Iron deficiency in older people: interactions between food and nutrient intakes with biochemical measures of iron; further analysis of the National Diet and Nutrition Survey of people aged 65 years and over

OBJECTIVE

To quantitatively investigate relationships between food consumption, nutrient intake and biochemical markers of iron status in a population of older people.

DESIGN

National Diet and Nutrition Survey: cross-sectional survey of a nationally representative population of men and women aged 65 y and over.

SETTING

Mainland Great Britain

SUBJECTS

1268 participants (651 men and 617 women) who provided both dietary intake and blood biochemistry. 986 were living in private households and 282 were living in residential or nursing homes.

RESULTS

Intakes of alcohol, vitamin C, protein, haem and non-haem iron and fibre were positively associated with iron status. Consumption of meat, poultry and fish were positively associated with six measures of iron status, and vegetables and potatoes with four measures. Calcium, dairy foods and tea generally had a negative association with most measures of iron status.

CONCLUSIONS

A varied diet containing meat, poultry and fish, vegetables and fruit, with a moderate intake of alcohol will make a positive contribution to the iron status of elderly people.

Micronutrients: highlights and research challenges from the 1994-5 National Diet and Nutrition Survey of people aged 65 years and over

The aims of the National Diet and Nutrition Survey series are summarized, and the new National Diet and Nutrition Survey of people aged 65 years and over is explored, with particular emphasis on micronutrient intakes and status indices. Mean nutrient intakes were generally satisfactory for most micronutrients, but intakes of vitamin D, Mg, K and Cu were low. Intakes of vitamin D were far below the reference nutrient intake for people aged 65 years and over, and there was also biochemical evidence of vitamin D deficiency, for 8% of free-living and 37% of institution participants, attributed partly to limited exposure to sunlight. A substantial proportion of people living in institutions had inadequate biochemical status indices, notably for vitamin C, Fe and folate. Relationships between intake and status were close for vitamins. Mineral intakes did not correlate well with currently used status indices. Some intakes and indices, especially those of vitamin C, carotenoids, Na and K, were strongly correlated with socio-economic status and with north-south gradients in Britain. Future research challenges should address the functional and health significance of low intakes and sub-optimal biochemical indices for certain micronutrients, especially for people living in institutions; the shortcomings of mineral status indices especially as indicators of mineral intake; the social and geographical inequalities of micronutrient intakes and status, and why micronutrient status deteriorates with increasing age. The answers to these questions will help to define the characteristics of nutritional risk for older people in Britain, and to clarify future needs for education and intervention.

Relationship between cigarette smoking and nutrient intakes and blood status indices of older people living in the UK: further analysis of data from the National Diet and Nutrition Survey of people aged 65 years and over, 1994/95

OBJECTIVES

To examine the relationship between cigarette smoking and a range of nutrient intakes and blood status indices in older people.

DESIGN

National Diet and Nutrition Survey: cross-sectional survey of nationally representative sample of people aged 65 years and over.

SETTING

Mainland Britain during 1994/95.

SUBJECTS

1191 people (619 male, 572 female) aged 65 years and over, of whom 920 were living in private households and 271 were living in institutions.

RESULTS

Cigarette smoking was inversely correlated with intakes of antioxidants and other micronutrients after adjustment for age, sex and domicile. Cigarette smoking was also inversely correlated with a number of antioxidant micronutrient status indices including plasma vitamin C and the carotenoids (but not vitamin E status indices), and with other micronutrient status indices, including plasma pyridoxal phosphate, red cell and serum folate, after adjustment for age, sex, domicile and the corresponding nutrient intake. Previous cigarette smoking or cigar/pipe smoking was not generally associated with lower nutrient intakes or status indices, however, both current and previous cigarette smoking was associated with increased concentrations of acute phase indicators. Further adjustment for total energy intake and/or sociodemographic, health and drug usage variables attenuated only a few of the associations observed.

CONCLUSION

Older people who smoke cigarettes are at increased risk of suboptimal antioxidant and other micronutrient intakes and status, but the lower intakes found in cigarette smokers only partly explain their reduced blood indices.

Plasma total homocysteine response to oral doses of folic acid and pyridoxine hydrochloride (vitamin B6) in healthy individuals. Oral doses of vitamin B6 reduce concentrations of serum folate

Plasma total homocysteine response was compared in four groups of healthy individuals given orally divided doses of vitamin supplementations for a duration of 5 weeks. The vitamin supplements; A, 0.3 mg folic acid; B, 120 mg vitamin B6; C, combination of 0.3 mg folic acid and 120 mg vitamin B6 or D, 0.6 mg folic acid reduced the concentrations of plasma total homocysteine 20, 17, 32 and 24%, respectively. However, the intergroup comparisons did not show a significant difference in the effects of vitamin supplements. Multivariate analysis with correction for differences in pre-supplement values indicated a significant effect of vitamin B6 supplementation on plasma total homocysteine and serum folate. Our data show that plasma total homocysteine concentrations are reduced with low to medium divided doses of folic acid alone or in combination with vitamin B6.

Plasma pyridoxal phosphate and pyridoxic acid and their relationship to plasma homocysteine in a representative sample of British men and women aged 65 years and over

Concentrations of pyridoxal phosphate and pyridoxic acid were measured in fasting plasma samples from British men and women aged 65 years and over, participating in a National Diet and Nutrition Survey during 1994-5, selected to be representative of the population of mainland Britain. In this population, the concentration of pyridoxal phosphate declined, whereas pyridoxic acid rose, with increasing age and frailty; however, both status indicators were strongly and directly (with a positive coefficient) correlated with estimates of vitamin B6 intake. This was little affected by the inclusion of food energy and protein intakes in the model. Forty-eight percent of the participants living in the community and 75% of those living in institutions had plasma pyridoxal phosphate concentrations below a range considered normal from other studies. In a univariate regression model, plasma pyridoxal phosphate concentrations were inversely correlated with plasma homocysteine concentrations, consistent with the hypothesis that vitamin B6 status may influence plasma homocysteine levels, and hence vascular disease risk. However, this relationship was partly attenuated in a multiple regression model including age, sex, domicile and biochemical status indices, including those of folate and vitamin B12. There was evidence that plasma pyridoxal phosphate was sensitive to metabolic conditions associated with inflammation and the acute-phase reaction, and that plasma pyridoxic acid was sensitive to renal function. Thus, neither index is an ideal predictor of vitamin B6 status in older people, unless these confounding factors are allowed for. Since poor vitamin B6 status may have health implications, e.g. for immune function, cognition, and for essential intermediary metabolic pathways in older people, it needs to be investigated as a possible public health problem.

Vitamin D: seasonal and regional differences in preschool children in Great Britain

OBJECTIVES

To examine seasonality of 25-hydroxyvitamin D (25OH-D) levels in British preschool children and the effect of vitamin D supplementation on this.

DESIGN

The National Diet and Nutrition Survey of children aged 1.5 4.5 y in Britain during 1992-3 measured dietary intakes and blood status indices, including those for vitamin D, during all four seasons. The present study addresses the seasonal dependence of the relation between vitamin D intake and status.

SETTING

100 randomly selected postcode sectors throughout Britain, whose locations were classified as (a) Scotland; (b) Northern England; (c) Central, Wales, South+SW; (d) London+SE.

SUBJECTS

Of 1859 whose parents or guardians were interviewed, 1675 provided a weighed diet estimate, and blood vitamin D status (25OH-D) was measured in 756, with approximately equal numbers in each season.

RESULTS

Vitamin D status is highly dependent on season: moreover, the relation between vitamin D intake and status is also seasonally dependent, being strong in the winter and negligible in the summer. During the winter, those children who had relatively low 25OH-D concentrations generally were those not receiving vitamin D supplements. Vitamin D intakes and supplement use were lower in the north than in the south of Britain.

CONCLUSIONS

For British preschool children, dietary vitamin D is of much greater importance in the winter than in the summer. There is evidence of regional inequality, with lesser use of supplements in the north. Supplements are needed in the winter, to achieve satisfactory vitamin D status and minimise the risk of rickets and of poor bone health, especially in high-risk groups.

Use of medicines by older people in a large British national survey, and their relation to vitamin status indices

OBJECTIVE

To describe the extent of use of medicines by older people living in Britain, and to explore relationships with vitamin status indices.

DESIGN

The National Diet and Nutrition Survey of people aged 65 years and over collected data from a British sample during 1994-95. The present study has made novel use of it, to relate medicine use with biochemical indices of vitamin status.

SETTING

Eighty postcode areas, selected randomly from mainland Britain.

SUBJECTS

1506 people, 65 years and over gave information about use of medication, and a 4-day weighed food record. Three-quarters gave blood for status indices.

RESULTS

78% of those living in the community and 93% of those in institutions were using medication. Certain vitamin status indices: plasma retinol, erythrocyte folate and riboflavin, paradoxically suggested better status in users than in non-users of antihypertensive, gastrointestinal, central nervous system, corticosteroid or diabetic drugs. There was evidence of a link with renal insufficiency, especially for plasma retinol, but neither this nor increased nutrient intake, acute phase effects or haemoconcentration could explain the paradoxical associations.

CONCLUSIONS

Caution is needed in interpreting certain vitamin status indices, especially in older people who are extensively using medicines. New vitamin indices are needed, to avoid confounding interferences.

A simple, sensitive and reproducible assay for pyridoxal 5'-phosphate and 4-pyridoxic acid in human plasma

We describe a procedure for the measurement of pyridoxal 5'-phosphate and of 4-pyridoxic acid in human plasma samples. It is based on the conversion of pyridoxal 5'-phosphate to 4-pyridoxic acid 5'-phosphate by cyanide in alkaline medium, followed by a high pressure liquid chromatographic separation, with fluorescence detection at acid pH. The assay is robust, sensitive, linear over a wide range, reproducible, and simple to perform. Samples stored at -80 degrees C are stable. Satisfactory agreement was obtained with results from the tyrosine decarboxylase-based assay for pyridoxal 5'-phosphate, in two other laboratories. Plasma samples from a National Survey of older British people were analyzed, and reference intervals for plasma pyridoxal 5'-phosphate intervals were derived. From the lower 2.5 percentile of the reference group, taken as the lower cut-off of the normal range, ca. 20% of elderly men and 11% of elderly women in the UK showed evidence of biochemical deficiency.

Diagnosis and detection of vitamin deficiencies

Vitamin deficiencies can be detected in several ways, none of which is entirely unambiguous. Evidence of several types is, therefore, required. For instance, it is rare for clinical signs to result from a single cause, except in controlled experiments. Natural diets are rarely deficient in only a single nutrient, and individual requirements vary considerably. Biochemical and functional status indices can help bridge the gap between inadequate diet and resulting pathology. Some indices are very specific for individual vitamins; others, although only semi-specific, are useful if closely linked to tissue malfunction and hence to pathology. Ideally, biochemical indices should separate severe deficiency, mild subclinical deficiency, normal status and overload toxicity. Vitamin concentrations in plasma, serum, red cells, urine, and other accessible tissues have been used, and metabolic products of vitamin-dependent metabolic pathways have been exploited. However, many of the assays are difficult to perform and interpret, and are limited to few laboratories, world-wide. There is a need for simpler and more 'portable' tests, for routine laboratories and for the medical profession.

Estimation of the use of dietary supplements in the National Diet and Nutrition Survey: people aged 65 years and Over. An observed paradox and a recommendation

OBJECTIVE

To compare the evidence derived from blood biochemical status indices with the evidence from a questionnaire and from a 4-day weighed dietary record of micronutrient supplement use in the British National Diet and Nutrition Survey (NDNS) of People Aged 65 Years and Over; to resolve some apparent incompatibility between nutrient intake and status estimates, and to recommend an approach towards supplement recording that should improve accuracy.

DESIGN

The survey procedures described in the National Diet and Nutrition Survey Report (1998) included a health-and-lifestyle questionnaire, a 4-day weighed diet record, and fasting blood and urine sample for biochemical indices, including a wide range of micronutrients.

SETTING

Eighty randomly selected postcode sectors from mainland Britain during 1994-1995.

SUBJECTS

Of 2060 people interviewed, 1467 provided a blood sample and 1217 provided both a blood sample, and a complete 4-day diet record. About 20% were living in institutions such as nursing homes, and the remainder were living in private households.

RESULTS

After assigning the subjects to four categories by the use of dietary supplements (A, those not taking supplements (by questionnaire or by the 4-day record); B, those taking supplements (excluding prescribed ones) by questionnaire only; C, those taking supplements by 4-day record only; and D, those taking supplements by both questionnaire and 4-day record), these categories were then compared with respect to estimated total nutrient intakes and blood biochemical indices. Those in category B had estimated (4-day) nutrient intakes (from foods and supplements) that were indistinguishable from those in category A, but had biochemical indices that indicated significantly higher dietary intakes of several vitamins. CONCLUSIONS AND RECOMMENDATION: The 4-day weighed intake record may not have identified all of the subjects who were regularly taking micronutrient supplements in amounts sufficient to improve their biochemical status. Because survey respondents may use supplements irregularly or change their usual patterns of supplement use during a period of intensive diet-recording, it is important to design a dietary instrument that will minimise this potential source of inaccuracy. We therefore recommend that population surveys in which an accurate estimate of micronutrient intakes is required, from supplements as well as from food, should record supplement use for a period longer than 4-days. It is likely that a better estimate of long-term intakes can be achieved by combining a 4-day weighed diet record with a structured recall or several weeks of diary records, which focus specifically on the use of supplements.

Relationship between alcohol and nutrient intakes and blood status indices of older people living in the UK: further analysis of data from the National Diet and Nutrition Survey of people aged 65 years and over, 1994/5

OBJECTIVE

To examine the relationships between alcohol consumption and a range of nutrient intakes and blood status indices in older people.

DESIGN

National Diet and Nutrition Survey: cross-sectional survey of nationally representative sample of people aged 65 years or over.

SETTING

Mainland Britain during 1994/5.

SUBJECTS

1198 people (623 males, 575 females) aged 65 years or over, of whom 925 were living in private households and 273 were living in institutions.

RESULTS

Intermediate alcohol consumption (particularly 0.1-14 units week(-1); 1 unit = 8 g) derived from a 4-day diet diary or a 12-month recall questionnaire, was associated with higher intakes of vitamins C, E, B1, iron, calcium, energy from food, carbohydrate and non-starch polysaccharides than heavy alcohol consumption (28 + units week(-1)) or abstinence, after adjustment for a number of factors (age, sex, domicile, social class, cigarette smoking, self-reported health, grip strength and total energy intake). Intermediate alcohol consumption was also associated with higher blood concentrations (independent of intake) of vitamin C, beta-cryptoxanthin, lutein and calcium, with the lowest concentrations being found in heavy alcohol users. The lowest concentrations of serum ferritin were found in light drinkers and the highest levels in heavier alcohol drinkers. Alcohol consumption ranging from 0.1 to >28 units week(-1) was directly correlated with intakes of B vitamins, total energy and fat, with blood concentrations (independent of intake) of lycopene, high density lipoprotein (HDL)-cholesterol, plasma pyridoxal phosphate and retinol, and with blood pressure and grip strength.

CONCLUSIONS

Compared with abstinence and heavy drinking, light to moderate alcohol consumption in older people is associated with higher intakes of certain nutrients, and higher blood concentrations (independent of intake) of some micronutrient status indices, including antioxidants. The explanation for the latter associations remains unclear and further investigation is recommended. Heavier alcohol consumption is associated with both beneficial and adverse effects with respect to nutrient intakes and health status.

Does vitamin C reduce blood pressure? Results of a large study of people aged 65 or older

OBJECTIVE

To characterize relationships among blood pressure, pulse rate, vitamin C status and other protective and risk factors for older British people, from a national survey.

DESIGN

A cross-sectional analysis of survey data.

SETTING

A population study, representative of mainland Britain.

SUBJECTS

Among 914 people of both sexes living in the community, 373 were taking blood-pressure-lowering drugs and were therefore excluded from the analyses.

INTERVENTIONS

Completion of an interview on health, lifestyle and dietary habits, recording of a 4-day dietary record, anthropometry and taking of a blood sample to determine haematological and biochemical status.

MAIN OUTCOME MEASURES

Systolic and diastolic blood pressures, pulse rate, indices of micronutrient status including plasma ascorbate concentration, nutrient intake and haematology.

RESULTS

Plasma ascorbate concentration was inversely correlated to systolic and diastolic blood pressures and pulse rate. Other covariates of blood pressure included age, sex, domicile, plasma retinol, fibrinogen and gamma-tocopherol concentrations, erythrocyte count, prothrombin time and urine sodium: creatinine ratio. Covariates of pulse rate included sex, domicile, plasma fibrinogen and platelet count. Blood pressure was also correlated to intake of vitamin C.

CONCLUSIONS

Plasma ascorbate concentration and intake of vitamin C are covariates of blood pressure in older people living in Britain. New intervention studies are now needed, to test for possible causalities.

Zinc and phytate intake of rural Gambian infants: contributions from breastmilk and weaning foods

Zinc and phytate intakes of 183 rural Gambian infants were obtained from weighed records of breastmilk and food intake and measured contents in foods. Total zinc intake of 2.7 mg/d in the first month of age declined to 1.5 mg/d at 3 months, then increased to 4.3 mg/d by 17 months. Breastmilk was an important source of zinc, but the predominant cereal and groundnut-based foods had high [phytate]/[Zn] molar ratios ranging from 13 to 28, indicating potential impaired zinc bioavailability. The [phytate]/[Zn] molar ratio for the diet as a whole was low in early infancy, but increased to 13 in the second year. In contrast, this ratio was less than 6 for the diet of 48 Cambridge breastfed infants up to 18 months. A further disadvantage to the Gambian infants was indicated by their lower intake of protein of animal origin. However, calcium intake was estimated in both communities to be below the level which could give rise to zinc chelation in association with phytate. Compared to 'basal' and 'normative' requirements, total zinc intake of the Gambian infants showed the greatest shortfall between 3 and 12 months, making this the age band for maximum probable benefit from focused intervention programmes.

Gastric cancer, gastritis and plasma vitamin C: results from an international correlation and cross-sectional study. The Eurogast Study Group

Low intake of foods rich in vitamin C is associated with an increased risk of gastric cancer, and geographic variation in average vitamin C intake, therefore, could explain some of the wide international variation in gastric cancer rates. This multicentre study investigated the relationships between plasma levels of vitamin C, as an indicator of vitamin C intake, and gastric cancer rates, markers of gastritis and other socio-demographic variables. Fasting plasma samples from about 1,400 individuals from 9 centres in 7 countries worldwide were assayed for total vitamin C using a fluorometric assay. There was no association between average plasma vitamin C levels and either gastric cancer mortality or incidence rates in the populations studied. Therefore, variation in fasting plasma vitamin C levels, as an indicator of consumption of vitamin C, does not appear to explain any of the wide geographic variation in gastric cancer rates. Furthermore, there was no association between plasma vitamin C levels and Helicobacter pylori infection, low serum levels of pepsinogen A (as a marker of severe chronic atrophic gastritis) or the presence of DNA adducts in blood leukocyte DNA. Multivariate models showed that fasting plasma vitamin C levels were associated positively with female sex, higher levels of education, never having smoked and increasing height and negatively with number of cigarettes smoked per day and increasing weight. This suggests not only that gender and tobacco smoking, in particular, are important predictors of plasma vitamin C levels but also that their effects are consistent throughout the developed world.

Plasma total homocysteine in a representative sample of 972 British men and women aged 65 and over

OBJECTIVES

To provide a reference range for plasma total homocysteine (tHcy), an independent risk factor for vascular disease, and to explore relationships with nutritional indices for people aged 65 y and over, in the UK National Diet and Nutrition Survey (NDNS).

DESIGN

The survey procedures described in the National Diet and Nutrition Survey Report (1997) included a health-and-lifestyle interview, a four-day weighed diet record, anthropometric and blood pressure measurements and a fasting blood sample for biochemical indices, including tHcy.

SETTING

Eighty randomly selected postcode sectors from mainland Britain during 1995-1996.

SUBJECTS

Of 2060 people interviewed, 1527 were visited by the nurse, 1276 gave a blood sample and 972 had tHcy measured. About 80% were in their own homes and the remainder were in nursing homes or similar institutions.

RESULTS

Significant cross-sectional relationships, both univariate and multivariate were found between tHcy and index concentrations of folate and vitamin B12 (P < 0.0001), and between tHcy and plasma creatinine, urea, calcium, zinc, alpha 1-antichymotrypsin, lutein and cysteine (P = 0.013 to < 0.0001). Dietary nutrient analyses showed an association with folate intake. tHcy was also correlated with age and with domicile (free-living or institution), with history of vascular disease and with use of four classes of drugs, two of which are prescribed for vascular diseases. There was a north-south gradient in tHcy (P = 0.005), and also in food choices, blood micronutrient indices and vascular disease prevalence.

CONCLUSIONS

The concentrations of tHcy found in this study provide a reference range for people aged 65 y and over, in mainland Britain. tHcy is a valuable functional index of micronutrient status and intakes for British people aged 65 y and over, which can assist the development of health-promotion strategies.

Vitamin C and copper interactions in guinea-pigs and a study of collagen cross-links

The purpose of this study was, first to explore metabolic interactions between Cu and ascorbic acid in guinea-pigs, particularly with respect to any possible disadvantages of high ascorbate in the presence of low Cu intakes, and second, to test the hypothesis that variations in ascorbate and/or Cu status might influence collagen cross-linking, either by inducing a change in the crosslinks: hydroxyproline ratio, or by inducing a change in the pyridinoline: deoxypyridinoline crosslinks ratio. Four matched groups, each of eight male weanling Dunkin-Hartley guinea-pigs, were maintained on purified diets containing either no added Cu, or 150 mg Cu/kg diet, and either 0.1 g or 30 g ascorbic acid/kg diet. They were then killed 8 weeks later, and the following indices were measured: body and organ weights; blood haemoglobin; adrenal ascorbate concentrations; Cu concentrations in plasma, liver and femur; superoxide dismutase (EC 1.15.1.1) activity in whole blood and liver; hydroxyproline, pyridinoline and deoxypridinoline in femur and in urine. The principal observations were: Cu intake significantly affected blood and tissue Cu concentrations and superoxide dismutase activity; and ascorbic acid intake significantly affected adrenal ascorbate levels and the deoxypyridinoline: pyridinoline cross-links ratio, especially in bone (femur). There was evidence of a significant interaction between ascorbate and Cu with respect to adrenal and plasma Cu concentrations, blood superoxide dismutase activity and body weights. We conclude that interactions between ascorbate and Cu at the functional level were present but modest, and that a new and potentially powerful functional index of ascorbate status may exist within the deoxypyridinoline:pyridinoline collagen cross-link ratio.

Effect of acyclovir and prednisolone on the serological response in herpes zoster

The serological response of patients with acute herpes zoster was studied to determine whether a diagnosis could be made on a single serum sample, and whether this response was modified by treatment with antiviral and/or steroid therapy. The patients received one of four regimes of acyclovir and prednisolone, Varicella zoster virus (VZV) IgG, IgM, and IgA responses were measured by commercial and in-house enzyme immunoassays (EIA) using serum samples taken at days 0, 7, and 21 after entry into the study. Samples were also tested for IgM to Epstein-Barr virus (EBV) viral capsid antigen (VCA), and cytomegalovirus (CMV) IgM and for herpes simplex virus (HSV) antibodies by the complement fixation test (CFT). Analysis was carried out on data from 71 patients. VZV IgM was detected in 72%, VZV IgA in 78%, and either VZV IgM or IgA in 88% of patients tested, at some time during the 3-week study period. The optimal time to detect either class of antibody was approximately 1 week after the onset of the vesicular rash, when 85% of patients had one or both classes of acute phase antibody in their serum. There was no evidence of cross reaction with EBV, CMV, or HSV antibodies. Neither treatment with prednisolone nor the length of therapy with acyclovir affected significantly the VZV IgM or IgA responses. Therefore it is possible to make a serological diagnosis of herpes zoster on a single sample, optimally 1 week after the onset of the rash, in patients treated with acyclovir alone or with acyclovir and steroids.

Biochemical evidence of thiamine depletion during the Cuban neuropathy epidemic, 1992-1993

During an epidemic outbreak of neuropathy in Cuba during 1992-1993, blood and urine samples were collected from 107 persons with confirmed neuropathy, from 106 control subjects without clinical abnormality who were broadly matched with the affected persons by age and domicile, and from 537 unmatched subjects, also free from clinical abnormality. The unmatched subjects lived in two locations in Cuba; at each location they were drawn from two age ranges: 11-15-y-old secondary school students and 16-64-y-old adults. Measurements of urinary thiamine and blood transketolase and its activation with thiamine pyrophosphate were made. For the neuropathy subjects, these measurements were repeated after 3 wk of rehabilitation. All groups showed biochemical evidence of thiamine depletion affecting 30-70% of their members, which is a high prevalence. Severity of biochemical depletion was, however, no greater in the neuropathy subjects than in the control subjects (P > 0.05). However, it was greater in Pinar del Rio, where the incidence of disease was higher, than in the city of Havana, where less disease was seen. Although the majority of the affected subjects responded biochemically to a daily oral multivitamin supplement containing thiamine (P < 0.001), in some cases normal biochemical status was not achieved even after 3 wk of intensive treatment. In the affected group, thiamine status was inversely correlated with the amount of alcohol consumed (P = 0.007). Thiamine status at the outset was correlated with clinical outcome after treatment. Although neither thiamine depletion nor alcohol abuse were likely to have been the sole cause of the neuropathy epidemic, they may have been contributory factors. Thiamine supplementation or food fortification may therefore be necessary in Cuba.

Measurement of ascorbic acid kinetics in man using stable isotopes and gas chromatography/mass spectrometry

The feasibility of studying ascorbic acid kinetics in man using stable isotope-labelled tracers and gas chromatographic (GC) separation followed by mass spectrometric (MS) quantitation was assessed. Preliminary studies with 13C-labelled material showed that although better precision at low levels could be achieved using the GC/combustion/MS technique, consideration of likely enrichments in a human study made the simpler GC/MS method just as suitable. On this basis, a small pilot study of the kinetics in man was carried out. The enrichment of the ascorbic acid in plasma was measured for a 24 h period after oral administration of 13C-labelled material. The results were fitted to a simple three-compartment model and rate constants and pool sizes were deduced. The results obtained are comparable to those obtained in other published studies, from which we conclude that the technique may be useful as a non-invasive method for the assessment of nutritional status in a variety of populations.

Documentation of blood culture results

AIMS

To evaluate the adequacy of documentation of blood culture results in patients' medical notes.

METHODS

A pro-forma was completed following review of medical notes at 24 and 48 hours after a blood culture had been reported as positive. The study was performed on blood cultures received at the Department of Microbiology, Royal Hallamshire Hospital, Sheffield, from two local hospitals. Two periods were studied: (A) May to June 1993 and (B) September to October 1993.

RESULTS

There were 43 results studied in period A and 79 in period B, giving a total of 122 results studied. Overall, 72 (59%) of 122 results were recorded in the medical notes at 24 hours. Of those results deemed highly significant, 40 (63%) of 63 were recorded. There was no significant difference in the documentation of results if the result was given personally or via the telephone. Nor was there any difference in documentation between different medical grades. Throughout the study there were six inaccurate records. The cumulative documentation over 48 hours of positive results was 54 (86%) of 63 of highly significant, 27 (69%) of 39 of uncertain significance, and 11 (55%) of 20 probable contaminant results.

CONCLUSIONS

Documentation of blood culture results is currently suboptimal.

Survival of Salmonella species in eggs poached using a microwave oven

The use of microwave ovens is becoming increasingly popular, but there is little data on the bactericidal effect of this mode of cooking. Following a family outbreak of gastroenteritis due to Salmonella enteritidis PT4, where eggs poached in a microwave oven were the suspected source, we investigated the survival of Salmonella spp. in artificially contaminated eggs cooked in a microwave oven. The survival of six serotypes of Salmonella at various inocula were studied, after cooking the eggs using two recognized poaching methods. Salmonellae were readily recovered after cooking if the yolk was still soft, whichever serotype, inoculum or cooking method was used. The survival of organisms was related to the number of organisms present in the raw eggs. The advice regarding eating lightly cooked eggs should be the same whether microwave or more conventional cooking techniques are used.

Ascorbic acid deficiency in guinea pigs: contrasting effects of tissue ascorbic acid depletion and of associated inanition on status indices related to collagen and vitamin D

To investigate the sensitivity of guinea pig tissues to ascorbic acid depletion, as distinct from inanition, young male guinea pigs were maintained with either ascorbic acid restriction or total diet restriction for 8 weeks. One group (A) received no ascorbic acid for 3 weeks, then 0.5 mg/d for 5 weeks; one group (B) was weight-matched by restricted food intake to the first group; a third (marginally deficient) group (C) received 1 mg ascorbic acid/d throughout; a fourth was weight-matched to this group (D); and a fifth group received the control diet ad lib. (E). Both of the groups with restricted ascorbic acid intakes (A and C) developed very low tissue ascorbic acid contents, but only the first group (severely deficient group A) also exhibited a severely reduced growth rate. This group also exhibited reduced femur calcium and hydroxyproline contents and reduced skin hydroxyproline content. These changes were not seen in the corresponding weight-matched group (B). Neither plasma alkaline phosphatase (EC 3.1.3.1) activity, nor a variety of indices of vitamin D status exhibited changes which could be attributed specifically to reduced ascorbic acid intake and hence to lowered tissue ascorbic acid content. It is concluded that low tissue ascorbic acid levels in guinea pigs clearly alter the connective tissue composition of growing femur and skin, but do not necessarily produce a major, specific effect on vitamin D status. Moreover, the control of inanition is crucial to permit interpretation of the changes in metabolism that are caused by ascorbic acid deficiency.

Biochemical indices and neuromuscular function tests in rural Gambian schoolchildren given a riboflavin, or multivitamin plus iron, supplement

Ninety preselected children, aged between 8 and 14 years, living in two rural West African (Gambian) villages, were randomly divided into three groups, matched for age and sex. One group received a placebo (lactose) tablet, one received riboflavin (5 mg) on 5 d every week, which was sufficient to correct an endemic riboflavin deficiency, and one received a multivitamin supplement (Protovit; Hoffmann La Roche), on 5 d every week, together with FeSO4 (200 mg) once weekly, and the supplements were given for 1 year. Neuromuscular tests, including arm tremor and manipulative skills, were performed on three occasions: once just before the introduction of the supplements; again 6 weeks after commencing the supplements; and again 1 year later. Venous blood samples were collected at the same time as the first two sets of neuromuscular tests. These samples were used for haematology and nutrient status indices: plasma ferritin, ascorbic acid, cyanocobalamin and pyridoxal phosphate, and erythrocyte tests for folate status, for riboflavin status (erythrocyte glutathione reductase activation coefficient) and thiamine status (erythrocyte transketolase activation coefficient). The riboflavin in both supplements achieved a clear-cut response in biochemical status, which was dose-dependent. The pyridoxine, ascorbic acid and Fe components of the multivitamin also affected the associated biochemical indices. Although overall the arm tremor and related neuromuscular function tests did not respond significantly to the supplements, significant improvement was seen in the boys for the arm-tremor test in both the supplemented groups.

Seasonal variations in vitamins A, C, riboflavin and folate intakes and status of pregnant and lactating women in a rural Gambian community: some possible implications

OBJECTIVE

To relate measured intake of vitamins A, C, folate and riboflavin to biochemical indicators of nutritional status for these micronutrients, and to examine seasonal variations.

SETTING

MRC Dunn Nutrition Unit Field Station, Keneba, The Gambia, which has heavy rainfall in August, and little or no rain between late September and mid-June. Data were collected during 1978-80.

SUBJECTS

Pregnant or lactating women in a rural farming community whose diet has been studied throughout the year.

RESULTS

Mean daily intake of vitamin C varied from virtually nil during the rainy season to about 100 mg/d in May, while plasma ascorbate ranged from 0.2 to 1.2 mg/dl, and breast-milk ascorbate from 2 to 6 mg/dl, changing synchronously with changing intake. Intake of retinol equivalents ranged from 120 micrograms/d in December to 900 micrograms/d in June, and plasma carotenoids showed synchronous fluctuation from 60 to 180 micrograms/dl, whereas plasma retinol was virtually unchanged throughout the year at 30 micrograms/dl. Intake of riboflavin was very low throughout the year, but erythrocyte glutathione reductase activation coefficient ranged from a minimum of 1.5 in July to a maximum of 1.9 between December and March. Obstetric outcome also exhibited seasonal variation with lowest birthweights during the rainy season. Intakes of food energy are assumed to be the major dietary influence on birthweight, but micronutrient intakes and status may have additional effects, and seasonality clearly affects ascorbate intakes by suckling infants.

CONCLUSIONS

In countries such as The Gambia seasonality is a major determinant of micronutrient status. However, dietary intake is not the only factor which determines micronutrient status: thus there are seasonal fluctuations in riboflavin status which, for example, may relate to changes in the balance between energy intake and output, rather than to seasonal changes in riboflavin intake.

Breast milk as a source of vitamins, essential minerals and trace elements

Human breast milk provides all of the vitamins and essential minerals and trace elements (micronutrients) that are required by the normal term infant, until weaning. With a few exceptions, excessive micronutrient supplies to the mother, or a moderate deficiency in her diet, do not greatly alter the supply to the infant. Thus, the infant is well-protected by maternal homeostatic processes, although the mechanisms of these are not yet well understood. Considerable progressive changes in concentration occur for some of the micronutrients during the course of lactation. Because the concentration of these nutrients, and of other substances that modify their absorption by the infant, such as binding proteins, differs considerably between human milk, animal milk and, hence, commercial milk formulae, there is great interest in the quantitative significance of micronutrient supplies, and their variability in breast milk, in the quest for improvement of commercial formulations. The aim of this review is to summarize the available information about the factors that determine breast milk contents of micronutrients.

Adequacy of dietary mineral supply for human bone growth and mineralisation

The evidence on the relationship between dietary mineral supply and bone development in children has been extensively reviewed. Data from children and primates suggest that overt deficiencies of Ca, P and Zn are likely to produce rickets and growth retardation, while the effects of Mg deficiency on human bone are unknown. The manifestations of marginal deficiencies are little understood. The biological needs for Ca, P, Mg and Zn in childhood have been calculated based on mineral deposition rates, using published values for the mineral content of the human body, and on obligatory endogenous losses. As a rough guide, the estimated biological requirements for the Ca, P, Mg and Zn can be taken as 200, 100, 4 and 1 mg/d respectively. A comparison of measured daily intakes of children in developing countries with biological requirements was made. This revealed that P and Mg intakes were many times higher than estimated needs. Ca intakes at all ages were found to be close to the biological requirement for children in many Third World societies, before any allowance for possible poor absorption. Zn intakes approach estimated needs in breast-fed infants, particularly during weaning, but are 4-5 times higher in older children. Poor absorption from phytate-rich diets could affect Zn supply. Supplementation studies indicate that raising Zn intakes can increase height gains in certain vulnerable groups, such as infant and adolescent boys. In conclusion, the evidence suggests that inadequate dietary intakes of Ca and Zn may contribute to linear growth retardation in children of developing countries but more research is needed.

Does vitamin C intake influence the rate of tyrosine catabolism in premature babies?

A study was conducted to investigate the relationship between vitamin C intake and the rate of tyrosine catabolism in premature babies. A 13C tyrosine breath test was developed for the measurement of tyrosine catabolism. Premature babies were randomly allocated to receive a daily intake of vitamin C which ranged from 8 to 100 mg/kg body weight, for 5 days. Tyrosine catabolism was measured at the beginning and the end of this period. Daily intakes of vitamin C of 20 mg/kg or more elicited a greater increase in tyrosine catabolism over 5 days than 8 mg/kg/day. The magnitude of the difference, in terms of percentage of tyrosine metabolised, was, however, small and of doubtful biological significance. Vitamin C intakes above 20 mg/kg/day had no further measurable effect on the catabolism of tyrosine.

The efficacy of a hospital dry cleaning cycle in disinfecting material contaminated with bacteria and viruses

It is not known how efficiently a standard dry cleaning cycle can kill bacteria or viruses. In-situ experiments were carried out to determine the cidal activity of such a cycle using perchloroethylene solvent against five clinical bacterial isolates and a DNA bacteriophage. Viable counts of bacteria recovered from material after dry cleaning were reduced by 3-8 logs, with up to 10(3) colony forming units (cfu) surviving per strip. Numbers of bacteriophage were only reduced by 10-100 fold. The resistance of the bacteriophage to solvent and heat (60 degrees C) was compared with that of polio and herpes simplex viruses in vitro. Polio virus and bacteriophage, but not herpes simplex virus, survived exposure to perchloroethylene at room temperature for 40 min. Dry cleaning with perchloroethylene is not bactericidal and is particularly poorly virucidal for non-enveloped viruses.

Nutritional efficacy of a fortified weaning rusk in a rural area near Beijing

A micronutrient-fortified rusk for weanling children was tested in a rural area near Beijing. Two hundred twenty-six children aged 6-13 mo were randomly assigned by village to either a micronutrient-fortified or an unfortified rusk, daily for 3 mo. The fortified rusk contained extra zinc; iron; calcium; vitamins A, D, and B-12; thiamin, riboflavin, niacin, and folic acid. Infants receiving the fortified rusk exhibited no decline in hemoglobin concentrations during the study whereas those receiving the unfortified rusk exhibited a significant decline. Improvements were also seen in erythrocyte porphyrin, plasma vitamin A, and riboflavin status, but these improvements were seen in both of the groups. Micronutrient fortification was probably beneficial for iron status and the fortified rusk promises to be an effective vehicle for supplementation.

A trial of zinc supplementation in young rural Gambian children

The present study tested the hypothesis that inadequate Zn intake might be responsible for failure to thrive and impaired catch-up growth in young rural Gambian children, and that Zn supplements might be beneficial. Gambian children might be deprived of Zn because of its poor availability from their predominantly plant-based diet. Rural Gambian children (110; fifty boys, sixty girls) aged between 0.57 and 2.30 years were divided into two matched groups, one to receive 70 mg Zn twice weekly for 1.25 years, and the other a placebo. Growth and mid-upper-arm circumference were measured at weekly intervals throughout the study and illnesses were monitored. Capillary blood and urine samples were collected at 0, 2 and 8 weeks. Body weights and arm circumferences showed a linear increase, plus a seasonal effect (rainy season faltering). For body weight there was no significant overall effect of the supplement. For arm circumference, a very small (2%) but significant (P < 0.01) difference favoured the supplemented group. Plasma thymulin was much lower at the first clinic than at the second and third clinics, and in vitro Zn stimulation was greater at the first clinic. There was, however, no effect of Zn in vivo. Likewise, Zn did not significantly benefit T-cell numbers or ratios, secretory IgA in urine, circulating hormone levels or biochemical indices of Zn status. One index of intestinal permeability, i.e. lactulose: creatinine, was improved (P < 0.02) by the supplement, but the lactulose: mannitol value was not; this requires further investigation. Dietary Zn deficiency is, thus, unlikely to be of major overall importance for rural Gambian children's ability to thrive, and blanket Zn supplementation is not justified. There may, however, be vulnerable sub-groups who would benefit from Zn supplements.

A study of whole-body isotope dilution of [14C]ascorbic acid in guinea-pigs with graded ascorbate intakes

The purpose of the present study was first to assess the extent to which unlabelled ascorbate in the diet of guinea-pigs can exchange with labelled ascorbate within their organs when the dietary intake is varied over a wide range, and second to determine whether the retention of label might be used to assess either the amount of ascorbate intake or its biological availability where these are not known. The retention of [14C]ascorbate in the body and in various organs of guinea-pigs were, therefore, measured following a 13 d period of graded dietary intakes of ascorbate. It was found first, that the amount of label retained in each of the organs, 13 d after the initial dose of labelled ascorbate, was much more closely related to the amount of ascorbate intake after labelling than to the intake (and tissue ascorbate levels) before and at the time of labelling. Second, most of the individual internal organs exhibited a constant relationship between the specific activity at 13 d and the dietary intake, except for brain which was flushed to a smaller extent. Third, in agreement with several previous studies a high proportion of the radioactive label in the tissues was found to be still present in ascorbate. The specific activity of column-purified ascorbate was very similar to the estimated specific activity in the crude extract, which implies that it may be possible to estimate specific activities (or stable isotope enrichments) at certain sites without rigorous isolation procedures. Fourth, the amount of radioactivity appearing in the urine 2 d before killing the animals was correlated with the amount of ascorbate intake and with tissue specific activities, suggesting that intakes (or bioavailability) might be predicted from the patterns of label-appearance in the urine.

Incorporation of [3H]proline into collagen and other proteins in rats fed diets with various zinc concentrations

Incorporation of labeled proline into liver and skin proteins of weanling rats was studied during zinc restriction. Reduced incorporation of labeled proline into skin proteins including collagen hydroxyproline and an increase in its incorporation into liver and plasma proteins was observed with 0 or 0.046 mumol zinc/g diet, compared with 0.092, 0.153 or 0.306 mumol/g diet. Food (energy) restriction was then compared with zinc restriction, during recovery from protein restriction. A shift in proline incorporation from skin protein and skin collagen hydroxyproline, towards liver and plasma proteins, was closely correlated with body weight gain, whether it was limited by zinc restriction or by energy restriction. This diversion of label from skin to liver and plasma is probably mediated through mechanisms that limit growth during food restriction. Proline-incorporation patterns during zinc or energy restriction are clearly different from those of vitamin-C deficiency in guinea pigs.

Effect of vitamin C on sorbitol in the lens of guinea-pigs made diabetic with streptozotocin

Marginally vitamin C-deficient guinea-pigs treated with the diabetogenic agent streptozotocin were compared with those liberally supplied with vitamin C, for functional indices of vitamin C status, particularly in the eye lens. Weanling male Dunkin-Hartley guinea-pigs were fed on diets with 0.1 g vitamin C/kg (marginally deficient), or 5 g/kg (liberally supplied), and some received intraperitoneal streptozotocin (two doses of 150 mg/kg body-weight). About half the streptozotocin-treated animals had high urinary glucose following an oral glucose dose; these animals also grew more slowly than the others. At 4 months after streptozotocin the animals were killed for measurement of tissue vitamin C, glucose and sorbitol. Streptozotocin moderately increased the concentration of glucose in plasma, lens and aqueous humour. Lens sorbitol levels increased only in the group exposed to streptozotocin plus marginal vitamin C. There was a significant (P less than 0.02) positive correlation between urinary glucose and lens sorbitol levels overall. Liberal vitamin C intake may thus counteract the effect of streptozotocin diabetes on lens sorbitol, suggesting a new function of vitamin C, possibly related to cataractogenesis and to the biochemical lesions associated with diabetes.

Plasma folate levels in preterm infants, with and without a 1 mg daily folate supplement

One hundred and four preterm infants were studied during the first few months of life in the Special Care Baby Unit of Addenbrooke's Hospital, Cambridge, United Kingdom. Previously, it had been the daily practice within the Unit to give a 1 mg oral supplement of folate (in the form of pteroylglutamic acid), once the infants had commenced full enteral feeding. At least one blood sample was obtained from 70 infants before oral folate supplementation was started. In these, the plasma folate levels fell progressively from a median value of 45 micrograms/l to a median of 12 micrograms/l, by the 2nd-3rd week of life. Once started on the oral supplement, 83 of the infants provided at least one blood sample. The plasma folate level of these infants rose immediately to a median value of 300 micrograms/l and a maximum of 1000 micrograms/l. Within individuals, these plasma folate levels decreased progressively following the introduction of the supplement, despite continuing daily supplementation. In a typical baby this decrease appeared to be explained by an increase in body-size, i.e. dilution of the folate into a larger pool. The implications of this level of supplementation are discussed, and in the light of our observations we suggest that daily supplementation in the range, 0.05-0.2 mg folate may be preferable for well preterm infants.

High folate intakes related to zinc status in preterm infants

The former practice of giving 1 mg (2.27 mumoles) oral folic acid daily to premature infants receiving enteral feeds was assessed with respect to zinc status in Cambridge, United Kingdom. A group of 60 preterm infants, 80% of whom were receiving 1 mg oral folic acid daily, were studied for up to the first 16 weeks of life. Plasma folate and plasma zinc were measured for each subject. A significant inverse relationship was found between the maximum attained serum folate level and the minimum attained serum zinc level, (t = 5.0, 58 df, P less than 0.0001). This remained significant after corrections had been made for gestational age at birth, fetal growth retardation, birth weight, sex, diet, assisted ventilation and length of time to full enteral feeding. The hypothesis that very high folate intakes may adversely affect serum zinc levels and, by inference, zinc status in preterm infants could not be rejected. Caution is therefore advised when prescribing such very high folate doses daily for small preterm infants.

Glutathione and related indices in rat lenses, liver and red cells during riboflavin deficiency and its correction

Biochemical changes in lenses and at other sites in adult rats were investigated during the induction and correction of riboflavin deficiency. Riboflavin deficient (D), 1-day-repleted (R1), 2-days-repleted (R2), 16-days-repleted (R3), food-restricted, weight-matched controls (CFR) and ad libitum-fed controls (CAL) were compared. Activation coefficients of erythrocyte and lens glutathione reductase, which became abnormal in the deficient (D) animals, were corrected to varying extents in the repleted (R) groups. Hepatic flavin concentrations were lowered in the groups with raised glutathione. Inter-group differences in hepatic glutathione concentrations were not simply related to tissue flavin depletion or its reversal, but were complicated by changes in liver: body-weight ratios. Inter-group differences in lenticular glutathione levels were very small. In both liver and lens, sorbitol concentrations were lowest in group R3 and highest in groups D, R1 and R2. Lens ascorbate levels and the lens enzymes, aldose reductase, sorbitol dehydrogenase, glutathione peroxidase and superoxide dismutase, were not significantly affected by diet. Thiobarbituric acid-reactive substances were increased in riboflavin-deficient rat lenses but were lowered in riboflavin-deficient plasma samples. The results suggest overall that while riboflavin deficiency may affect certain biochemical indices, such as sorbitol and thiobarbituric-reactive substances, in the lens and other tissues, these changes are not the result of lowered glutathione levels. They also clearly demonstrate the importance of inanition as a confounding factor in the interpretation of changes resulting from riboflavin deficiency in experimental animals.

Liberation of 14CO2 from [14C]adipic acid and [14C]octanoic acid by adult rats during riboflavin deficiency and its reversal

The purpose of the present study was to test the hypothesis that the already well-established mitochondrial lesion in fatty acid oxidation in riboflavin-deficient experimental animals, might be accompanied by an alteration in vivo in the kinetics of oxidation of labelled adipic acid. This dicarboxylic acid was chosen for testing as a metabolic probe because a block in its oxidation was already apparent from urine analysis of riboflavin-deficient animals, whereas the oxidation of medium- or long-chain monocarboxylic acids seemed to be little affected by deficiency in vivo. Female adult Norwegian hooded rats fed on purified diets containing either 15 mg riboflavin/kg diet (controls) or about 0.4 mg/kg (riboflavin-deficient) received an intragastric dose of either [1,6-14C]adipic acid or [1-14C]octanoic acid. Expired carbon dioxide was then collected in an alkaline trap over 3 h, for determination of radioactivity. This test was repeated at intervals for up to 2 weeks following riboflavin repletion of the deficient animals, and in riboflavin-dosed controls. Whereas the rate and extent of [14C]octanoic acid oxidation was not significantly affected by the deficiency or repletion, the extent of [14C]adipic acid oxidation was markedly and significantly increased during repletion of the deficient animals. The time-course indicated a temporary overshoot, followed by a slow return to the control values over 1-2 weeks. Adipate oxidation was also much less affected by a preceding period of overnight starvation, than was octanoate oxidation. Thus, adipic acid (or a related metabolic probe) may have appropriate properties for the design of a functional test of fatty acid oxidation efficiency, during riboflavin deficiency or allied metabolic conditions in human subjects.