Background: Adults with intellectual disabilities experience equivalent or higher rates of obesity in comparison to the general population. This increases the risk for health conditions associated with adverse weight gain including cardiovascular disease and type II diabetes. Clinical guidelines on the management of obesity recommend multi-component interventions which include an energy deficit diet (EDD) of 600 kcal per day, support to increase physical activity and key behaviour change techniques including goal setting and self-monitoring to facilitate these healthy lifestyle changes. However, the current evidence base and provision of health services on the management of obesity in adults with intellectual disabilities is limited. A systematic review of multi-component weight management interventions was conducted and identified only seven randomised controlled trials of weight management interventions in adults with intellectual disabilities and obesity. The intervention components primarily focussed on a health education approach including diet, physical activity, and behaviour change techniques. However, no intervention adhered to clinical recommendations in terms of including an EDD, a weight maintenance intervention or investigating the long term efficacy of the intervention at 12 months. Meta-analyses revealed that post intervention (Weighted mean difference; WMD: -0.92kg; 95% CI -2.11kg, 0.28kg; p = 0.13) and at 12 months (WMD: -1.15 kg (95% CI -4.15 kg to 1.86 kg; p = 0.45), current multi-component weight management interventions are not more effective than no treatment. The results of this review illustrate that the current evidence base is insufficient to support multi-component weight management interventions focussed on a health education approach and therefore, future studies should investigate the efficacy of an alternative approach and the inclusion of an EDD to examine the efficacy of this approach to the management of obesity in adults with intellectual disabilities. Methods: The primary aim of this thesis was to add to the limited evidence base on multi-component weight management interventions in adults with intellectual disabilities by examining the feasibility of conducting a full-scale trial of a multi-component intervention, TAKE 5. TAKE 5 adheres to clinical recommendations on weight management and was specifically designed for adults with intellectual disabilities, and where applicable implemented with support from carers. The study design was a single blind cluster randomised controlled trial comparing two active interventions. The comparator intervention, WWToo, was based on a health education approach and consisted of multiple components focussed on diet, physical activity and behaviour change techniques. A multi-point recruitment strategy was piloted. Participants were recruited from multiple organisations, from specialist intellectual disabilities services, provider organisations and local day centres. Additional feasibility outcomes included retention rates and the fidelity and implementation of the intervention. The primary efficacy outcome was change in body weight at 12 months. Additional secondary outcomes included anthropometric outcomes (BMI, waist circumference, percentage body fat), objective measure of physical activity (time spent in light, moderate to vigorous intensity and total physical activity) and sedentary behaviour and health related quality of life. Results: The multi-point recruitment strategy was shown to be feasible and 50 participants were successfully recruited to the study. This study design was shown to be acceptable to adults with intellectual disabilities as retention to both interventions was high with 90% of participants completing the intervention. The TAKE 5 multi-component weight management intervention with support from carers led to significant reductions in weight, BMI, waist circumference and percentage body fat at six and 12 months. Furthermore, 50% of the participants in the TAKE 5 intervention achieved a clinically significant weight loss of 5% or greater of initial body weight in comparison to 21% of the participants in the WWToo intervention. Significant improvements in the above outcomes were not found in participants completing the WWToo intervention. A limitation of both interventions was the inability to engage participants in physical activity, reduce the sedentary lifestyle behaviours and improve health related quality of life of this population group. Both interventions were implemented as intended, and both interventions were shown to be feasible and accessible to all adults with varying levels in intellectual disabilities due to the social support provided by carers in implementing the interventions. Conclusion: This study is the first ever randomised controlled trial of a weight management intervention that adheres to clinical recommendations in adults with intellectual disabilities. This study provided evidence on the feasibility of this study design in adults with intellectual disabilities and demonstrated the acceptability of the EDD approach tailored to meet the needs of adults with intellectual disabilities. Furthermore, this study has provided preliminary evidence that an EDD may be an efficacious approach to weight management, and provided further evidence that current service provision based on health education approach is ineffective in the treatment of obesity in adults with intellectual disabilities. On the basis of these findings a future full-scale randomised controlled trial is necessary to confirm these findings and provide evidence on the optimum approach to weight management in this population group.

Background: The consumption of plant based foods has demonstrated an inverse association with disease prevalence. Among the components of plant based foods, polyphenol and fibre are two of the main contenders for many health benefits. The majority of polyphenols and fibre pass through the small intestine unabsorbed, reaching the colon where they are subjected to the action of the colonic microbiota; resulting in the production of the potentially bioactive metabolites: phenolic acids and SCFA. These metabolites are potentially responsible for many of the health benefits exerted by polyphenols rich foods and fibre. Given the recent advances in understanding the role of colonic microbiota in metabolic and immune responses, factors, which may positively or negatively modify the composition of the colonic bacteria have also received much attention. Foods rich in dietary fibre and polyphenols have the potential to modify colonic bacteria through prebiotic and antibiotic action. The potential bacterial inhibition by polyphenolics and the stimulation of bacterial growth by fibre and polyphenols means potential for both sets of compounds to influence metabolite production from each other. Polyphenols and fibre are most often present in the same foods and may be found together in plant cell walls. Thus they most often enter the colon together. We aimed to explore how the presence of these two components in the diet may impact on the metabolite production from the other by the colonic microbiota. Methods: The food matrix interaction of fibres and polyphenols was assessed using the fibres: raftiline, pectin and ispaghula, having different physio-chemical properties (rate of fermentation and viscosity) and the polyphenols: rutin and catechin, epicatechin and other polyphenols present in cocoa in vitro models of phenolic acid and short chain fatty acid (SCFA) production. The impact of ispaghula on urinary phenolic acids after cocoa ingestion was then investigated in an acute human study. In Chapter-3 the impact of the fermentable fibres on phenolic acid production from isolated parent compound: rutin in-vitro using 24 hour batch cultures using human faecal samples from volunteers (n=10) after being on a 3-day low polyphenol diet was investigated. Using the same model the impact of rutin, quercetin and their metabolites on SCFA production from raftiline, ispaghula and pectin was then investigate. The SCFA were measured by GC-FID and phenolic acids by GCMS. pH and gas were also measured. Using the same methodology the matrix interaction between raftiline, ispaghula and pectin separately on phenolic acid production from their parent compounds within their food matrix was investigated using cocoa as a rich source of polyphenols, as well as the impact of cocoa polyphenols and their metabolites on SCFA production from the fermentable fibres (Chapter-4) In Chapter-5, 24-hour urinary polyphenolic acids were measured in 5 batches (0, 0-2, 2-5, 5-8, 8-24 hour) in 12 human volunteers after ingestion of 1g paracetamol with 20g cocoa (extra brute Cocoa-Cacao Barry, Barry Callebaut, Hardricourt, France) with water, 15g of ispaghula with water or the combination of the two. Urine samples were also used for total phenol and antioxidant capacity measurement. Plasma was collected over six hours (every half hour for 4 hours and at 6th hour) and used for the measurement of total phenols as well as paracetamol concentrations for the estimation of gastric emptying rate. Breath hydrogen was used for estimation of small bowel transit time and visual analogue scales (VAS) were used for the estimation of subjective appetite response to meals. Results: The faecal fermentation of rutin resulted in the production of the following phenolic acids: PAA, 4-HBA, 3-HPAA, 4-HPAA, 3,4-DHPAA, 3-HPPA and 4-HPPA. All of these phenolic acids were significantly reduced by at least one of the three fibres, with the exception of 3-HPPA and 4-HPPA. The extent of inhibition of total sum of phenolic acids from raftiline and pectin was similar (p < 0.01) and ispaghula demonstrated the least inhibitory effect (p=0.03). Rutin and quercetin had no impact on the SCFA production from the fermentable fibres. The phenolic acids identified from cocoa faecal incubations consisted of: of PAA, 3-HPAA, 4-HPAA, 3,4-DHPAA, 3-HPPA, 4-HPPA, 3,4-DHPPA, 4-HBA, 3,4-DHBA, hippuric acid and vanillic acid. Unlike the rutin study where majority of phenolic acids were significantly reduced, in this study only four of eleven phenolic acids were affected (PAA, 3-HPAA, 4-HPAA, 4-HBA: also inhibited in the rutin study).The extent of phenolic acid reduction was the highest for pectin (p < 0.01), followed by raftiline (p < 0.01) and ispaghula (p=0.03). These phenolic acids or their parent compounds had no impact on SCFA production from the fermentable fibres. The consumption of cocoa resulted in the urinary excretion of the following phenolic acids: 3-HPAA, 4-HPAA, 3,4-DHPAA, Hippuric, 4-HPA, 4-HBA, 3,4-DHBA, Vanillic, 4-HVA, Mandelic and 4-HMA. All of which, with the exception of vanillic acid and 3,4-DHPAA, were reduced by ispaghula (Table-I). Ispaghula accelerated gastric emptying rate but had no impact on small bowel transit time. The analysis of total phenol (TP assay) concentration (plasma and urine) and antioxidant capacity (urine) did not demonstrate any difference between cocoa and ispaghula, which were both high. However when they were ingested together there was a signification reduction in both total phenol and antioxidant capacity (p < 0.01). Given that urinary and plasma concentration of total phenols was no different for ispaghula and cocoa we analysed the free phenolic and bound phenolics in both ispaghula and cocoa, showing that cocoa has significantly higher free phenolics than ispaghula, whereas bound phenolics were higher in ispaghula. The sum of bound and free total phenols was higher in cocoa than ispaghula (approximately 10 fold). Urinary, faecal SCFA were not measured as they are not validated to represent in-vivo production. Conclusion: there is a strong inhibition of phenolic acid production from polyphenol by the fermentable fibres and their metabolites. This inhibition is stronger in-vivo than in-vitro for ispaghula, which may reflect the longer interaction time in the colon and potential small bowel interaction. The production of SCFA from fermentable fibres was not inhibited by the polyphenols or their metabolites. These interactions need to be considered when assessing the bioavailability of phenolic acid production and their potential health benefits.

Background Artificial nutrition and hydration (ANH) is the provision of nutrition and/or fluid via artificial means into the gut or into the blood. Decisions about ANH can be difficult and emotive. Dietitians assess patients to recommend whether ANH is indicated, and manage patients once ANH has begun. This research aimed to give voice to dietitians’ experiences of their involvement in decision-making about ANH, by exploring dietitians’ perceptions of their role and exploring how different contexts influenced dietitians’ experiences of decision-making about ANH. Methods Sixteen dietitians were interviewed twice for a qualitative phenomenological study which explored their experiences of decision-making related to ANH. The transcribed interviews were analysed using an interpretive phenomenological framework. Findings Three themes emerged from the data: ‘so much more than just deciding on a feed’; ‘wanting to be heard’; and ‘the emotional roller coaster’. Professional autonomy, being recognised as an expert, and wanting to be involved in decisions were important for all participants. Some participants were involved in decision-making and some implemented decisions made by others. When their professional expertise was not recognised, the emotional experiences were negative. Emotional labour and moral distress were displayed by some. Professionalism was shown by speaking out and acting as moral agents. Some believed that their emotions should not be shown. None of these experiences have been reported by UK dietitians before. Conclusions This study contributes rich and complex new knowledge to the understanding of dietitians’ experiences. These experiences included strong and complex emotional responses and correspondingly complex strategies to cope, which enabled dietitians to protect themselves, colleagues, and patients. Professional identity and challenges to their professionalism were also important aspects of their experiences. This research has expanded the concept of professionalism within dietetics. Implications for practice include the need to develop emotional intelligence and for dietitians to raise their profile by building strong collaborative partnerships with healthcare staff to facilitate their professionalism. Guidance on ethical decision-making for dietitians is required.

Survivors of critical illness suffer from a range of problems affecting physical, psychological and social well-being (Needham et al 2011). Weakness, fatigue and malnutrition are highly prevalent during the months following a critical illness. Few studies have systematically and comprehensively explored the factors that influence nutritional recovery or ways to overcome them. The aim of this study was to provide a comprehensive understanding of the factors influencing nutritional recovery, and the relationship between them, in post intensive care (ICU) patients. A model of care was then developed to improve current management of nutrition for patients recovering from critical illness. Grounded theory methodology was used with a mixed method research design. Nutritional status and intake were assessed on discharge from ICU and at three months post ICU discharge. The process of nutritional recovery during the first three months post ICU discharge was explored from a patient perspective and at the level of ward organisation of care, through observation of practice and interviewing patients and staff. Seventeen patients, who had required greater than 48 hours ventilation, were recruited on discharge from the ICU. On transfer to the ward 9 of the 17 patients were assessed as well-nourished and 8 were malnourished using Subjective Global Assessment. At three months post ICU discharge 14 patients were followed up (1 lost to follow up, 1 incapacitated following illness and 1 went overseas). Seven of these were classified as well-nourished and the other 7 were malnourished. Patients universally failed to meet their nutritional targets during their ward stay and although intakes had improved by three months post ICU discharge, the majority of patients were still not achieving their nutritional requirements. Qualitative data revealed that patients' nutritional intake was influenced by interrelated system breakdowns during the recovery process; this emerged as the overarching core theme. Three sub-themes were ‘experiencing a dysfunctional body’, ‘experiencing socio-cultural changes in relation to eating and ‘encountering organisational nutritional care delivery failures’. This study identified connections and interrelations between these concepts and provided new insights into the factors that influence the nutritional care of post ICU patients. In order to optimise nutritional rehabilitation in this patient group a model of care has been developed which addresses the identified organisational and patient related factors that were shown to influence the nutritional recovery of patients after critical illness. This nutritional strategy will need to be evaluated in clinical trials or quality improvement programmes.

Epidemiological studies have suggested associations between the consumption of plant foods and beverages, especially those rich in phenolic compounds, and the prevention of chronic diseases, and there is a growing evidence indicating that these dietary phytochemicals are involved in enhancing long-term health. The antioxidant capacity of these compounds appears to be, at least in part, responsible the reduction of certain oxidative stress pathologies. Common fruits, vegetables and nuts available in supermarkets in Scotland were screened to identify products that are rich in phenolic antioxidants. The selection of products analyzed was based on their availability in local supermarkets. Two different assays were used to assess antioxidant acitivity, electron-spin resonance spectroscopy (ESR) and Ferric Reducing Antioxidant Potential (FRAP). Total Phenolics content (TPC) was also quantified using the Folin-Ciocalteau assay. Due to interest in the Zutphen study in the early 1990's that showed that dietary intake of flavonols was inversely correlated with the incidence of coronary heart disease, the analysis of quercetin, isorhamnetin and kaempferol was done. There were differences of up to 758-fold in the total FRAP antioxidant capacity (AOC) of the individual products. Those especially rich in antioxidants included peanuts, almonds, broad beans, blueberries, raspberries, strawberries and purple broccoli. The vitamin C and flavonol concentrations were not correlated to the AOC. The results obtained by FRAP and ESR are significantly high correlated. There was no correlation between FRAP and flavenols. The data obtained in this study were used in a separate collaborative investigation that is not included in this thesis to evaluate the overall intake of antioxidants in the UK. Berries were selected for further analysis because they constitute a group of fruits with very high AOC. Raspberries (Rubus idaeus), blueberries (Vaccinium corymbosum), blackcurrents (Ribes nigrum), redcurrants (Ribes rubrum) and cranberries (Vaccinium oxycoccus) were included in the study. A detailed analysis revealed not only the nature and concentration of individual phenolic compounds but also their contribution to the overall antioxidant activity of the berries. The importance of such a detailed quantitative and qualitative analysis of phenolics from any specific source is considerable because their chemical structure has an impact on the absorption and bioavailability although the mechanisms involved are still unclear. Changes in the chemical structure of dietary phenolics following ingestion by humans and animal models cna in part help unravel this puzzle. The phenolic compounds present in major quantities are principally responsible for the antioxidant capacity in blackcurrants and blueberries were the anthocyanins. Blackcurrants contained large amounts of anthocyanins (5446 nmol/g) and vitamin C (2328 nmol/g) and had the highest AOC of the five berries. Blueberries were the second highest with anthocyanins levels of 4908 nmol/g but the sample study contained no vitamin C. Raspberries, redcurrant and cranberries contained anthocyanins but in lower amounts. Ellagitannins such as sanguiin H-6 were responsible for 58 per cent of the AOC of raspberries. Flavonols (16 per cent) and vitaimin C (23 per cent) were important antioxidants in cranberries while in redcurrants a number of unidentified peaks were the major contributors of the AOC (33 per cent) along with 28 per cent from anthocyanins. Raspberries were chosen for an intervention study with human subjects. The bioarailability of anthocyanins, ellagitannins and ellagic acid in raspberries was investigated. Plasma and urine were collected from six healthy human subjects after ingestion of 300 g of raspberries. Three healthy volunteers with an ileostomy were included in the study, providing ileal fluid, plasma and urine at different time points for 24 h after consuming a 300 g raspberry portion. All samples were analyzed using HPLC-PDA-MS[superscript 2]. No anthocyanins, ellagitannins or their metabolites or breakdown products were detected in the plasma of any of the volunteers. Eight of the anthocyanins identified in raspberries were detected and quantified in ileal fluid in their native form. They reached a maximum level of 36.5 per cent of intake in samples collected 0-4 h after supplementation and after 24 h there was an overall anthocyanin recovery of 39.6 per cent. With regard to ellagitannins, 16.3 [.moles] of sanguiin H-6 was detected in ileal fluid after 0-4 h with 26.2 per cent of intake being detected over the 0-24 h collection period. No lambertianin or sanguiin H-10 were found. The levels of ellagic acid in 0-24 h ileal fluid corresponded to 239.4 percent of intake 24 h with 162.9 per cent being collected 0-4 h after ingestion. This coincided with the peak levels of ellagic acid in urine although the levels, 13.1 nmoles and 33.6 nmoles for non ileostomy and ileostomy volunteers respcectively, were low and equivalent to no more than 0.4 per cent of intake. No ellagic acid or metabolites were detected in plasma at any time point. This study, therefore, found a low absorption and excretion of anthocyanins and ellagic acid in human subjects. The ca. 40 per cent recovery of these compounds in ileal fluid indicates that in healthy subjects with a colon substantial quantities pass from the small to the large intestine where they will be cataabolised by the gut microflora. The present study also investigated the distribution of anthocyanins, ellagitannins and their metabolites in the gastrointestinal tract and their presence in other tissues of rats fed 2.77 mL of raspberry juice by gavage. One hour after feeding the ellagitannins, sanguiin H-6 and lambertianin C had disappeared with only traces of ellagic acid being detected in the stomach. Up to 2 h after supplementation there was a very high recovery of unmetabolised anthocyanins, principally cyanidin-3-sophoroside, cyanidin-3-(2[superscript G]-glucosylrutinoside) and cyanidin-3-glucoside, a they passed from the stomach to the duodenim.jejunum and ileum. After 3 h, less than 50 per cent was recovered, after 4 h this declined to 11 per cent of intake and after 6 h only 2 per cent remained. Only trace quantities of anthocyanins were detected in the caecum, colon, and faeces and tehy were absent in extracts of liver, kidneys and brain. These findings imply anthocyanins are poorly absorbed and that which does occur takes place before ileum, in keeping with evidence indicating that the stomach and jejunum are sites of anthocyanin absorption in mice and rats. Because anthocyanins are poorly absorbed substantial amounts pass from the small to the large intestine where their rapid disappearance suggests they are degraded by faecal bacteria.

The objectives of the studies presented in this thesis were to identify and quantify the major phenolic components of red wine and to assess the contribution of individual compounds to the total antioxidant activity. Red wines were analysed for their phenolic content and antioxidant activity using a range of complementary techniques including HPLC-tandem mass spectrometry, preparative HPLC and HPLC with an on-line antioxidant detection system. HPLC-MS2 revealed the presence of a number of flavoids and phenolic compounds of which 19 were identified, with gallic acid, the flavin-3-ols and anthocyanins being the most abundant. Preparative HPLC was used in an effort to isolate the antioxidant components in red wine and 60 aliquots were collected. Each wine fraction was analysed for total phenolics, catechins and anthocyanins, while antioxidant activity was determined by electron spin resonance spectroscopy (ESR). The preparative HPLC step did into completely separate the compounds in red wine, nonetheless increasing antioxidant activity was highly and significantly associated with total phenolics (r = 0.816, P < 0.001) and total catechins (r = 0.188, p = 0.151). HPLC with an on-line antioxidant detection system was subsequently used to separate and identify red wine phenolics. The findings from this study indicate that gallic acid, (+)-catechin, (-)-epicatechin, and procyanidin dimersB1 and B2 were the major in vitro antioxidants identified in red wine. Collectively, the flavin-3-ols contributed > 50% of the total antioxidant capacity of each wine, while gallic acid contributed between 24-44%. The flavonols and anthocyanins were minor antioxidant components in red wines. By combining HPLC, MS2 and on-line assessment of antioxidant activity, the major phenolic compounds present in red wine were identified, together with their direct contribution to the total antioxidant activity.

No description available.

No description available.

No description available.

No description available.