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Edited by
David Mabey, London School of Hygiene and Tropical Medicine,Martin W. Weber, World Health Organization,Moffat Nyirenda, London School of Hygiene and Tropical Medicine,Dorothy Yeboah-Manu, Noguchi Memorial Institute for Medical Research, University of Ghana,Jackson Orem, Uganda Cancer Institute, Kampala,Laura Benjamin, University College London,Michael Marks, London School of Hygiene and Tropical Medicine,Nicholas A. Feasey, Liverpool School of Tropical Medicine
Nutrition is amongst the most powerful of the environmental factors influencing health and disease. As Africa passes through the demographic transitions of increasing wealth and urbanisation, the patterns of diet-related diseases are changing. Stunting and underweight among children remain unacceptably widespread, but in adults non-communicable diseases associated with excess weight are becoming common and are overtaking infectious diseases as the leading causes of death. The need for physicians to focus on their patients’ nutrition is therefore crucial.
This article addresses the social, material, and practical dimensions by which intertextuality is managed in a corporate setting. Managing intertextuality entails more than the circulation of entextualized fragments—it involves the everyday ways in which individuals come to negotiate with environments saturated and defined by textual objects. Based on fieldwork at a Korean brand consulting firm, I chart a range of ways that employees took different stances to intertextual practice—from how they defined relationships with their business partners to how they disciplined internal activities, even to how documents became “leaked” from within the office. This article advocates for a broader view of the practical and material dimensions of intertextuality, the diverse ways individuals can engage with texts, and the importance of considering intertextuality in the construction of managerial figures.
The coronavirus disease (COVID-19) pandemic and resulting restrictions on physical access to long-term care homes culminated in health declines for older adults living there and their families. Knowledge gaps exist regarding maintaining social connectedness when physically separated. The study aimed to explore family members’ perceptions of the impact that restrictions on physical access to long-term care homes had on the experience of social connectedness between family members and older adults living in long-term care. The method used was a qualitative description, using in-depth semi-structured interviews. Themes arising from inductive qualitative content analysis of 21 interviews with family members included: (a) lack of connection threatening mental, emotional health, and physical health; (b) navigating trust in the unknown; (c) feelings of stress and anxiety for family members; and (d) technology – an asset, but not for everyone. Study findings suggest more emphasis should be placed on supporting social connections between older adults and their families in the context of long-term care beyond COVID-19.
Young people are worried about climate change but the association between climate worry and current and past mental health has not been examined in population-based samples.
Objectives
To examine 1) the prevalence of worry about climate change at age 23-years and its association with contemporaneous mental health symptoms, and 2) and adolescent mental health symptoms.
Methods
We used a Canadian population-based birth cohort (n=1325) to examine associations between 1) climate change at age 23-years and concurrent anxiety, depression, and suicidal behaviors, and 2) mental health at age 15 and 17 years defined as anxiety, depression, aggression-opposition, inattention-hyperactivity. We adjusted for participants’ socioeconomic status, childhood IQ, sex, and parental history of psychopathology.
Results
Most participants were worried about climate change: 190 (14.3%) were extremely worried, 553 (41.7%) were somewhat worried, 383 (28.9%) were very worried, and 199 (15.0%) were not at all worried. Worry about climate change was associated with significantly elevated contemporaneous anxiety, depression, and suicidal thoughts. In longitudinal analysis, adolescent anxiety was associated with higher climate change worry at age 23-years while adolescent aggression-opposition was associated with lower climate change worry.
Conclusions
Worry about climate change is associated with contemporaneous mental health symptoms. However, longitudinal analysis suggests that this is largely explained by prior mental health, with adolescent anxiety symptoms linked with higher worry and aggression-opposition with lower worry. Future studies should aim to better define the dimensions of climate anxiety and track it alongside symptoms using prospective follow-up studies.
Anxiety disorders are a common presenting problem for young people under the care of Melksham Community CAMHS. Guidelines from NICE outline recommendations for best practice in assessment and treatment of these disorders. A local gap analysis in 2017 identified areas for improvement in assessment of anxiety disorders. Measures were implemented following this, including training for staff. A repeat audit was conducted in 2021 and results compared.
Methods
NICE guidelines were used to set audit standards, which were used for data collection in both 2017 and 2021. A proforma was developed. A pilot sample of five patients was used to test the proforma. A cut off of 80% compliance was used. Caseload screening by clinicians was used to identify all eligible patients, then a random sample of these was selected by the project leads. Case note review was then conducted. Patients with a diagnosis of autism were excluded from the sample. ROMS, SDQ, GAD-7 or general clinical observation was used as a measure of treatment response. In total in the 2021 sample, 22 patient records were audited.
Results
Treatment and follow up for anxiety disorders was good or excellent in 2017 and remained so in 2021. Areas for improvement lay in the assessment of anxiety disorder. In the 2017 audit, there was poor documentation of: mental health history (this had improved from unacceptable to good by 2021), past treatments (improved from unacceptable to requires improvement by 2021), family history (improved from unacceptable to good by 2021), domestic violence/CSA (improved from unacceptable to requires improvement by 2021). Response to treatment was inconsistently documented in the 2017 audit. In 2021 there remained some inconsistencies in documentation. Improvements in recording response to treatment would assist with clearly evidencing compliance with the NICE standards.
Conclusion
Overall, treatment and follow up for anxiety disorders was good or excellent (and remained so in 2021). Areas for improvement lay in the assessment of anxiety disorder. Recommendations to promote ongoing improvement include: 1) Circulation of re-audit results to the team 2) Brief recap of guidelines on assessment of social anxiety disorder to the team 3) Written/ email reminder to consider and document the other areas that received less than 80% compliance 4) Continue use of ROMS. Effective assessment and management of anxiety disorder is an important area of clinical practice for all clinicians in the team; we would recommend this is re assessed in 2023 to ensure standards continue to improve.
Growth patterns of breastfed infants show substantial inter-individual differences, partly influenced by breast milk (BM) nutritional composition. However, BM nutritional composition does not accurately indicate BM nutrient intakes. This study aimed to examine the associations between both BM intake volumes and macronutrient intakes with infant growth. Mother–infant dyads (n 94) were recruited into the Cambridge Baby Growth and Breastfeeding Study (CBGS-BF) from a single maternity hospital at birth; all infants received exclusive breast-feeding (EBF) for at least 6 weeks. Infant weight, length and skinfolds thicknesses (adiposity) were repeatedly measured from birth to 12 months. Post-feed BM samples were collected at 6 weeks to measure TAG (fat), lactose (carbohydrate) (both by 1H-NMR) and protein concentrations (Dumas method). BM intake volume was estimated from seventy infants between 4 and 6 weeks using dose-to-the-mother deuterium oxide (2H2O) turnover. In the full cohort and among sixty infants who received EBF for 3+ months, higher BM intake at 6 weeks was associated with initial faster growth between 0 and 6 weeks (β + se 3·58 + 0·47 for weight and 4·53 + 0·6 for adiposity gains, both P < 0·0001) but subsequent slower growth between 3 and 12 months (β + se − 2·27 + 0·7 for weight and −2·65 + 0·69 for adiposity gains, both P < 0·005). BM carbohydrate and protein intakes at 4–6 weeks were positively associated with early (0–6 weeks) but tended to be negatively related with later (3–12 months) adiposity gains, while BM fat intake showed no association, suggesting that carbohydrate and protein intakes may have more functional relevance to later infant growth and adiposity.
The regulation of health claims for foods by the Nutrition and Health Claims Regulation is intended, primarily, to protect consumers from unscrupulous claims by ensuring claims are accurate and substantiated with high quality scientific evidence. In this position paper, the Academy of Nutrition Sciences uniquely recognises the strengths of the transparent, rigorous scientific assessment by independent scientists of the evidence underpinning claims in Europe, an approach now independently adopted in UK. Further strengths are the separation of risk assessment from risk management, and the extensive guidance for those submitting claims. Nevertheless, four main challenges in assessing the scientific evidence and context remain: (i) defining a healthy population, (ii) undertaking efficacy trials for foods, (iii) developing clearly defined biomarkers for some trial outcomes and (iv) ensuring the composition of a food bearing a health claim is consistent with generally accepted nutrition principles. Although the Regulation aims to protect the consumer from harm, we identify some challenges from consumer research: (i) making the wording of some health claims more easily understood and (ii) understanding the implications of the misperceptions around products bearing nutrition or health claims. Recommendations are made to overcome these challenges. Further, the Academy recommends that a dialogue is developed with the relevant national bodies about Article 12(c) in the Regulation. This should further clarify the GB Guidance to avoid the current non-level playing field between health professionals and untrained ‘influencers’ who are not covered by this Article about the communication of authorised claims within commercial communications.
Prostate cancer is a common malignancy with rising incidence in Western countries such as the United Kingdom. In localised disease there are a variety of curative treatment modalities. Patients can be referred for surgery, or for a combination of hormonal therapies and radiotherapy (external beam radiotherapy or brachytherapy). Each treatment option comes with side effects and in the case of radiotherapy one potential complication is bowel toxicity from radiation exposure. New technologies are being developed to try and mitigate the side effects and long term morbidity of this treatment, and to expand access to radiotherapy for patients who may previously have been excluded (i.e those with inflammatory bowel disease). Rectal Spacers are absorbable polyethylene glycol hydrogels injected into the perirectal space. These position the anterior rectal wall away from the prostate, subsequently minimising radiation dose to the rectum. Rectal Spacers have been introduced to National Healthcare Service (NHS) practice as part of the Innovation and Technology Payment (ITP) programme, however, their use is now under review.
Methodology and Results:
In this editorial we conduct a narrative review of some of the available evidence for Rectal Spacers, discuss their utilization within the NHS and the barriers to their wider use. We also explore preliminary dosimetry and quality of life data for use of Rectal Spacers in our centre where we have been part of the NHS ITP programme. Dosimetry data and Quality of life questionnaires were gathered from 22 treated patients and 11 matched controls. This indicated lower radiation doses to the prostate in those treated with Rectal Spacers.
Conclusion:
Rectal Spacers are an effective method to reduce radiation dose to the prostate in men treated for localised prostate cancer, however, their use remains under review in the NHS and there are a variety of barriers to upscaling their use.
A multi-disciplinary expert group met to discuss vitamin D deficiency in the UK and strategies for improving population intakes and status. Changes to UK Government advice since the 1st Rank Forum on Vitamin D (2009) were discussed, including rationale for setting a reference nutrient intake (10 µg/d; 400 IU/d) for adults and children (4+ years). Current UK data show inadequate intakes among all age groups and high prevalence of low vitamin D status among specific groups (e.g. pregnant women and adolescent males/females). Evidence of widespread deficiency within some minority ethnic groups, resulting in nutritional rickets (particularly among Black and South Asian infants), raised particular concern. Latest data indicate that UK population vitamin D intakes and status reamain relatively unchanged since Government recommendations changed in 2016. Vitamin D food fortification was discussed as a potential strategy to increase population intakes. Data from dose–response and dietary modelling studies indicate dairy products, bread, hens’ eggs and some meats as potential fortification vehicles. Vitamin D3 appears more effective than vitamin D2 for raising serum 25-hydroxyvitamin D concentration, which has implications for choice of fortificant. Other considerations for successful fortification strategies include: (i) need for ‘real-world’ cost information for use in modelling work; (ii) supportive food legislation; (iii) improved consumer and health professional understanding of vitamin D’s importance; (iv) clinical consequences of inadequate vitamin D status and (v) consistent communication of Government advice across health/social care professions, and via the food industry. These areas urgently require further research to enable universal improvement in vitamin D intakes and status in the UK population.
Policy decisions and the practice of public health nutrition need to be based on solid evidence, developed through rigorous research studies where objective measures are used and results that run counter to dogma are not dismissed but investigated. In recent years, enhancements in study designs, and methodologies for systematic reviews and meta-analysis, have improved the evidence-base for nutrition policy and practice. However, these still rely on a full appreciation of the strengths and limitations of the measures on which conclusions are drawn and on the thorough investigation of outcomes that do not fit expectations or prevailing convictions. The importance of ‘hard facts’ and ‘misfits’ in research designed to advance knowledge and improve public health nutrition is illustrated in this paper through a selection of studies from different stages in my research career, focused on the nutritional requirements of resource-poor populations in Africa and Asia.
For many people, micronutrient requirement means the amount needed in the diet to ensure adequacy. Dietary reference values (DRV) provide guidance on the daily intake of vitamins and minerals required to ensure the needs of the majority in the population are covered. These are developed on estimates of the quantity of each micronutrient required by the average person, the bioavailability of the micronutrient from a typical diet and the interindividual variability in these amounts. Sex differences are inherent in the requirements for many micronutrients because they are influenced by body size or macronutrient intake. These are reflected in different DRV for males and females for some micronutrients, but not all, either when data from males and females are combined or when there is no evidence of sex differences. Pregnancy and lactation represent times when micronutrient requirements for females may differ from males, and separate DRV are provided. For some micronutrients, no additional requirement is indicated during pregnancy and lactation because of physiological adaptations. To date, little account has been taken of more subtle sex differences in growth and maturation rates, health vulnerabilities and in utero and other programming effects. Over the years, the MRC Nutrition and Bone Health Group has contributed data on micronutrient requirements across the lifecourse, particularly for calcium and vitamin D, and shown that supplementation can have unexpected sex-specific consequences that require further investigation. The present paper outlines the current issues and the need for future research on sex differences in micronutrient requirements.
The El Cañizar de Villarquemado pollen record covers the last part of MIS 6 to the Late Holocene. We use Tolerance-Weighted Averaging Partial Least Squares (TWA-PLS) to reconstruct mean temperature of the coldest month (MTCO) and growing degree days above 0°C (GDD0) and the ratio of annual precipitation to annual potential evapotranspiration (MI), accounting for the ecophysiological effect of changing CO2 on water-use efficiency. Rapid summer warming occurred during the Zeifen-Kattegat Oscillation at the transition to MIS 5. Summers were cold during MIS 4 and MIS 2, but some intervals of MIS 3 had summers as warm as the warmest phases of MIS 5 or the Holocene. Winter temperatures declined from MIS 4 to MIS 2. Changes in temperature seasonality within MIS 5 and MIS 1 are consistent with insolation seasonality changes. Conditions became progressively more humid during MIS 5, and MIS 4 was also humid, although MIS 3 was more arid. Changes in MI and GDD0 are anti-correlated, with increased MI during summer warming intervals. Comparison with other records shows glacial-interglacial changes were not unform across the circum-Mediterranean region, but available quantitative reconstructions are insufficient to determine if east-west differences reflect the circulation-driven precipitation dipole seen in recent decades.
This Position Paper from the Academy of Nutrition Sciences is the first in a series which describe the nature of the scientific evidence and frameworks that underpin nutrition recommendations for health. This first paper focuses on evidence which underpins dietary recommendations for prevention of non-communicable diseases. It considers methodological advances made in nutritional epidemiology and frameworks used by expert groups to support objective, rigorous and transparent translation of the evidence into dietary recommendations. The flexibility of these processes allows updating of recommendations as new evidence becomes available. For CVD and some cancers, the paper has highlighted the long-term consistency of a number of recommendations. The innate challenges in this complex area of science include those relating to dietary assessment, misreporting and the confounding of dietary associations due to changes in exposures over time. A large body of experimental data is available that has the potential to support epidemiological findings, but many of the studies have not been designed to allow their extrapolation to dietary recommendations for humans. Systematic criteria that would allow objective selection of these data based on rigour and relevance to human nutrition would significantly add to the translational value of this area of nutrition science. The Academy makes three recommendations: (i) the development of methodologies and criteria for selection of relevant experimental data, (ii) further development of innovative approaches for measuring human dietary intake and reducing confounding in long-term cohort studies and (iii) retention of national nutrition surveillance programmes needed for extrapolating global research findings to UK populations.
Most techniques for pollen-based quantitative climate reconstruction use modern assemblages as a reference data set. We examine the implication of methodological choices in the selection and treatment of the reference data set for climate reconstructions using Weighted Averaging Partial Least Squares (WA-PLS) regression and records of the last glacial period from Europe. We show that the training data set used is important because it determines the climate space sampled. The range and continuity of sampling along the climate gradient is more important than sampling density. Reconstruction uncertainties are generally reduced when more taxa are included, but combining related taxa that are poorly sampled in the data set to a higher taxonomic level provides more stable reconstructions. Excluding taxa that are climatically insensitive, or systematically overrepresented in fossil pollen assemblages because of known biases in pollen production or transport, makes no significant difference to the reconstructions. However, the exclusion of taxa overrepresented because of preservation issues does produce an improvement. These findings are relevant not only for WA-PLS reconstructions but also for similar approaches using modern assemblage reference data. There is no universal solution to these issues, but we propose a number of checks to evaluate the robustness of pollen-based reconstructions.
Early childhood education and care (ECEC) policies and services in Canada exhibit marked gaps in access, creating ‘childcare deserts’ and distributional disadvantages. Cognate family policies that support children and families, such as parental leave and child benefits, are also underdeveloped. This article examines the current state of ECEC services in Canada and the reasons behind the uncoordinated array of services and policy, namely, a liberal welfare state tradition that historically has encouraged private and market-based care, a comparatively decentralised federal system that militates against coordinated policy-making, and a welfare state built on gendered assumptions about care work. The article assesses recent government initiatives, including the federal 2017 Multilateral Framework on Early Learning and Child Care, concluding that existing federal and provincial initiatives have limited potential to bring about paradigmatic third-order change.