'Experts', 'partners' and 'fools': exploring agency in HIV treatment seeking among African migrants in London

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and 'expert' patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008-2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use 'traditional' medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally. (C) 2009 Elsevier Ltd. All rights reserved

Animal-based beef and plant-based beef: HEI-2015 score comparisons

Maternal diet can affect breastmilk composition, and breastfeeding women gravitate towards a healthier diet compared to other women. However, a healthy diet can be difficult to navigate. For example, plant-based food is marketed as healthy but is also ultra-processed which leaves health-conscious consumers, like many new moms, wondering how to make healthy choices. Therefore, this report aims to determine whether HEI-2015 scores are higher on a beef or plant-based beef diet, with all other ingredients identical, and how either diet condition compares to HEI-2015 scores of participants’ usual dietary intake. This report uses data from participants who completed a double-blinded randomized cross-over controlled feeding trial (SUPER-BEEF) at the time of this report. Participants underwent a 6-day normal eating period followed by a 6-day diet condition (Diet A), 6-day washout period, and the other 6-day diet condition (Diet B). Because the blinded study is ongoing, Diet A was considered the beef and Diet B was considered the plant-based beef condition for this report. The feeding trial meals were designed to meet acceptable macronutrient ranges and energy requirements of breastfeeding women with Nutritionist Pro software. Additionally, meals were formulated to have equal amounts of beef or plant-based beef (113g) and dietary fat (13g). We entered data from normal eating 24-hour diet recalls and diet condition menu checkoffs into the Nutrition Data System for Research (NDSR) software from which Healthy Eating Index-2015 (HEI-2015) scores were calculated. The beef condition had higher average HEI-2015 scores and lower average daily calories compared to plant-based beef (mean 72.9 vs. 58.9, 2222 kcals vs. 2337 kcals; respectively). In Diet A (beef), average HEI-2015 scores were higher for all participants (mean 70.5-72.5) compared to normal eating (mean 42.6-66.8). In Diet B (plant-based beef), average HEI-2015 scores were mixed (mean 56.1-58.2) compared to normal eating. In conclusion, our trial diets with acceptable macronutrient distribution and calorie requirements for breastfeeding women only differing in plant-based vs. animal-based beef differed in HEI-2015 scores. Compared to participants’ usual diets, the beef diet universally yielded higher diet quality scores while the plant-based diet yielded a higher diet quality score for 44% of participants.Nutritional Science

Circulating 250HD, dietary vitamin D, PTH, and calcium associations with incident cardiovascular disease and mortality: The MIDSPAN Family Study

<p>Context: Observational studies relating circulating 25-hydroxyvitamin D (25OHD) and dietary vitamin D intake to cardiovascular disease (CVD) have reported conflicting results.</p> <p>Objective: Our objective was to investigate the association of 25OHD, dietary vitamin D, PTH, and adjusted calcium with CVD and mortality in a Scottish cohort.</p> <p>Design and Setting: TheMIDSPAN Family Study is a prospective study of 1040 men and 1298 women from the West of Scotland recruited in 1996 and followed up for a median 14.4 yr. Participants: Locally resident adult offspring of a general population cohort were recruited from 1972–1976.</p> <p>Main Outcome Measures: CVD events (n = 416) and all-cause mortality (n=100) were evaluated.</p> <p>Results: 25OHD was measured using liquid chromatography-tandem mass spectrometry in available plasma (n=2081). Median plasma 25OHD was 18.6 ng/ml, and median vitamin D intake was 3.2 µ g/d (128 IU/d). Vitamin D deficiency (25OHD<15 ng/ml) was present in 689 participants (33.1%). There was no evidence that dietary vitamin D intake, PTH, or adjusted calcium were associated with CVD events or with mortality. Vitamin D deficiency was not associated with CVD (fully adjusted hazard ratio=1.00; 95% confidence interval=0.77–1.31). Results were similar after excluding patients who reported an activity-limiting longstanding illness at baseline (18.8%) and those taking any vitamin supplements (21.7%). However, there was some evidence vitamin D deficiency was associated with all-cause mortality (fully adjusted hazard ratio=2.02; 95% confidence interval=1.17–3.51).</p> <p>Conclusion: Vitamin D deficiency was not associated with risk of CVD in this cohort with very low 25OHD. Future trials of vitamin D supplementation in middle-aged cohorts should be powered to detect differences inmortality outcomes as well as CVD.(J Clin EndocrinolMetab97: 0000 –0000, 2012)</p&gt

Diets containing the highest levels of dairy products are associated with greater eutrophication potential but higher nutrient intakes and lower financial cost in the United Kingdom

Purpose: Previously, the nutritional contribution, environmental and financial costs of dairy products have been examined independently. Our aim was to determine the nutritional adequacy, financial cost and environmental impact of UK diets according to dairy content. Methods: in this cross-sectional study of adults (19–64 years) from the UK National Diet and Nutrition Survey years 1–4 (n = 1655), dietary intakes assessed from 4-day estimated food diaries were organized into quartiles (Q) total grams of dairy (milk, cheese, yogurt, dairy desserts) and analyzed using ANCOVA controlling for age, sex and energy intake with Bonferroni post hoc test for nutritional adequacy, Alternative Healthy Eating Index (AHEI-2010), environmental impact [greenhouse gas emissions (GHGE), eutrophication and acidification potentials], financial cost, markers of health and cardio-metabolic diseases. Results: nutritional adequacy, particularly for protein, calcium and iodine (+ 18 g, + 533 mg, + 95 g, respectively, all P < 0.0001) and AHEI-2010 (P < 0.0001) were significantly higher and systolic BP (− 2 mmHg, P = 0.019) was significantly lower for the higher-dairy diets (Q4, 274–1429 g/day dairy), compared with diets containing lower dairy (Q1, 0–96 g/ day dairy). Diets in Q4 had lower financial cost (− 19%, P < 0.0001) and the greatest eutrophication potential, compared with Q1 (+ 29%, P < 0.0001). Yet the environmental (GHGE) and financial costs per unit nutrient (riboflavin, zinc, iodine, magnesium, calcium, potassium) were lower in Q4 than Q1 (all P < 0.0001). Conclusion: diets with the highest dairy content had higher nutrient composition, better diet quality, were associated with lower BP and financial cost, but with higher eutrophication potential. Robust environmental data for many of food groups are limited and this needs an urgent addressing. Trial registration: this trial was registered on clinicaltrials.gov as NCT03407248

Parenteral nutrition in patients with renal failure – Guidelines on Parenteral Nutrition, Chapter 17

Partial EN (enteral nutrition) should always be aimed for in patients with renal failure that require nutritional support. Nevertheless PN (parenteral nutrition) may be necessary in renal failure in patient groups with acute or chronic renal failure (ARF or CRF) and additional acute diseases but without extracorporeal renal replacement therapy, or in patients with ARF or CRF with additional acute diseases on extracorporeal renal replacement therapy, haemodialysis therapy (HD), peritoneal dialysis (PD) or continuous renal replacement therapy (CRRT), or in patients on HD therapy with intradialytic PN. Patients with renal failure who show marked metabolic derangements and changes in nutritional requirements require the use of specifically adapted nutrient solutions. The substrate requirements of acutely ill, non-hypercatabolic patients with CRF correspond to those of patients with ARF who are not receiving any renal replacement patients therapy (utilisation of the administered nutrients has to be monitored carefully). In ARF patients and acutely ill CRF patients on renal replacement therapy, substrate requirements depend on disease severity, type and extent/frequency of extracorporeal renal replacement therapy, nutritional status, underlying disease and complications occurring during the course of the disease. Patients under HD have a higher risk of developing malnutrition. Intradialytic PN (IDPN) should be used if causes of malnutrition cannot be eliminated and other interventions fail. IDPN should only be carried out when modifiable causes of malnutrition are excluded and enhanced oral (like i.e. additional energy drinks) or enteral supply is unsuccessful or cannot be carried out

Hepatology – Guidelines on Parenteral Nutrition, Chapter 16

Parenteral nutrition (PN) is indicated in alcoholic steatohepatitis (ASH) and in cirrhotic patients with moderate or severe malnutrition. PN should be started immediately when sufficientl oral or enteral feeding is not possible. ASH and cirrhosis patients who can be sufficiently fed either orally or enterally, but who have to abstain from food over a period of more than 12 hours (including nocturnal fasting) should receive basal glucose infusion (2–3 g/kg/d). Total PN is required if such fasting periods last longer than 72 h. PN in patients with higher-grade hepatic encephalopathy (HE); particularly in HE IV° with malfunction of swallowing and cough reflexes, and unprotected airways. Cirrhotic patients or patients after liver transplantation should receive early postoperative PN after surgery if they cannot be sufficiently rally or enterally nourished. No recommendation can be made on donor or organ conditioning by parenteral administration of glutamine and arginine, aiming at minimising ischemia/reperfusion damage. In acute liver failure artificial nutrition should be considered irrespective of the nutritional state and should be commenced when oral nutrition cannot be restarted within 5 to 7 days. Whenever feasible, enteral nutrition should be administered via a nasoduodenal feeding tube

Energy expenditure and energy intake – Guidelines on Parenteral Nutrition, Chapter 3

The energy expenditure (24h total energy expenditure, TEE) of a healthy individual or a patient is a vital reference point for nutritional therapy to maintain body mass. TEE is usually determined by measuring resting energy expenditure (REE) by indirect calorimetry or by estimation with the help of formulae like the formula of Harris and Benedict with an accuracy of ±20%. Further components of TEE (PAL, DIT) are estimated afterwards. TEE in intensive care patients is generally only 0–7% higher than REE, due to a low PAL and lower DIT. While diseases, like particularly sepsis, trauma and burns, cause a clinically relevant increase in REE between 40–80%, in many diseases, TEE is not markedly different from REE. A standard formula should not be used in critically ill patients, since energy expenditure changes depending on the course and the severity of disease. A clinical deterioration due to shock, severe sepsis or septic shock may lead to a drop of REE to a level only slightly (20%) above the normal REE of a healthy subject. Predominantly immobile patients should receive an energy intake between 1.0–1.2 times the determined REE, while immobile malnourished patients should receive a stepwise increased intake of 1.1–1.3 times the REE over a longer period. Critically ill patients in the acute stage of disease should be supplied equal or lower to the current TEE, energy intake should be increased stepwise up to 1.2 times (or up to 1.5 times in malnourished patients) thereafter

Gastroenterology – Guidelines on Parenteral Nutrition, Chapter 15

In patients with Crohn's disease and ulcerative colitis parenteral nutrition (PN) is indicated when enteral nutrition is not possible or should be avoided for medical reasons. In Crohn's patients PN is indicated when there are signs/symptoms of ileus or subileus in the small intestine, scars or intestinal fistulae. PN requires no specific compounding for chronic inflammatory bowel diseases. In both diseases it should be composed of 55–60% carbohydrates, 25–30% lipids and 10–15% amino acids. PN helps in the correction of malnutrition, particularly the intake of energy, minerals, trace elements, deficiency of calcium, vitamin D, folic acid, vitamin B12, and zinc. Enteral nutrition is clearly superior to PN in severe, acute pancreatitis. An intolerance to enteral nutrition results in an indication for total PN in complications such as pseudocysts, intestinal and pancreatic fistulae, and pancreatic abscesses or pancreatic ascites. If enteral nutrition is not possible, PN is recommended, at the earliest, 5 days after admission to the hospital. TPN should not be routinely administered in mild acute pancreatitis or nil by moth status <7 days, due to high costs and an increased risk of infection. The energy requirements are between 25 and 35 kcal/kg body weight/day. A standard solution including lipids (monitoring triglyceride levels!) can be administered in acute pancreatitis. Glucose (max. 4–5 g/kg body weight/day) and amino acids (about 1.2–1.5 g/kg body weight/day) should be administered and the additional enrichment of TPN with glutamine should be considered in severe, progressive forms of pancreatitis

Intensive medicine – Guidelines on Parenteral Nutrition, Chapter 14

In intensive care patients parenteral nutrition (PN) should not be carried out when adequate oral or enteral nutrition is possible. Critically ill patients without symptoms of malnutrition, who probably cannot be adequately nourished enterally for a period of <5 days, do not require full PN but should be given at least a basal supply of glucose. Critically ill patients should be nourished parenterally from the beginning of intensive care if they are unlikely to be adequately nourished orally or enterally even after 5–7 days. Critically ill and malnourished patients should, in addition to a possible partial enteral nutrition, be nourished parenterally. Energy supply should not be constant, but should be adapted to the stage, the disease has reached. Hyperalimentation should be avoided at an acute stage of disease in any case. Critically ill patients should be given, as PN, a mixture consisting of amino acids (between 0.8 and 1.5 g/kg/day), carbohydrates (around 60% of the non-protein energy) and fat (around 40% of the non-protein energy) as well as electrolytes and micronutrients

Amino acids – Guidelines on Parenteral Nutrition, Chapter 4

Protein catabolism should be reduced and protein synthesis promoted with parenteral nutrion (PN). Amino acid (AA) solutions should always be infused with PN. Standard AA solutions are generally used, whereas specially adapted AA solutions may be required in certain conditions such as severe disorders of AA utilisation or in inborn errors of AA metabolism. An AA intake of 0.8 g/kg/day is generally recommended for adult patients with a normal metabolism, which may be increased to 1.2–1.5 g/kg/day, or to 2.0 or 2.5 g/kg/day in exceptional cases. Sufficient non-nitrogen energy sources should be added in order to assure adequate utilisation of AA. A nitrogen calorie ratio of 1:130 to 1:170 (g N/kcal) or 1:21 to 1:27 (g AA/kcal) is recommended under normal metabolic conditions. In critically ill patients glutamine should be administered parenterally if indicated in the form of peptides, for example 0.3–0.4 g glutamine dipeptide/kg body weight/day (=0.2–0.26 g glutamine/kg body weight/day). No recommendation can be made for glutamine supplementation in PN for patients with acute pancreatitis or after bone marrow transplantation (BMT), and in newborns. The application of arginine is currently not warranted as a supplement in PN in adults. N-acetyl AA are only of limited use as alternative AA sources. There is currently no indication for use of AA solutions with an increased content of glycine, branched-chain AAs (BCAA) and ornithine-α-ketoglutarate (OKG) in all patients receiving PN. AA solutions with an increased proportion of BCAA are recommended in the treatment of hepatic encephalopathy (III–IV)