Duplicate faecal specimens were examined twice, using the Kato thick Smear technique. Infected children were treated with mebendazole (Janssen, Pharmaceuticals). Helminths occurred with similar prevalence among the well-nourished (38 percent) and the malnourished (44 percent) children. However, the prevalence was highest in the mildly wasted children (57 percent, n=30) and least in the moderately/severely wasted children (15 percent, p<0.05). Similar patterns were observed for both Ascaris and Trichuris. In both groups, the presence of helminths was positively associated with age (Xý = 10.7, p<0.05), acess to water (Xý = 9.1, p<0.05)and geophagia(Xý = 4.2, p<0.05). These results show that nutritional status alters the host-parasite relationship. Perhaps mild malnutrition increases whereas more severe malnutrition decreases susceptibility to helminths, as Bundy and Golden (Parasitolgy, 1987) have suggested (AU)

Community rehabilitation of the Jamaican malnourished child: the effects of supplementary feeding on growth - abstract

The feasibility of rehabilitating malnourished children in the community, using the health service framework, was examined over a 6-month period. Eighty moderately and severely malnourished children, aged 3-36 months, were recruited from the Casualty Department, U.H.W.I., and Clinics in Kingston. The results of the first fifty to complete are reported. The children were randomly assigned to two treatment groups which provided medical care with and without a dietary supplement. The supplement, as prescribed, provided 750 Kcal/day for 3 months (55 percent of their energy requirements). At enrollment, both group had similar weight-for-age (WFA), height-for-age (HFA) and weight-for-height (WFH). At this point, mean WFA were 67 percent and 66 percent for supplemented and control groups respectively. By the end of the second month, the supplemented group was better nourished than their controls (p<0.05). The mean WFA were 73 percent and 69 percent respectively. By the end of the third month, the advantage of the supplemented group was more pronounced (p<0.01) with mean WFA of 74 percent and 69 percent respectively. This represented 8 percent WFA improvements in the supplemented as opposed to a 2 percent improvement in their controls. Mean weight gains of 1.22 and 0.84 Kg in supplemented and control groups were 2.0 and 1.3 times respectively, the normal rate for children of the same age. After three months, the supplemented group which had had three severely malnourished children at enrollment had none, while the control group which had had four still had two. Twice as many supplemented as opposed to control children had advanced to the mildly malnourished category. However, three months after the supplementation ceased (6 months), both groups were distributed similarly between the Gomez categories. Both interventions resulted in some catch-up growth. The regime of medical care plus supplementation proved more effective during the supplementation period. However, this advantage was not maintained when both groups received medical care only. Continous medical care and a onger supplementation period are needed for community rehabilitation of Jamaican malnourished children (AU)

Thiamin status in normal and malnourished children in Jamaica

Thiamin status has been measured using the erythrocyte transketolase (EC 2.2.1.1) assay in twenty-eight normal children and in twenty-five severely malnourished children throughout the course of recovery. Subclinical thiamin deficiency was found in 7 percent of the normal children and 36 percent of the malnourished children on admission. There was no significant association between thiamin status and oedema, stunting or wasting, history of breast-feeding, pattern of weaning, age or sex. Five malnourished children, who died, all had a normal thiamin status on admission; however, two developed biochemical evidence of thiamin deficiency preterminally (AU)

Thiamine status in Jamaican patients with alcoholic cirrhosis compared with "normal" adults

Thiamine status has been determined in 22 "normal" adults and 8 adults with alcoholic cirrhosis. The activity of erythrocyte transketolase was measured with and without the addition of exogenous thiamine pyrophospate and expressed as a percentage stimulaion (TTP-E percent). Biochemical evidence of thiamine deficiency was found in 14 percent of normal adults and 38 percent of alcoholics. The most severe deficiency was found in an alcoholic with cardiac involvement (TTP-E of 58 percent). The three deficient alcoholics improved with thiamine therapy, but the response was slow, indicating, perhaps, an apotransketolase deficiency. One patient with Wernicke's encephalopathy had a normal thiamine status. Two of the deficient patients had hepatic encephalopathy, whilst the third had delirium tremens.(AU)

The non-invasive measurement of urea kinetics in normal man by a constant infusion of 15N15N-urea

A two-pool model is described for the non-invasive measurement of urea kinetics in man. The isotope, 15N-urea, was given until an isotopic steady state was reached in urine and the time taken achieve this is defined. During an isotopic steady state, a comparison was made of the effect of giving the isotope orally, intravenously and intragastrically; no differences were found between the different routes. Measurements of enrichment were made on excretion products in urine. In six normal adults with a protein intake of 200 mg N/kg/d, the urea production rate was 139 ñ 15 mg N/kg/d, 70 percent of which was excreted in urine. Of the 34 mg N/kg/d produced by hydrolysis of urea in the gastrointestinal tract, 41 percent was resynthesized to urea, and about 48 percent was available for other synthetic processes.(AU)

An assessment of the diets of Jamaican pregnant women - abstract

During a prospective study of nutrition in pregnancy, at the University Hospital of the West Indies, dietary histories were obtained to assess the dietary pattern. Energy and protein intakes were calculated using Food Composition Tables. The 24-hour recall records of 42 (35 percent) women form the subject of this preliminary report. The subsample comprised 18 private and 24 public patients, whose mean initial age was 25.7 ñ 6.2 (SD) years. Half the subjects were nulliparous with 14 (33 percent) mutiparous and 7 (17 percent) grandmultiparous women. They were 20 ñ 7.0 (SD) weeks pregnant at the time of interview. In comparison to the public patients, the private patients ate a significantly more varied diet (P<0.01), especially more animal products, and fruits and vegitables. The middle class women also had more frequent meals (<0.05). The calculated nutrient intakes showed considerable individual variable: with a mean of 1,895 ñ 692 kcals (COV, 36.5 percent). The mean total protein intake of 67.0g ñ 28.5 (COV, 42.6 percent), including 43.8g ñ 24.9g animal protein, contributed 14.1 ñ 3.6 percent of total energy. Mean nutrient intakes were higher for private than for public patients and higher for women in the second than in the first half of pregnancy, but the difference were not significant. Compared to the Caribbean Recommended Dietary Allowances (RDAs) the mean energy intake for the whole sub-sample (76 percent) and those for the majority of private (83 percent) and public (88 percent) patients were inadequate. By contrast the mean protein intake was generous (124 percent) with few inadequate intakes among both groups (28 percent and 33 percent, respectively). The generally low energy intakes may be partly due to systematic under-estimation inherent in the history method, as has been reported elsewhere. However, it is also possible that the RDA is too generous. Therefore, dietary inadequacy was more stringently defined as < 1,500 kcals and/or < 38g protein, i.e. < 60 percent and < 70 percent of the RDAs, respectively. By these criteria, 11 (26 percent) of women had inadequate diets, more of whom (27 percent) had light-for-dates babies (below the Scottish 10th centiles for sex, parity and gestation) than women with adequate diets (9.7 percent) but this difference was not significant (AU)

Skinfold thickness and nutritional status in young Jamaican children

Height, weight, and mid-upper arm circumference and skin-fold thickness at four sites (triceps, biceps, subscapular, and supra-iliac) were measured in a representative sample of 121 Jamaican children of predominantly African origin, aged 4-6 years. Subscapular skinfold thickness was slightly below standards based on white children, but triceps skinfold thickness was substancially smaller, suggesting ethnic differences in the distribution of subcutaneous body fat. Sum skinfold thickness explained less than half the variance in corrected weight, an estimate of weight for height and an accepted index of acute malnutrition. Sum skinfold thickness correlated with corected weight more closely among girls (r=0.72) than boys (r=0.48). Mid-upper arm circumference explained 64 percent of the variability in corrected weight and sex differences were less marked. Among populations of African origin, mid-upper arm circumference may be a more reliable index of nutritional status than triceps skinfold thickness which gives misleading results, especially in boys (AU)

The dietary habits and knowledge of folklore of pregnant Jamaican women

Dietary changes associated with pregnancy, cravings and knowledge of traditional folklore were explored in their socio-economic context in 125 pregnant Jamaican women of mixed parity and social class attending an urban clinic. Most women reported dietary changes, expressing increased preferences for fluids, notably water and milk. Aversions to meat or staples were common. Cravings, especially for ice and salt/salty foods, were mentioned but pica was rare. Numerous traditional dietary customs concerning prevention of malformations, birthmarks and foetal death and facilitation of delivery, were reported. Unusual cravings and knowledge of the traditional folklore of pregnancy were significantly associated with lower socioeconomic status. The results are in keeping with a society in transition, and reflect persistence of traditional folklore with some acquisition of modern ideas.(AU)

A community study of parasites, nutritional status and housing in young Jamaican children - abstract

Parasitic infections may contribute to gastoenteritis and protein-energy malnutrition (PEM) both important problems among young Caribbean children. We conducted an epidemiological study of the prevalence of parasitic infestation and its association with the environment and nutritional status of preschool age children in a poor Kingston neighbourhood. The sample comprised all the 145 children (6 -36 months old) in a defined area. There were equal numbers of boys and girls and in each of 5 age groups (6 - 11, 12 - 17, 18 -23, 24 -29, 30 -36 months). Single stool specimens were examined for helminth ova and protozoan cysts using the formolether method, with iodine staining for light microscopy. The children's weights and heights were measured and their guardians were interviewed about their housing, sanitation and social background. Thirty-four per cent of the children were infested with 1 - 5 organisms: Trichuris, 21 percent, Ascaris, 18 percent, with generally low - moderate loads (< 5,000 ova/500 mg stool). Giardia occurred in 12.6 percent with very few other protozoans (E. coli, 4.2 percent, C.mesnili, 2.1 percent and E. nana, 0.7 percent). The peak prevalence (70 percent) was among 30-36 month-olds, age being significantly positively associated with the presence of parasites (p 0.001). The infested children had significantly poorer sanitation and water facilities (p<0.05) and their parents had a lower educational level (p<0.05) than the non-infested. Sixty-one (42.9 percent) children had some degree of undernutrition with 13(9.1 percent)moderately - severly malnourished. Single stool specimens probably underestimated the true point prevalence and load of parasitic infestations. There was a significant positive association between nutritional status and the presence of parasites in this study, However, undernutrition occurred most often among young toddlers (12 - 17 months) and parasitic infestation among 30 - 36 month-olds. This suggests that parasitic infestation did not play an important role in the aetiology of PEM in this community (AU)

Child rearing in poor urban Jamaica

Child rearing practices and attitudes were investigated using a questionnaire, among 75 families with 31-60-month-old children in poor suburban Kingston. A pattern emerged of many social contacts, outdoor activities and authoritarian discipline. While teaching and preparation for school were highly regarded, there was little conscious effort to foster cognitive and language development through play. Child rearing appears to reflect the infleunces of an African heritage, Western urbanization and poverty. Items from the questionnaire were used to devise an index of stimulation. Developmental assessments (DQs) were performed on a subgroup of 45 children. The results correlated positively with the index of stimulation. (Summary)