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CASE NOTES
Tuesday 10 August 2004 - 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION 

RADIO SCIENCE UNIT 

CASE NOTES - 1. - Get Fit and Get Well Food

RADIO 4

TUESDAY 10/08/04, 2100-2130 

PRESENTER:
MARK PORTER 


REPORTER:
CONNIE ST LOUIS 


CONTRIBUTORS:
DAVID CANDY
HEIDI GUY
NICK FINER
SUSAN SMITH
MARK RICHARDSON
VICKY PENNINGTON
FIONA DRY
MIKE STROUD 

PRODUCER: HELEN SHARP   

NOT CHECKED AS BROADCAST

PORTER
Today's programme is all about how what we eat and how much we eat affects our day-to-day health. Supplements and sport - do nutritional supplements help athletic performance? And if they do should we all be taking them? And how can you be sure of what they contain? I'll be finding out how taking a supplement, bought on the high street, nearly cost this Olympic athlete his career. 

CLIP
I was just totally shocked, I've always abided by the rules of the sport, I've always respected them, and I've always tried to conduct myself as a role model. So it's the worst thing that can happen to any athlete when you know that you've abided by all the rules and you still find yourself in this nightmare situation. 

PORTER
And I'll also be discovering how diet can influence how quickly we recover from illness. 

CLIP
People often do think that if you're lying in bed all day, ill in hospital, you don't need anything because you're not doing anything but actually if you've had major surgery there's an awful lot of calories and proteins needed for the recovery process and if you've got a temperature then there's an increase in nutritional requirement for that. So yeah the requirements are as much, or if not more, than you or I who are standing here fit and healthy. 

PORTER
But first obesity - more than half the UK population is now overweight and one in six is obese and the problem looks set to get much worse. Childhood obesity has grabbed more than its fair share of headlines recently as public health experts struggle to grapple with an explosion in the rate of obesity among children. One in six 10 year olds and one in five 15 year olds is now obese and the proportion is increasing at around 5% per annum. 

Nine-year-old Jemma Williams Fynne attends one of the foremost child obesity clinics in the country - the New Leaf Clinic at St Richards Hospital in Chichester. LEAF being an acronym for Lifestyle, Eating, Activity and Fitness. 

Jemma, how long have you been coming to the clinic here? 

JEMMA
Six months. 

PORTER
And why did you come in the first place? 

JEMMA
Because I want to look after my weight. 

PORTER
Were you worried about your weight? 

JEMMA
Yeah. 

PORTER
What was the impetus from your direction mum? 

JEMMA'S MUM
A growing concern. She was hitting puberty early and I was concerned that she should be checked up because being only eight other children were noticing things about her, so that's why we came along and spoke to the doctors. 

PORTER
One of those doctors was David Candy, paediatric gastroenterologist and head of the New Leaf clinic. 

CANDY
Well the weight itself means very little in isolation because the taller a child is the more they're going to weigh and in fact of course a tall child is made of muscle and bone, which actually weighs more than fat. So there has to be some way, when you're assessing whether or not a child's overweight, of taking into account how tall they are. And the way that is done in practice is to come up with a figure called the body mass index where you take the height and divide the weight by the height twice, in other words it's weight over height, divided by height. So you can see from that it's not a terribly easy concept to get your head around, it's somewhat easier in adults because you can quote a level beyond which an adult's weight is giving cause for concern. 

PORTER
This is where they talk about the adult being over 25 as overweight and over 30 as obese.

CANDY
That's right. And then when you're over 40 you're getting into what's called the morbidly obese bracket. But in children the BMI's going to change with age. You're thinnest when you're six and normally speaking your BMI is at its least then and then you gain weight progressively as you're a teenager, so the BMI goes up to eventually adult ranges. 

PORTER
Heidi Guy is the paediatric dietician at the clinic. 

GUY
Unfortunately dieticians don't have the best PR in the world in that people think you're going to be told you can never have chocolate and crisps and chips ever again, so we work quite hard on trying to sort of emphasise that nothing is banned, it's more of a case of being careful. So you do definitely get mixed reactions. I think a lot of children come when they're really quite motivated to make some changes and part of the work that we're trying to do is to assess whether children are quite - you know this is the right time for them to change or whether they've just been brought here by their parents - and that makes a big difference. 

PORTER
What's different about the Leaf approach from what we've been doing historically? 

GUY
Well the major difference that we're trying to do here, well two things really, first of all we're trying to look at it from a much more holistic point of view, trying to offer both dietary intervention and also looking at increasing their activity levels, which again is not something that we've traditionally done, it tends to be much more sort of dietary led. And also the fact we're now concentrating less and less on looking at weight, much more interested in looking at their body composition. The main reason being is from all the research that we've come across it tends to be to do with the sort of body fat levels which is important not how heavy you are. 

PORTER
Right, so a muscly child might have the same body mass index as a child who's fat but it's the fat one that you're interested in. 

GUY
Yes we're tend to be looking for the ones who are over-fat rather than overweight, which is a definite difference. 

PORTER
And how do you tell the difference? 

GUY
The way we've been doing it is using something called bioelectrical impedance to measure body composition and what we've been able to do is show that from simple measurements that you can work out the children who have more body fat compared to their fat free tissue - which would be your muscle and bone - and those are the children that we're specifically trying to target now. 

PORTER
So what actually works for these children, what is the most effective way to get their weight off?

GUY
I think from the experience that I've got I think increasing their activity for me would be the one to go for, I think most people are aware now what makes up a good and bad diet - if there is such a thing - and so consequently the children are becoming less and less active and I think that is actually what's made a bit of a difference in what we're doing here. 

PORTER
So what happened when you came to the clinic - they changed what you ate a little bit and they asked you to do a little bit more activity didn't they - what sort of things have you been doing? 

JEMMA
Swimming, running, basketball, athletics, netball. 

PORTER
You like doing the activities. Has it made you feel any different? 

JEMMA
Yeah. 

PORTER
In what way? 

JEMMA
I feel more happy. 

PORTER
It must be tricky putting a growing child on a diet. I mean with adults it's much easier, we don't have the requirements for growth, how do you make sure that you're not starving the children and preventing their growth? 

CANDY
Well it's based on giving the child about 75% of their expected calorie requirements. So they're eating just the similar sort of foods that they were having before, keeping an eye on the high calorie foods of course, but most of them don't actually notice that they're actually having a diet because they're not being put on special foods, they're not having their diet drastically changed, but it's encouraging them to try and eat smaller portions because that's a very important contribution to weight loss. 

PORTER
And of course they're increasing their activities - burning more calories - they're taking less calories in, they're burning more calories and that's where the weight loss comes from. What sort of weight loss do you aim for? 

CANDY
Well in fact in children you're doing alright if you're keeping their weight the same because as long as they're continuing to grow to gain in height then the net effect, in fact, is for them to be proportionately lighter because they've got the same body weight for a given height. But of course what we also monitor as the children come to the clinic is the body composition. For example, some of the children actually gain weight under treatment, at the same time they're losing fat. So we imagine what's happening is they're putting on muscle, they're putting on bone but they're losing fat. And since muscle and bone is heavier the net effect is that they gain weight. Now if we weren't monitoring their body composition then we would classify those children as failures because they're coming to a clinic where we're asking them to lose weight and they're gaining weight. In fact these are some of the successes. 

PORTER
There is a belief among some parents, isn't there, that actually there's some sort of glandular problem or a metabolic reason for their child being overweight, now how common in practice is that? 

CANDY
Well it's exceedingly rare. The children who have glandular problems would tend to be short and fat and most of the children we see are actually very tall and fat. And that's because their nutritional state is driving their growth - they often have an early puberty and then stop growing earlier. So the children who are tall and fat are pretty unlikely to have any sort of glandular problems, it's much more likely to be nutritional and exercise. And uncontrolled obesity is a pretty serious problem. If you think of any of the complications of obesity - wearing out your joints, wearing out your heart, wearing out your pancreas - then those complications are something like 60 times more frequent in obese children. I mean doctors jump up and down and get excited if an illness is two or three times increased as a complication of a certain other condition but in obesity the increases are absolutely phenomenal. And that's the prospect that we face unless we do something about - for these children and treat them more effectively. 

ACTUALITY
Now you're going to show me how good you are at basketball okay? 

Here Jemma catch. 

You're butter fingers mum. 

PORTER
One of my guests today is Dr Nick Finer, a consultant in obesity medicine at Addenbrookes Hospital and he joins us from our Cambridge studio. 

Nick, presumably the key to a successful weight reduction programme in adults is much the same, as we just heard there, you cut back on the food and you try and get people to do a bit more. So why is it such a struggle for so many seriously overweight people? 

FINER
Well it's not quite the same I suppose as children, children can grow and therefore don't have to necessarily cut back on their calorie needs whereas for adults to lose weight they clearly have to produce an energy deficit in order to start burning the fat. And the problem is that we just haven't evolved to have mechanisms that make that process easy. 

PORTER
So what you're saying presumably is we're designed to make the most of what we've got when we've got it - is that right? 

FINER
Absolutely, I mean we have evolved from periods of time of energy deficiencies - famine and so on - and we have very, very powerful mechanisms not only to help us take energy in, in the form of food, but to defend our bodyweight really probably as tightly as any other physiological function in the body. I mean clearly in adults the additional thing to our physiology is the environment in which we're in and the environment is changing, so it's becoming much easier to gain weight because we spend less energy and food has never been so available. And we're under quite a lot of pressure from our peer groups, I suppose, in terms of, if you like, not turning down the opportunity to have another pint at the pub or go for a kebab afterwards. 

PORTER
Is there any truth in the popular belief that people who are prone to be overweight do have some form of different metabolism - I haven't hear in the surgery - Doctor, I must have a slow metabolism I only have to look at a cheese sandwich and it ends up on my hips, I eat like a church mouse. What does the science tell us about that? 

FINER
Well what the science tells us is that the bigger you are the greater your energy expenditure and if you think of energy expenditure at rest it's a bit like a car with an engine that's ticking over and quite clearly a jaguar uses more petrol than a mini. When it comes to including movement activity and so on that clearly depends a little bit on how much you do and who else is in the car with you, to extend the analogy. But the heavier you are the more expensive it is to keep your body going at rest and the most expensive in energy terms it is to move it around. So once you are obese you have a higher energy expenditure than somebody's who's thin. 

PORTER
We've had an e-mail from a listener Lyndon Nash, Nick, that I wanted to run past you. Lyndon's disabled and has gained a lot of weight recently and is obviously not mobile and says: Well this eat less and exercise more is a great mantra but anyone unable to exercise seems to be ignored. Of course it's obvious that one needs to restrict calories but are there any particular foods that calorie for calorie are more likely to make you fat? I suppose Lyndon's after the carbohydrate debate here. 

FINER
Yeah I mean well calorie for calorie foods are the same, I think there is really no evidence that if you have the same calories from let's say a hamburger or the same calories from bread that it makes an awful lot of difference. But the problem is that the way that we perceive and consume and the effects of different foods are very different. So what we do know is that foods which are highly dense in calories - so that tends to be things that contain a lot of fat or sugar - tend to deceive the body or the brain into knowing what we've eaten, so it's much easier to over consume on high fat or high sugar foods. 

PORTER
What about grazing versus eating regular meals? 

FINER
Yes, that's an interesting question. There's been one or two studies done, there was one study where the same amount of food was given as, I think, six or seven meals a day versus one or two meals a day and on the one or two meals a day people over a two or three month period gained more weight than those who had it broken up. So it does look as though you can, if you like, make the energetic efficiency with which we absorb and handle the food we eat, you can decrease that efficiency by breaking it down to lots of small meals. On the other hand behaviourally it may be better to constrain ourselves to just two or three eating periods of the day rather than allowing any time any place to be an eating opportunity. 

PORTER
And briefly last but not least what about the old adage - breakfast like a king, lunch like a prince etc.? 

FINER
Well I think the only thing that eating late at night does is perhaps give you indigestion, I don't know of any evidence that it really alters your overall energy balance. 

PORTER
Dr Nick Finer thank you very much.

You're listening to Case Notes, I'm Dr Mark Porter and we're talking about nutrition and health. 

Now what dietary changes should you make if you're due to go into hospital for an operation or perhaps you're recovering from surgery or a serious illness? Given that one out of four hospital patients is nutritionally deficient in some way before they're even admitted what could be done to prepare them for the insult of an operation or build their strength back up afterwards? Susan Smith is senior dietician at St Richards Chichester. 

SMITH
I think the first thing that we would try to do is encouraging them to eat more normal food. If they're in hospital then it's obviously close liaison with the catering department and it's encouraging them to actually order extra from the hospital menu - there are certain things that they can have in between meals like a piece of cake or cheese and biscuits are sort of a classic thing. Those good high calorie foods, the things that most people think we shouldn't be eating very much of are actually the things that these underweight malnourished people need more of. 

PORTER
So you're just basically trying to build them up?

SMITH
Yes and - yeah and trying to use the ordinary everyday foods as much as we possibly can. If that doesn't work then we can fortify things, again the first sort of line of that would be adding extra cream, adding milk powder into things that they're eating because there's only so much food one person can possibly get through in the period of a day whereas if you make a standard custard and you add some extra milk powder in you've greatly increased the nutritional quality without increasing the volume of food. And then of course there's lots of things like there's Complan and Build Up and then you're into prescribable products which we have access to. 

PORTER
One of the big problems of people who are having surgery of course is that they're not eating are they - I mean they're nil by mouth for 24 hours often before or more if they're poorly and then they might not be able to eat for two or three days, sometimes longer after the procedure, how do we get round that because basically all we're given them via their drip is salt water or sugary water? 

SMITH
Yes, I mean this is where getting the nutrition as good as possible beforehand is so important because then you can survive for a couple of days without having so much and then making sure as soon as it is possible to get them eating again or get some sort of nutrition into them whether it is orally with real food or whether it is resorting to a tube feed that that happens as soon as possible after surgery. Locally we have quite a high elderly population and it's the good old roast dinners kind of things and your cottage pie and mash which goes down really well and some of your modern fancy stuff isn't so popular. 

PORTER
But it's quite possible to get that - the cottage pie etc. - as nutritionally valuable as some of the more modern perhaps "healthier" type foods. 

SMITH
Oh definitely. And possibly even easier because you have got your mash potato and there's loads of stuff you can put into mash potato to increase the calorie and protein intake and the same with the meaty bit of it, so cottage pie is a really good one for putting in the extra. 

PORTER
A lot of people will lose quite a bit of weight when they're in hospital because they're ill, with the best will in the world they don't feel like eating as much as possible, they may have been nil by mouth for a while, what advice do you give to people to build their weight up once they're at home? 

SMITH
A lot of it is carrying on similar sort of stuff to what we've done in hospital, so it's back to again getting rid of this sort of bad idea that you shouldn't be eating cream cakes and we shouldn't be eating full fat milk and cheese and really encouraging people to do that. It would be small meals frequently, so probably every couple of hours or so, trying to have either a nutritious drink - so a milky drink or a fruit juice - or something to eat, whether it is a piece of cake or a bag of crisps and splitting possibly your main meals and your puddings up because then you get more in. 

PORTER
So not to worry too much - we're looking at calories basically here - build yourself up, get to the weight you want to be and then maintain that then revert to a healthier diet then. 

SMITH
Yeah. 

PORTER
Does the same apply to people who are underweight - people who regard themselves as being too thin, they're otherwise fit and well? 

SMITH
Yeah definitely, I mean that would be the sort of the first line advice that we would give and we do occasionally in community clinics come across people who you said are fit and well otherwise but just are a little bit lighter than they'd like to be. And it would be looking first at how can we increase their food intake, encouraging them to eat a little bit more, it might just be coming up with suggestions of meals that are a little bit easier, a little bit less fussy, or take a little bit less time to prepare because often - if it's an elderly person living alone the novelty of cooking for one isn't there so they just almost forget to eat. So it's just trying to look at the social factors and make it as easy for them as possible. 

PORTER
Dietician Susan Smith extolling the virtues of good old fashioned comfort food when you're below par. Music to my ears. 

Now you could have hardly failed to have noticed that the Olympic Games start on Friday. For the athletes competing in Athens the Games will be the culmination of years of punishing training regimes, strict diets and in many cases nutritional supplements. 

But what do these supplements actually do and how can athletes be sure what's in them? We sent Connie St Louis to investigate and she began by talking to retired athlete Mark Richardson - 400 metre relay silver medallist at Atlanta, who'd failed a drug test after taking high street supplements. 

RICHARDSON
They turned up to my flat and I was actually on route to a training session at a gym, so the drug tester in question had to follow me to the gym and I produced the sample at the gym and then I heard the news about three weeks later, I had a phone call that there was an irregular finding in the urine sample. And that started a very long and drawn out legal process. 

ST LOUIS
Why did you test positive? 

RICHARDSON
The supplements that I was using in good faith were contaminated with minute traces of Nandrolone, which is an anabolic steroid. 

ST LOUIS
When you bought your supplements where did you get them from? Did you know the source, did you know that they were pure? 

RICHARDSON
I always was very vigilant and as an athlete you have to be accountable and responsible, so any supplements that I did take I used to check out with the team doctor to make sure that the list of ingredients corresponded with the rules of our sport. 

ST LOUIS
But the problem was that when the substance was tested in your urine it was found to have other things in there that you didn't know about. 

RICHARDSON
Absolutely, you know this was a contamination issue - I unwittingly and unknowingly took a prohibited substance which should not have been in the product in the first place. 

ST LOUIS
Mark Richardson's case sparked the so-called Nandrolone review, which found that there's often contamination in over-the-counter supplements. So how certain are we about the safety and purity of these substances? Nutritionist Vicky Pennington is responsible for product quality and safety for Boots the Chemist. 

PENNINGTON
With supplements and so on there are some areas where there are set limits and safety limits that manufacturers will have to actually comply with and we would check their compliance with those limits. 

ST LOUIS
But with variable manufacturing if your raw products are changing you can't always ensure that what you're putting into those vitamins are the same from batch to batch. 

PENNINGTON
Well this is where the quality processes and the auditing that we conduct actually does ensure those consistent standards of quality. Equally we're not only testing the raw materials but we're testing the products every stage along the process. So that's where we help to ensure that the products actually sold in the store maintain those same high standards. 

ST LOUIS
So do you kite mark your products? 

PENNINGTON
No we don't. 

ST LOUIS
Is that because you can't ensure their quality? 

PENNINGTON The quality is absolutely integral to the standards that we have for our brand and as a retailer why would we want to kite mark? 

ST LOUIS
So that somebody can know exactly what's in there all the time. 

PENNINGTON
There's no need to kite mark because these areas are already controlled by legislation. There are food labelling regulations which determine exactly how you declare the levels, there's a food supplements directive which we, as Boots, are already working to which gives you a positive list of all the ingredients that are safe and appropriate for supplements and equally we work to these safety limits - the upper safe levels. We don't feel there's any need for a kite mark. 

DRY
Foods don't have to have the same licensing as drugs. 

ST LOUIS
Dr Fiona Dry is a GP, who has worked with elite athletes. 

DRY
So it is easy to have contaminants, it's very easy to do that. 

ST LOUIS
So all supplements are classified as foods not as a drug. 

DRY
No. 

ST LOUIS
How are we going to get to a situation where we actually - what's in the bottle is actually what we're taking?
DRY
Again it's - I think the only thing is legislation. 

ST LOUIS
A recent Culture, Media and Sport select committee has highlighted the government's concerns in this area. Its report calls for a voluntary move by the drugs industry to introduce a labelling scheme aimed at identifying medicines containing substances banned in elite sport. But such a requirement would be incredibly expensive. But why was Mark Richardson taking supplements in the first place and for that matter why do we spend millions of pounds each year on vitamins and supplements - do we need them? Fiona Dry again. 

DRY
I think some athletes feel they need them, that's the problem. The difficulty being a top class athlete in this country or in this time is that you're constantly searching for that edge over your competitors. The difference between first and second place or for instance a medal or non medal is so tiny that you constantly search for something that will give you just a little bit more than your competitors. And of course if your competitors are all taking supplements then you want to take them too, just in case they actually will give you that tiny edge. So yes they do want to take them. Do they need them? Most of the time probably not. 

ST LOUIS
Do ordinary non - people who are non competing elite athletes - do they need supplements? 

DRY
I think in some cases people could benefit from supplements but they are specific times. Most of us if we could have a healthy diet with a varied amount of food and good quality food we probably wouldn't need additional vitamins and minerals. However, we're in a practical world, we're in a world where we work very hard, we probably don't eat sufficient fruit and vegetables, many people don't eat properly during the day at all - I have patients who come in and probably don't have breakfast, maybe have coffee and a bun or something for lunch and will rely on one meal a day to provide all their nutrients, which is really difficult. I would advise them to eat better but in a practical situation if they can't do that then supplementation obviously in that situation may be quite useful. 

PORTER
Connie St Louis there talking to Dr Fiona Dry. 

Well I'm now joined by Dr Mike Stroud, senior lecturer in medicine and nutrition at Southampton, polar explorer and marathon man extraordinaire. 

Mike, do you take supplements? 

STROUD
No I don't. 

PORTER
What about during your polar trip or when you ran the seven marathons in seven days? 

STROUD
Well during the polar trip I did. We went out for a very extended time on a very odd diet because we were trying to get as much food into as little weight as possible, so it was all dehydrated and very high in fat to get lots of calories per gram. And arguably also we were working so hard every day that maybe our needs were higher. So we took a balanced multivitamin supplement, sort of one a day. The same applied during our marathons, we were doing these seven marathons in seven days round the globe eating aircraft food and it seemed a reasonable thing to take one multivitamin a day in case we weren't getting what we needed. 

PORTER
What sort of supplements are athletes taking and is there any evidence that they make any difference? 

STROUD
Well athletes appear to be just supremely gullible really, they'll take anything that they will be offered as long as - in most cases anyway - that it's legal. And so they'll believe any story and the evidence is very, very poor indeed. Every theory, every idea that this or that would help, when it has been looked at, it hasn't really done so, except in perhaps a couple of instances, anything that contains caffeine will rev you up a bit and then there is a substance called creatine, which helps with sort of power bursts in some people, only those people that are deficient in it and most people actually aren't. But vegetarians can be and it can have perhaps some benefit in those sports but unfortunately people hear this and they take it when they go long distance running or something and it doesn't do anything then. 

PORTER
What about the average person on the high streets who's not an athlete, is there any - I mean it would seem to be sensible to take a once daily multivitamin and mineral supplement, I mean the worse that could happen, one would have thought, is that you're wasting your money but in some cases presumably it may prevent deficiency, would you support that or not? 

STROUD
Well actually I do - I think that the athletes who are eating a great deal and tending to eat healthy food are the ones that probably don't need the supplements and I'm more concerned about people who are either eating junk and perhaps not eating very much. You talked earlier about obesity and people are obviously overeating in many cases but there's a lot of people who are very conscious of their weight but they're not doing very much exercise, so overall they actually eat very little food. The elderly perhaps at home are consuming very small quantities and if it isn't really good quality stuff can they get enough vitamins for their needs out of a little of poor quality food? And I'm not sure they can. So a balanced vitamin may be the answer. 

PORTER
Do you have any particular concerns about products that are available on the high street? 

STROUD
Well I do because although I might commend a balanced multivitamin which means not too much of one thing and something of everything, I think if you take many of the supplements on the shelves they've got huge amounts of one vitamin and nothing in another and there's no science behind it at all and too much of a vitamin it might be poisonous in itself, if you are short of another vitamin you could make that shortage even worse because the big dose that you take of one thing will drive your metabolism in one direction and that will then call on another. So I'm terrified by what's on the shelves and I'm terrified by what's on the back pages of the colour supplements making recommendations about such things. You need to have a problem identified and otherwise try and eat well and maybe the balanced multivitamin approach. 

PORTER
Dr Mike Stroud thank you very much. 

Well that's all we have time for. Next week's programme is about prescribing - drug budgets and prescription charges. Ever wondered why your GP keeps switching you to a different brand of pill? Well tune in and all will be revealed. 

ENDS


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