Low Income Diet and Nutrition Survey: summary and analysis of the main findings prepared by

1. Low Income Diet and Nutrition Survey:summary and analysis of the main findingsprepared by Dr Alan Stewart www.stewartnutrition.co.uk

2. Low Income Diet and Nutrition Survey: Lecture Contents and Slides • Introduction 3-5 • Methodology, Analysis, Population Characteristics 6-12 • Malnutrition: undernutrition 13-20 • Malnutrition: overnutrition 21-24 • Malnutrition Risk Factors: socio-economic and personal 25-55 • Lessons from History

3. Poverty and Malnutrition: Background • Though the industrial and agricultural revolutions did much to reduce widespread food shortages malnutrition still occurs • Landmark discoveries in nutrition made in the 20th century began to document the specific impact of poor nutrient intake on health • These discoveries and the need for even food distribution during the two World Wars resulted in the formulation of advice and food policies to prevent undernutrition in the general population • Financial hardship and deprivation are not the only determinants of inadequate food intake and malnutrition in the UK population • Poor nutrient status affects all age groups - growth, development, physical and mental health, earning capability and longevity • Correcting undernutrition benefits both the individual and society • To correct problems of malnutrition requires an understanding of the findings of nutritional surveys as well as lessons from history

4. Malnutrition and Health • The term malnutrition covers both undernutrition and overnutrition • In the UK obvious severe undernutrition is not common outside of serious illness or dietary problems but overnutrition – obesity, is • Numerous nutritional surveys of the UK population reveal that mild deficiencies of micronutrients are not uncommon, may co-exist with overnutrition and can adversely influence physical or mental health • Deficiencies of three micronutrients (iron, vitamin A and iodine) in all countries are monitored by the WHO and are only marginally more common in the low income groups in the UK. www.int/vmnis/en • However, deficiencies of folate, vitamins D and C are more common and potentially affect health in all age groups • The causes of the these and other deficiencies include poor food choices, illness, smoking, alcohol excess and lack of sun exposure

5. Classifying Diet-Related Health Problems Undernutrition • Poor Growth - Protein-energy, vitamin A and iodine • Underweight – Protein-energy • Anaemia – Iron, folate, vitamins B12 and C • Rickets and Osteoporosis - Calcium and vitamin D • Poor Pregnancy Outcome – Folate, severe anaemia, vitamins C and D • Major Deficiency Syndromes – Vitamin C (scurvy), vitamin B1(beri-beri) etc. Overnutrition • Obesity – Energy from food or alcohol • Hypertension – Obesity, excess of sodium and alcohol • Poor Pregnancy Outcome – Obesity, excess of vitamin A • Liver disease – Obesity, alcohol, excess of iron or vitamin A Unwise Food Choices • Increased Mortality – vascular disease and cancer mainly • Increased Morbidity – many: dental caries, digestive problems, food allergy

6. Low Income Diet and Nutrition Survey of the UK Population (2008): Methodology • Being in receipt of benefits has often been associated with a less healthy diet and poorer nutritional state and health • The LIDNS was commissioned by the Food Standards Agency to assess the nutritional status of this group • A representative sample aged 2 to over 80 years was drawn from those in the most deprived 15% of society, living in a household where at least one adult was in receipt of benefits • Data was collected on food intake over 4 days, measures of height, weight and blood pressure and, on those aged 8 years and over, blood samples to assess specific nutrients • Information about alcohol consumption, smoking, medication, supplement use, physical activity and oral health was collected • See www.food.gov.uk/science/dietsurveys/lidnsbranch/

7. LIDNS: Data Analysis and Presentation • 3,728 people took part in the survey and completed the diet record and 1,435 (age >8yrs) provided a blood sample • As in the previous four National Diet and Nutrition Surveys (NDNS) those in institutions, of no fixed abode or who were pregnant or very ill were not included • The data have been analysed by sex, age, geographic location, whether urban or non-urban dwelling and by ethnicity • In the report data on micronutrient intake is presented from Food Sources only and not All Sources (food and supplements) • This means that the prevalence of inadequate intake (below the LRNI) may have been slightly overestimated • Supplements usually provided <10% of total intake • Direct comparison with the corresponding NDNS, which looked at intakes from All Sources, is thus not straightforward

8. LIDNS: Socio-demographic Characteristics • SexMale 40% Female 60% • Ages2-10 yrs 19% 11-18 yrs 14%19-34 yrs 17% 35-49 yrs 17%50-64 yrs 12% 65+ yrs 21% • Marital StatusMarried 28% Separated 6%Divorced 19% Widowed 18%Never married, single 29% • Dwelling LocationUrban 19% Sub-urban 78% Rural 3% • EducationThose aged >16 yrs with no qualification Men 51% Women 58%

9. LIDNS: Location of Dwelling All participants (aged >2yrs) • England n = 2433. Scotland n = 392, Wales n = 437, N. Ireland n = 466 • Total n = 3728

10. LIDNS: Ethnic Group • The small number of people in the different ethnic minorities makes detailed interpretation of nutritional differences unreliable

11. LIDNS: Health Status –Limiting/Not-Limiting Illness

12. LIDNS: Sources of Income • Many had income from more than one type of source/benefit

13. Undernutrition: Main Nutrients of Concern

14. LIDNS: Undernutrition Prevalence - Macronutrients

15. LIDNS/NDNS: Prevalence of Low Protein IntakeLower 2.5 percentile of percentage of energy as protein • Protein intakes <10% of energy intake are likely to be inadequate for some people unless total energy intakes are very high • Intake of protein/kg body weight and related measures were not presented • Low protein diets are often low in iron, vitamin B12 and other nutrients

16. LIDNS: Fruit and Vegetable ConsumptionPortions per day. (Advised Adult Target = 5) • NDNS Adult (19-64 yrs) intakes of those in receipt of benefits are 70% of those who are not • Low intakes of fruit and vegetables will often result in poorer status of vitamin C and folate and reduced iron absorption

17. LIDNS: Prevalence of Anaemia • Haemoglobin Normal Ranges World Health Organisation; 1.5-6.0 yrs >11.0g/dl, adult women >12.0g/dl, adult men >13.0g/dl. • Adult ranges have been adopted from ages 15yrs and upward • British laboratories often use a normal range of >11.5g/dl for adult women • Levels of 11.5-11.9g/dl in women can result in symptomatic iron deficiency

18. LIDNS: Undernutrition Prevalence - Micronutrients

19. LIDNS: Prevalence of Folate Deficiency IRed Cell Folate • Test red cell folate; normal range is >350 nmol/l • Group Boys age 8-10 yrs only 7 subjects - too few to analyse • Symptomatic deficiency often develops before macrocytic anaemia develops

20. LIDNS: Prevalence of Folate Deficiency IIPlasma Folate • Test plasma folate; normal range is >7 nmol/l • Group Boys age 8-10 yrs only 7 subjects - too few to analyse • Plasma folate is easily raised by supplements and may not reflect tissue status • Multivitamin supplements were taken by men 6%, women 10%, children 4%

21. LIDNS: Prevalence of Vitamin B12 DeficiencySerum Vitamin B12 • Test serum vitamin B12; normal range is > 118 pmol/l • Serum level may be reduced by o.c. pill without deficiency developing • Symptomatic deficiency often develops before macrocytic anaemia

22. LIDNS: Prevalence of Vitamin C DeficiencyPlasma Vitamin C • Test plasma vitamin C; normal range is >11 umol/l • Milder depletion was present in ~7% of 8-18yr olds and ~20% of adults

23. LIDNS: Prevalence of Vitamin D DeficiencySerum 25 Hydroxy vitamin D • Test serum 25-hydroxy vitamin D; normal range >25 nmol/l • Group Boys age 8-10 yrs only 7 subjects - too few to analyse • No measure of correlation between intake and serum status was made

24. NDNS/DNSBA: Correlation Coefficients between Intake and Laboratory Level of the Nutrient • No attempt was made as part of LIDNS to determine the degree of correlation between intake of a nutrient and its level on testing • This was assessed in other nutritional surveys (see opposite) • Data presented for males (above) and females (below) • All data from NDNS except adults 19-64 yrs – vit. B12, from DNSBA • All correlations were significant (p<0.05) except for vit. D (4-18 yrs) and vit. B12 men 65+ yrs • The higher the correlation coefficient the more likely that a deficiency could be caused or treated by dietary factors alone

25. Overnutrition: Main Nutrients of Concern

26. LIDNS: Overnutrition Prevalence

27. LIDNS: Distribution of BMI - Men

28. LIDNS: Distribution of BMI - Women

29. LIDNS: Non-Milk Extrinsic Sugars Intake Percentage of Food Energy means and upper 2.5 percentiles • Population advised mean intakes for adults is 11% of food energy • Highest Mean Intakes were observed in:White men and boys and Black women and girlsWomen and girls in Scotland and boys in Northern Ireland

30. LIDNS: Dietary Sources of Non-Milk Extrinsic SugarsPercentage of total intake of NMES

31. LIDNS: Carbohydrate Provision by Fruit and Sugary DrinksMean percentage contribution to total carbohydrate intake • Sugary drinks = carbonated + not carbonated (approximately 75% are carbonated) • No other food groups show anything like the same degree of age-related variation in carbohydrate provision as fruit and nuts, and sugary drinks • Soft, sugary drinks occupy the “space” left by the lack of dietary fruit

32. NDNS: Carbohydrate Provision by Fruit and Sugary DrinksMean percentage contribution to total carbohydrate intake • Sugary drinks = carbonated + not carbonated (approximately 75% are carbonated) • No other food groups show anything like the same degree of age-related variation in carbohydrate provision as fruit and nuts, and sugary drinks • Age ranges for young people are slightly different to those of LIDNS

33. NDNS: Carbohydrate Provision by Fruit and Fizzy Sugary DrinksMean percentage contribution to total carbohydrate intake • Drink figures for 1.5 to 4.5 years are estimates • Approximately 15% of participants in NDNS were in receipt of benefits • Age-related change in carbohydrate source is similar to but less marked than LIDNS

34. NMES: Adverse Health Effects of High IntakesNon-Milk Extrinsic Sugars

35. LIDNS: Vitamin A Status – Plasma Retinol umol/lUpper 2.5% percentiles and Mean values • Levels >2.8 umol/l indicate excess and an increased risk of osteoporosis • They can be due to excessive intake (diet or supplements), obesity, type 2 diabetes, alcohol excess or renal failure [LIDNS causes are unclear] • Retinol supplements were taken by <13% of men and <22% of women • The highest regional upper 2.5 percentile levels were: Northern Irish men 4.0 umol/l and Scottish women 3.78 umol/l

36. LIDNS: Iron Status – Plasma Ferritin ug/lUpper 2.5% percentiles and Mean values • Plasma ferritin levels are lower in women due to menstrual losses of iron • Levels >300 ug/l can be due to chronic inflammation, infection, injury, liver disease, iron excess (diet or supplements) or haemochromatosis • Iron supplements were taken by <6% of men and <9% of women • In Wales the upper 2.5 percentiles were: men 3,338 ug/l, women 620 ug/l

37. Malnutrition: causes, significance and treatment The Scientific Advisory Committee on Nutrition reviewed the LIDNS and concluded… “ Identification of the pathways of causality linking deprivation, diet and health are critical to understanding of the clustering of diet-related disease and the development of targeted interventions designed to lessen inequalities in diet-related ill health in the UK.” www.sacn.gov.uk

38. Socio-economic Low income/food expenditure* Food insecurity* Lack of domestic facilities* (cooker, fridge, microwave etc) Poor mobility/access to shops* Poor educational attainment* Poor ability or cooking skills* Household type and number of dependents Lone dweller or lone parent family* Ethnic origin Personal Poor dental health* Alcohol excess Obesity* Smoking* Life stage – infant, menstruating woman, pregnant/lactating, elderly Physical illness* Lack of exercise* Country or location of dwelling Malnutrition: potential risk factors*More common in the low income group compared with the general population

39. LIDNS: Household Income and Nutrient Intake Difference in consumption between those with a net weekly equivalised income <£160 compared (lowest two quintiles) vs. >£160 (upper three quintiles) • All differences shown are significant p<0.05. • Males and females in the lower income group tended to consume less food • Few differences between the groups were significant (only limited data presented) • Differences: men - energy (-8%), sodium (-5.5%) and iron (-6.0%); women - none

40. What would Facilitate Dietary Change?Factors expressed by the 35% of men wanting to change • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <6%

41. What would Facilitate Dietary Change?Factors expressed by the 44% of women wanting to change • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <7%

42. LIDNS: Weekly Expenditure on Food and Drink£s per capita and household type • There would appear to be a saving of ~10% if not dwelling alone • Older people did not spend less than younger people but drank less alcohol

43. LIDNS: Transport and Food Intake – AdultsDifference in consumption between those who do not use a private car for food shopping and those who do * Differences significant p<0.05, for men and women ** Differences significant p<0.05, for women only

44. LIDNS: Transport and Nutrient Intake – AdultsDifference in consumption between those who do not use a private car for food shopping and those who do All differences are significant p<0.05

45. Food Security/Insecurity Defined as: • Security “Access by all people at all times to enough food for an active and healthy life” • Insecurity “Limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” Assessed by: A series of questions to determine current and past availability of food, whether the person is regularly able to obtain the food that they need

46. Food Security and Nutrient Intake:% difference in intake if moderately/severely food insecure compared with food secure • Only limited data on men presented • All differences in women were significant p <0.031 • Food insecurity in women approximately doubled the risk of inadequate intake (<LRNI) for iron, zinc, magnesium and potassium

47. LIDNS: Household Amenitiespercentage of participating households with adequate facilities

48. Educational Attainment and Nutrient Intake:% less intake if education < 5 GCSE grades A-C or equivalent • In males energy difference significant p <0.031; all other nutrients p <0.004 • In females all nutrients difference significant p <0.009

49. What would Facilitate Dietary Change?Factors expressed by the 35% of men wanting to change • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <6%

50. What would Facilitate Dietary Change?Factors expressed by the 44% of women wanting to change • Other options – support from others, information on food and health, more time, better cooking skills, facilities or local shops were each rated, on average, at <7%