Nutrition Summit part 2: Micro and phyto nutrients

Vit D & Phytonutrients

resveratrol

Key points:
- Vit D2 is the synthetically available substitute for vit D3 which is found in foods and is dependant on sunlight exposure. 
- A lack of Vit D results in inadequate mineralisation of bone and osteomalacia in older people, but is also associated with diabetes, Rheumatoid Arthritis, fractures and muscle weakness. 
- Links with movement disorders and neurodegenerative conditions could be caused by as well as linked to the causes of vit D deficiency, as people with movement disorders such as MS or Parkinson's are less likely to get enough sun exposure due to limited mobility.
- When sun exposure is low, and skin tone is darker, it is important to supplement vit D in the diet with foods such as wild salmon, herring, mackerel, mushrooms and tinned tuna. 
- The Vit D produced by the skin during sun exposure lasts longer and is carried differently in the body, so it is important but needs to be balanced with the risks of sun exposure. 

Phytochemicals & Phytonutrients
- Phenolics are a type of phytochemical which are very useful in plants' response to stressors and typically produce colour as an evolutionary strategy: e.g. berries and coffee. 
- Absorption & bio-availability of phenolics varies greatly between people as 99.9% of the absorption takes place in the colon where they are transformed by gut enzymes to metabolites. 
- Colon gut phenotypes (metaphenotypes) are important in defining whether an individual is able to absorb the phenolics. 

** Hence, to test the effect of phenolics in 'superfoods', the metabolites need to be investigated, as the whole phenolic molecule is not going to be reaching in vivo cells! 

For example, research pointing to the benefits of 1000 micrograms of resveratrol on your lymphocytes is not reflective of what metabolites of resveratrol will be reaching the lymphocytes in a person**

- As polyphenols are converted by the microbiome, reducing diversity of the gut bacteria will reduce the microbiome's ability to convert them into beneficial phytonutrients. Thus disrupting the microbiome by taking antibiotics when they aren't necessary, reducing the variety of foods consumed with a restricted diet or people who suffer with persistent colon diseases cannot benefit from the benefits of consuming polyphenols.

** In addition, consuming phenol containing foods can change the microbiota! So consuming a variety of phenol containing fruits and vegetables could create a better microflora to promote lean mass instead of obesity. **

International Summit on Medical Nutrition Education and Research

INTRODUCTION & FOUNDATION

The summit took place at the University of Cambridge, England earlier this summer covering a variety of topics from the focus on macronutrients to nutrition and workplace wellbeing. The sessions were designed to allow for debate and knowledge exchange, which led to very interesting discussions in the captive and diverse audience. 

Some key issues arose, listed below:

What are the priorities for nutrition research?

How are dietary guidelines reflecting current research?

How do we translate bonafide information with an evidence based framework to give people appropriate information and avoid myths and fads from being adopted as facts?

Some myth busting took place at the summit, the most interesting of which to me where:

  1. All calories are not created equal - calorie counting is not the most effective way to consider individuals' energy balance. 
  2. Fructose has a much higher thermic effect than glucose, making fruit a better source of sweetness to maintain a healthy weight.
  3. Homeostatic control of energy intake is overridden by the hedonic control activated by our taste receptors in response to the activation of our brain's 'reward centres'.
  4. The ratio of lean mass to fat mass is more important to body mass alone. 
  5. Resting energy expenditure levels vary greatly between people, especially obese and non-obese. We also need to consider genetic differences (for e.g. APOA2 variance).
  6. The majority of the human population does not posses the gain of function gene mutation for lactase persistence, which is a difference of just 1 bp, making their intestinal enterocytes unable to express lactase after weaning in infancy. This means that consuming milk and milk products into adulthood is not natural for a lot of the world's populations. 

Interestingly, the impact that exercise has on energy expenditure extends to beyond the time of exercise itself - post-workout burn is significant and adds to the beneficial effects of exercise.

The Glycaemic Index and fat consumption were also discussed, with the messaging surrounding both scrutinised. The GI is a useful tool for determining glucose content, however it does not take into account other sugars such as fructose and lactose, making it less useful for real food and complex meal measurement. 

Dietary fats are a hot topic of debate in the press and popular media at the moment, but what was clear from the summit is that it depends on the type and source of the fats we are referring to. Certainly, animal derived fats are not beneficial to health, whereas olive oil and other polyunsaturated fats have been proven to be beneficial (see Wang et al in JAMA

Whilst our resting metabolic rate undergoes small and slow variances throughout the lifecourse, we can boost our energy expenditure and increase our lean muscle mass through daily activities and exercise to maintain a healthy body weight. 

Daily Energy Expenditure

Speakers: Prof Sumantra Ray, NNedPro, Prof Luc Tappy, University of Lausanne, Prof Martin Kohlmeier, UNC School of Medicine & Public Health, Prof Caryl Nowson, Prof Daniele del Rio, University of Parma, Andre Laperrier and Dr Daniela Beltrame, Dr Rachel Pryke, Dr Minha Rajput-Ray.

WHO Regional Office consultation on Integrated Health Service Delivery

Strengthening people-centred health systems: a European framework for action on integrated health services delivery

Thanks to the Erasmus mobility training scheme, I was invited to attend the WHO Regional Office’s consultation of the European framework for action on Integrated Health Service Delivery, along with some colleagues from the WHO CC and representatives from all over the region.

The consultation began with the ideological discussion of what the ‘ideal health system’ would consist of. The factors which came up from several countries, and remained a priority throughout the consultation, were:

- Positive connections between health and social services

- Continuity of care with a life-course approach

- Health Promotion

- Overcome silo practices

- Excel in not only leadership, but also admin and management.

People are the centre of the new framework, looking to drive health systems according to their needs and preferences, not only in what needs to be done but also how it is executed.

A new definition of what being healthy means offered the possibility to reflect on not only physical and emotional wellbeing, but also on individuals’ ability to adapt and self-manage. Integrated care is the future of health systems because it incorporates the health management and prevention of disease alongside treatment of illness.

Professional training and ease of information sharing is key in being able to provide an infrastructure fluid enough to cater for modern populations. The medical curriculum and training need some careful attention in order to ensure that medical care is aligned with people’s needs and preferences, moving away from the paternalistic model of care.

Technology plays an important role as a tool for empowerment, but it is not the answer. People are at the centre of the evolution of healthcare, and with them their carers, family and environments. The role of nurses in providing continuity of care both in the hospital setting and in the community was a topic which came up time and again from all member states: a fascinating presentation was given by an Irish group of nurses who provide at home care for their patients who would rather be home than in a hospital bed. It is clear that there is so much to be learned from with Europe, it is vital that the information and learnings are shared.

Enough pilots have taken place in the EU now to highlight that integrated care works for patients and care givers, what is needed now is disruptive innovation to ensure that integrated care becomes the norm. Co-creation at local level, following an established framework proposed by the WHO can allow for this.

The key elements of the framework proposed are outlined below:

The European Framework for Action on Integrated Health Services Delivery

 

The consultation allowed for individuals from all member states to discuss the framework, exchange ideas and share their respective countries’ challenges and successes, highlighting the importance of collaboration to avoid ‘reinventing the wheel’.

The experience opened my eyes to how research and theory can be transformed and applied to practice in order to improve population health and care delivery. It highlighted the importance of our department and our centre’s work to build collaborative relationships in order to learn and communicate effectively across all disciplines.

More detailed information can be found at: http://www.euro.who.int/en/health-topics/Health-systems/health-service-delivery/publications

1st International Conference of Primary Care & Public Health Report

The 1st International Conference of Primary Care and Public Health, 3rd International Congress of Person Centred Medicine,  was held at Imperial College London, United Kingdom, from the 29th to 31st of October 2015. 

 

The conference covered five central themes: Primary Care in the 21st Century, Ageing and Ageism, Children and Adolescences, Integrated Care, and Public Health in Primary Care. The programme comprised of keynote lectures, brief oral presentations and posters, featuring prominent figures as well as members of local communities from numerous global settings, including the UK, US, Middle East and Mauritius. Over 250 individuals attended from countries all over the world.

The importance of this conference was laid out in the opening remarks from Imperial College President Alice Gast together with Professor James Appleyard, President of the International College of Person Centred Medicine, Dr Derek Bell of NIHR CLAHRC NWL and His excellency Professor Ala Alwan Eastern Mediterranean Regional office for the WHO. The trans-boundary issues which threaten health warrant an international response, and events such as this conference are crucial for knowledge exchange and the planning of action.

A summary of the calls to action from the conference below and more information from each speaker can be found on the conference website www.icpcmlondon2015.org

i.Establish a shared goal of improvement in the health of the population through person and people centered care, taking into account biomedical, socio-cultural, psychological and spiritual elements that form part of the whole person and the demography of diverse populations.

ii.Primary care and Public health professionals shouldcreate and enhance local links and build relationships with each other and local stakeholders.

iii.Prevention programmes at all levels should be fully integrated within primary care.

iv.Create health care databases and identify new data sets, creating from these a consolidated information system a platform for sharing and displaying local population health data that could be used by communities.

v.To create common research networks to foster and support the integration of primary care and public health to improve population health.

vi.To develop multidisciplinary educational programs developing the curriculum and clinical experience that ensures the integration of primary care and public health.

vii.That primary care should be delivered within the social and occupational network of each person, alongside the provision Social Care and recognized as being part of a complex adaptive system withmany components that reciprocally influence one another. 

Primary Care in the 21st Century

This theme was explored throughout the conference both in addressing the complexity of a world in which displaced people’s health needs require action and in widening our understanding of what it means to be healthy. From Professor Ted Epperly’s insight to the American Health model and how our spending on medical services is not in line with what maintains health, through to Professor Marisa Papaluca’s clear explanation of how Regulators are driving innovation in providing personalised medicines. The challenges and opportunities for primary care and achieving universal health coverage in the Gulf Cooperation Countries were succinctly described by Professor Tawfik Khoja and His Excellency Anil Gayan for the setting of Mauritius.

Ageing and Ageism

The fact that the world’s population is ageing and the need to account for increasing longevity is widely acknowledged, exploring attitudes to ‘casual ageism’ both in the elderly and the often overlooked adolescent group was integral to Professor Jon Snaedal’s talk. Professor the Baroness Ilora Finlay brilliantly summarised the importance of palliative care and highlighted the lack of focus and expertise which health systems provide for end of life care. The one time all people will require healthcare is at the time of death so it is important to focus on the end as well as the beginning.

Childhood and Adolescence

Sir Al Aynsley-Green delivered a powerful talk on the most significant and influential period of an individual’s life: childhood. With changing population demographics it is more important than ever to invest in and nurture children. The importance of person centred medicine was emphasised by Professor John Cox with particular regards to perinatal depression, an issue which can have enduring effects on families involved. Professor Mitch Blair, in his inspirational talk, stressed the need for doctors to pay attention to the crucial first years of life and seeing the patient in the wider context of family, school, and immediate community circumstances.

Integrated Care

Professor Azeem Majeed raised important points about the need for research and innovation in primary care, and explained the proposals for family practitioner led and hospital led integration. Professor the Baroness Sheila Hollins spoke compassionately about the need for person centred medicine and the imperative for care givers to work with the patient and their family and loved ones, to see the person behind the disability. Using integrated care for the treatment of atrial fibrillation was informatively described by Dr Abdul-Majeed Salmasi.

Public Health in Primary Care

Building health systems on a foundation of primary care and public health is vital for universal health coverage and improved population health. Professor Salman Rawaf spoke passionately about how crucial primary care is in order to tackle the growing prevalence of non-communicable disease and for ensuring healthcare is family and person orientated. The importance of primary care in public health was stressed in a video message from Professor Ala Alwan, director of EMRO, who highlighted that primary care is at the core of the region wide priorities for EMRO, including health system strengthening, addressing non-communicable disease, promoting health security and building capacity.

A Report from Dr Margaret Chan's Lecture in London

MeetingDrChan

MHRA Annual Lecture Report

Speaker: Dr Margaret Chan, Director General, WHO

In occasion of the MHRA’s 11th annual lecture, Dr Margaret Chan was invited to give a lecture, which she titled “From healthcare products to health and reliance: the expanded role of regulatory authorities in an era of global health perils.”

Sir Michael Rawlins introduced Dr Chan, describing her impressive experience, from medical practice in Australia to Director of Health of Hong Kong, and now in her second five-year post as Director General at the WHO. Forbes named her the 30th most powerful woman in the world.

She gave an eloquent, precise and targeted talk with some very strong messages regarding Health Systems preparedness, antimicrobial resistance, collaborative working, the power of vaccines, and the fundamental priority that is prevention.

On the issue of healthcare budgets

“When the need to cut costs takes precedence over the duty towards the public’s health, disaster like the Flint Water Crisis happen”. Dr Chan’s opening message was clear with regards to the important role that regulatory bodies and the WHO hold in safeguarding population health, where other interests may interfere.

Dr Chan spoke of the unfeasibility of the current response model, in which pharmaceutical companies are expected to burden the cost and risk of rapid research and development to respond to global crises like Ebola. There was a call for a new financing model that brings everyone together to work ahead of future emergency outbreaks and helps fund clinical trials. This is a message that has been proposed by Roger Stein, you can see his proposition here for TED Talks. The world is woefully underprepared for high impact pandemics like Ebola and we must adapt quickly in order to respond to these threats in an increasingly globalised population setting.

Dr Chan called for innovation and a review of the status quo. Aiming for the moon when health budgets are shrinking, calls for approaches that use existing resources more wisely.

The role of regulators in creating credibility

Public confidence in medicines translates to confidence in the national health services. Much of the work that regulators do is silent and has a protective nature, it is absolutely crucial that the public can remain confident in regulators’ role especially as counterfeit and harmful drugs make it onto the market due to criminal greed.

Vaccines are the future

“Vaccines are the most cost effective interventions, especially in the face of a post-antibiotic era”. Dr Chan made many references to the threat of antimicrobial resistance and how close we are to being in a position where simple infections could kill, just how they did pre-modern medicine. The fight against antimicrobial resistance is complex and involves many sectors including the farming industry, primary and secondary care, and crucially, patient information and cultural shifts in different contexts.

However, instead of focusing on the importance of continued R&D for new antimicrobials, Dr Chan spoke of the huge potential which vaccines hold in helping move modern medicine forward. She called once more for a new type of funding, where all countries contribute to speed up production whilst maintaining high standards, for which she praised the UK’s National Institute of Biological Standards and Control (NIBSC).

How crisis builds collaboration

 “The collaborative mechanisms that brought scientists, national health officials, pharmaceutical companies, and regulatory authorities together during the Ebola response establish pathways that can expedite product development during other health emergencies.” New pathways were forged during the Ebola crisis, the blue print of which is now helping the world to face the threat of the Zika virus. Where crisis happens, it is important to learn and implement real changes to keep populations safe and ensure information is shared efficiently to help contain outbreaks.

Unexpected threats highlight our weaknesses

“The refugee crisis has shattered the notion that far away wards don’t have an impact at home… The Ebola outbreak has shattered the notion that exotic diseases can’t cross our borders.” Dr Chan reiterated the importance of strong health systems in their ability to respond. When I told her about the health systems development work we do at Imperial WHO CC in the primary care and public health department, she was enthusiastic to point out the importance of health systems development and happy to hear that we are proactive in creating frameworks with which people can strengthen their own.

Who would have thought a mosquito bite could lead to neurological defects? In the 21st century, our response is still not fast enough but by collaborating and learning from every event, systems and response teams can be created which allow for progress and faster reactions whenever there is a need. As an example, Dr Chan quoted her experience in Brazil with Zika, saying that their ability to respond so quickly was down to their health system development.

Global warming is set to hit the countries who least contributed to it, in the most severe way.

Dr Chan spoke briefly but pointedly on the very real health impact which global warming is having on the world’s population, highlighting especially the plight which less developed countries, who contribute less to Global Warming itself, face in being the countries which face the direst consequences with the least resources to keep their populations safe.

Again, a collaborative global effort needs to be made not only to mitigate the damaging effects which global warming is having on the worlds’ most vulnerable populations, but also to prepare adequate responses for when crises do happen.

Antimicrobial resistance needs a cross sectorial approach

Dr Chan expressed her thanks to Dame Sally Davis’ work on focusing the need for the agricultural sector to act in diminishing antimicrobial resistance. Overuse of cheap, widely available antibiotics in the farming industry to be able to factory farm animals in confined spaces with the end goal to increase their mass and prevent infection within the farms, has caused a huge influx of antimicrobials to our food chain. 75% of new diseases come from animal sectors, and the agricultural use of antibiotics has a well-established link with antimicrobial resistance in humans.

The WHO working together with the FAO and other agencies need to address these issues as a matter of urgency. The December 2015 review on antimicrobial resistance has more in-depth information on the matter, and why it is a priority.

Sustainable Development Goals by 2030

Dr Chan spoke of the new sustainable development goals and the big aims of eliminating AIDS, TB and Malaria, and ending preventable childhood and maternal deaths. Again, Dr Chan highlighted that to ‘reach for the moon’ on shrinking budgets, innovation is key. She made reference to an exciting upcoming project in Rwanda, where drones will be used to bring medical supplies to those in most need. By working together, British architects, Rwandan ministers and global partners can make bringing medical supplies to remote areas a reality.

WHO’s message to the population: Prevention. Prevention. Prevention!

When asked what the one takeaway message is from the WHO, Dr Chan didn’t hesitate to clearly state: “Prevention! Prevention! Prevention!” Health literacy is key and more focus must be placed on building capacity for healthy lives. The WHO will be announcing a renewed focus on the battle against childhood obesity and again reiterated the SDG of improving maternal health, because, after all, having a good start in life is always a good start for life.

You can read the MHRA’s official report on their website: https://www.gov.uk/government/news/dr-margaret-chan-delivers-mhra-annual-lecture