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Physical activity and diet
Physical activity and diet
Healthy lifestyle concept
Since the beginning of written history — and likely before this as tomb drawings attest — civilisations have linked physical activity and diet with health and
wellbeing. Ancient Greeks believed that maintaining good health relied on the balance of black bile, yellow bile, phlegm and blood — the body’s four ‘humours’
— and that diet modifications could restore this balance if it was out of synch. It was also an Ancient Greek, Hippocrates in fact, who advised that, “All parts of
the body… if unused they become liable to disease, defective in growth and age quickly.”
Whilst it may once have been dismissed as mumbo jumbo and at
who are obese or overweight has risen significantly in recent years. In
The financial costs are enormous. In the UK, poor diet-related ill health
best, educated guesswork, science has steadily proved the Ancient
England, this increased from 53.1 per cent in 1993 to 62.15 per cent in
costs the NHS an estimated £5.8 billion each year and physical inactivity
Greeks right. Physical inactivity is the fourth leading cause of global
2013-144. Being overweight or obese increases a person’s risk of high
around £900 million10.
mortality , being linked to cancers, heart disease and diabetes. The
blood pressure, type 2 diabetes, stroke and coronary heart disease .
World Health Organization estimates that around 3.2 million people
Vitamin and mineral deficiencies, including iron, folate and vitamin D, are
The MRC has been at the forefront of research linking physical activity
die each year because of physical inactivity . And Public Health England
also common and contribute to diseases such as osteoporosis, which
and diet to health and wellbeing. This research has been behind many
(PHE) cautioned in 2014 that half of women and one third of men were
affects more than three million people in the UK6. And after smoking,
public health policy decisions and interventions aimed at addressing
damaging their health through insufficient physical activity .
1
2
5
diet is the major modifiable risk factor for cancer , with 30-35 per cent of
nutrient-deficient diets and inactivity. These range from the Department
cancers being attributed to poor diet8. An estimated 70,000 premature
of Health recommendation that all pregnant women should take folic acid
An unhealthy diet is also a major risk factor for many chronic diseases.
deaths in the UK could be avoided each year if UK diets matched
supplements to healthy living schemes such as Football Fans in Training.
The UK faces a double disease burden caused by dietary excess and
nutritional guidelines9.
3
7
imbalance and by nutritional deficiencies. The proportion of people
© Medical Research Council 2014
Physical activity and diet
1918:
1939:
1953:
1977:
Sir Edward Mellanby demonstrates that a
By walking miles in the Lake District on
dietary deficiency is the cause of rickets
proposed Second World War diet rations,
MRC scientist Professor Jeremy Morris
A large population study coordinated by
consumption reduces death from heart
and that this could be resolved with the
Dr Widdowson and Professor McCance
demonstrates for the first time the link
the MRC Dunn Nutrition Unit links low fibre
disease by 29 per cent in patients who
treatment of cod liver oil . This study is
demonstrate that they provide sufficient
between physical activity and coronary
intake to increased colon cancer rates .
had already experienced a myocardial
funded by the MRC.
nutrition for healthy functioning. They
heart disease13. See case study ‘Physical
infarction – or heart attack. This added
also conclude that in a rationed diet with
activity and heart disease’.
to the evidence compiled by the
11
1929:
An MRC trial shows that oily fish
16
Committee on Medical Aspects of Food
limited dairy, calcium fortification of
bread would be beneficial. This led to the
Professor Sir Frederick Gowland Hopkins,
statutory fortification of bread with
a founding MRC member, wins the 1929
calcium, which still continues today.
Policy (COMA) who advised people
1965:
to ‘eat at least two portions of fish, of
An MRC study shows that in patients
which one should be oily, weekly’. The
Nobel Prize in Physiology or Medicine
with coronary heart disease, a low fat
study also showed that a reduction in fat
for the discovery of vitamins. He had
diet results in a 10 per cent reduction in
consumption was not associated with any
shown that rats failed to grow if fed a
cholesterol but has no effect on the rate
diet of pure proteins, carbohydrates,
of death or reinfarction - a successive
fats, minerals and water and concluded
heart attack within 28 days of the first.
that foods must contain unidentified
The researchers therefore conclude that
substances needed for survival12. Before
a low fat diet is not necessary in the
his work, most researchers believed that
treatment of heart attacks .
Walkers in Mickleden Valley, English Lake District
certain foods.
1940:
Babies of a low birth-weight, and typically
suffering from poor nutrition, are more
Epidemiology Unit follow up a large
likely to develop coronary heart disease as
cohort of elderly people to assess the link
adults, according to Professor David Barker
between calcium intake, physical activity
and colleagues at the MRC Environmental
Professor Jeremy Morris demonstrates
and risk of hip fracture . They find that
Epidemiology Unit19. Adults of low birth-
that vigorous aerobic exercise including
whilst reduced calcium intake did not
weight are also more prone to strokes,
diet-linked illnesses, such as the scurvy
trips, were caused by a toxic substance in
1989:
Researchers at the MRC Environmental
14
that sailors suffered from during long
difference in death rate18.
Salmon
1968:
17
running, swimming, cycling and brisk
seem to be a risk factor for hip fracture,
higher blood pressure, altered stress
Dr Widdowson and Professor McCance
walking results in fewer heart attacks
the risk did increase with decreasing
responses and chronic bronchitis.
In an MRC-funded study, Dr Elsie
publish The Composition of Foods, regarded
when compared to comparatively
outdoor activity and in those with the
Widdowson and Professor Robert
as the foremost nutrition publication and
sedentary leisure activities such as
weakest grip. The researchers conclude
McCance demonstrate that the amount
the basis of most nutritional databases
gardening or DIY .
that physical activity and muscle strength
of iron in the body is regulated by
around the world. 2014 saw the publication
may protect against hip fracture by
absorption rather than excretion.
of its eighth edition.
preserving bone mass or reducing the risk
1934:
15
and severity of falls.
© Medical Research Council 2014
Physical activity and diet
1991:
2005:
2007:
2009:
An MRC-funded trial shows that folic
The MRC Collaborative Centre for Human
Findings from the MRC-funded
A study discovers that B vitamins in the
A study by researchers at the MRC
acid supplements taken at the time
Nutrition Research (HNR) produces a
Southampton Women’s Survey show that
body decrease significantly with age,
Epidemiology Unit finds that for each
of conception can prevent neural
review summarising the evidence behind
mothers with the least healthy diets were
corresponding with higher levels of
hour per day participants spent watching
tube defects such as anencephaly and
the public health target to reduce salt
less likely to follow guidance on optimum
homocysteine, a chemical in the blood
television, their risk of death from heart
spina bifida20. The study is halted so
intakes to 6g per day24.
infant feeding30.
linked to heart disease. B vitamins are
disease multiplied by seven per cent35.
that all participants can receive folic
thought to play a role in combating heart
acid supplements. This leads to the
disease by mopping up homocysteine.
Government recommendation that
2006:
The research, involving researchers at MRC
both women wishing to conceive and
The EPIC study demonstrates a 20-25
HNR, also found that children who ate
pregnant women take a 400µg folic
per cent reduced risk of developing
fortified breakfast cereals had higher levels
acid supplement. The UK Scientific
colon cancer among the physically
of B vitamins and lower homocysteine
Advisory Committee on Nutrition also
active population .
levels than those who did not32.
25
Young family watching TV
recommends that folic acid is added
to flour or bread. See case study ‘Food
Bowl of corn flakes
fortification and supplements’.
1992
MRC research highlights that maternal
Researchers at the MRC Epidemiology
vitamin D deficiency is common and
Unit at the University of Cambridge show
MRC-funded researchers show that a
that there is an association between time
‘prudent’ diet (high in fruit, vegetables,
The UK’s first national dietary survey
mineral accrual in the offspring during
It might not always be true that poorer
spent physically inactive, or sedentary,
oily fish and wholemeal cereals) is linked
programme begins, with on-going
childhood . Researchers at the MRC
neighbourhoods have fewer health-
and increased levels of insulin in the
to good lung function and a lower
collaboration with the MRC21. It provides
Epidemiology Resource Centre in
promoting resources, for example, access to
blood, a predictor of type 2 diabetes and
rate of chronic obstructive pulmonary
the Government with sound scientific
Southampton suggest that vitamin D
recreational physical activities, and are more
cardiovascular disease .
disease (COPD)36.
evidence on which to base nutrition and
supplementation of pregnant women
exposed to health damaging resources such
public health strategies.
could reduce osteoporotic fracture
as fast food outlets31. Professor Dame Sally
risk in their children. This, together
Macintyre at the MRC/CSO Social and Public
with other research at the centre, has
Health Sciences Unit (SPHSU) highlights
Minute weight changes have a bigger
reinforced recommendations by the
the need to engage in further research on
impact on insulin sensitivity than changes
A high-fibre diet reduces colorectal cancer
Department of Health , Food Standards
the importance of interactions between
in the macronutrient composition of the
risk, according to the part-MRC funded
Agency28 and NICE29 for daily vitamin D
individual and environmental factors in
diet, according to research conducted by
EPIC study involving researchers from the
supplementation during pregnancy.
shaping behaviour.
Professor Susan Jebb and colleagues at
2003:
22
MRC Dunn Human Nutrition Unit23.
that it is linked to reduced bone26
27
33
2010:
MRC HNR34.
© Medical Research Council 2014
Physical activity and diet
Pregnant woman cooking vegetables
2011:
2012:
MRC-funded researchers assemble the
Research led by the MRC Epidemiology
MRC-funded researchers at the University
largest database of objective physical
Unit demonstrates that consuming at
of Leeds develop My Meal Mate, a
activity data in children40. They show
least one sugar-sweetened beverage
smartphone app that enables users to
that higher levels of moderate to
each day is associated with increased
monitor their food intake and exercise. A
vigorous physical activity in children
risk of developing type 2 diabetes44. This
study found that those using the app lost
and adolescents are linked to better
research is part of the world’s largest
more weight than those monitoring food
cardio-metabolic risk factors, such as
study of new-onset diabetes across eight
intake and exercise via an online diary
European countries .
and a paper-based version. This is the
MRC-funded scientists discover that a
Researchers at the MRC Lifecourse
blood pressure and cholesterol level.
mother’s nutrition during pregnancy
Epidemiology Unit (LEU) show that
This is despite how much time they
first weight loss app to be supported by
can strongly influence her child’s risk
adequate calcium intake may be required
spent being sedentary .
published peer-reviewed evidence48.
of obesity and, as an adult, their risk of
to maximise the benefits of physical
heart disease, stroke and diabetes. This is
activity on bone development. Improving
Researchers at MRC HNR demonstrate
caused by epigenetic change, which alters
levels of physical activity and calcium
a link between the high consumption
the function of her child’s DNA .
intake in childhood may help to improve
of sugary drinks by teenagers and risk
Researchers at MRC HNR demonstrate
bone mass accrual38.
factors for heart disease in later life46.
that supplementing Gambian children
These include lower ‘good’ cholesterol
and pregnant women with calcium
levels and higher levels of the ‘bad’
causes unintended, potentially adverse,
triglyceride form of fat in their blood.
long-term effects on growth and skeletal
37
41
Children on bikes
The MRC/CSO SPHSU launches the
45
first ‘Football Fans in Training’ (FFIT)
Researchers at the MRC/CSO SPHSU
mineralisation without the anticipated
programme. This is a free 12-week
examine the relationship between
benefits49, 50. This cautions against
physical activity and healthy eating
ethnic concentration and access to
programme for overweight and obese
fast food outlets, supermarkets and
In the largest twin study of its kind to
Iodine deficiency in pregnancy has an
based on Western populations to
men delivered by community coaches
physical activity facilities and show that
date42, MRC-funded researchers show
adverse effect on children’s mental
countries such as The Gambia without
at professional football clubs. 412 men
increasing ethnic minority concentration
that daily physical activity and sedentary
development, according to the MRC-
supporting evidence. See case study
who were on FFIT in autumn 2010 lost a
is associated with increasing rates of
behaviour are moderately heritable (43
funded Avon Longitudinal Study of
‘Calcium and health in The Gambia’.
total of 2,300 kg in weight. This leads to
fast food outlets . The study highlights
per cent) . These findings have important
Parents and Children (ALSPAC) .
a European-wide programme to increase
that neighbourhood strategies to reduce
consequences for public health initiatives
physical activity after a further £5 million
barriers to maintaining health lifestyles
because adherence to a physical
funding is awarded.
should incorporate targeted strategies to
activity intervention is likely to be more
reduce the density of fast food outlets in
challenging for individuals who lack a
ethnically-dense areas.
biological drive to be active.
39
2013:
43
applying dietary recommendations
47
© Medical Research Council 2014
Physical activity and diet
2011-2014:
2014:
MRC Epidemiology Unit research51
Adherence to public health guidelines
Research undertaken by the EPIC-InterAct
The award-winning Football Fans in
The health benefits of the London
highlights the first large-scale evidence
recommending 30 minutes physical
consortium led by the MRC Epidemiology
Training (FFIT) programme is effective
Cycle Hire scheme outweigh the
in Europe linking dietary factors to risk
activity per day is associated with
Unit and involving researchers from MRC
and cost-effective in delivering long-term
negative impacts from injuries and
of type 2 diabetes. Key findings include
reduced death rate during more than 20
Human Nutrition Research demonstrates
weight loss and other health benefits,
exposure to air pollution, according to
associating increased type 2 diabetes risk
years of follow-up in the Allied-Dunbar
that not all saturated fatty acids are the
including increased physical activity and
computer modelling studies at the MRC
with regular high red and processed meat
National Fitness Survey .
59
same . It highlights the importance of
healthier eating patterns . Researchers
Epidemiology Unit. This helps make the
intake52 and reduced risk with fruit and
recognising differences between the
at the MRC/CSO SPHSU and Glasgow
public health case for cycle hire schemes62.
57
58
60
vegetable intake . The research also shows
health effects of different types and the
University show that the setting, mode
that certain food subtypes (eg oily fish,
need for more nuanced public health
of delivery and content has strong
fermented dairy products) have inverse
messages about overall intake.
appeal for many overweight and obese
53
2015:
associations with the disease, which may
men. It has engaged men who are often
Researchers at the MRC Epidemiology
be missed if only the total intake of those
considered high risk and ‘hard-to-reach’
Unit show that lack of physical exercise
food groups is considered (total fish intake,
across the socio-economic spectrum61.
may be responsible for twice as many
total dairy products intake)
54, 55, 56
.
Older couple exercising
deaths as obesity63.
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26. Javaid MK et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet 2006;367:36-43.
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31. Macintyre S. Deprivation amplification revisited; or, is it always true that poorer places have poorer access to resources for healthy diets and physical
activity? International Journal of Behavioral Nutrition and Physical Activity 2007, 4:32 doi:10.1186/1479-5868-4-32
32. Kerr, Maeve, Livingstone, Barbara, Bates, Christopher J., Bradbury, Ian, Scott, John M., Ward, Mary, Pentieva, Kristina, Mansoor, Mohammad Azam and McNulty, Helene (2009) Folate,
Related B Vitamins, and Homocysteine in Childhood and Adolescence: Potential Implications for Disease Risk in Later Life. PEDIATRICS, 123 (2). pp. 627-635.
33. Helmerhorst HJ et al. Objectively measured sedentary time may predict insulin resistance, independent of moderate and vigorous physical activity. Diabetes. 2009 Aug;58(8):1776-9. doi: 10.2337/db08-1773. Epub 2009 May 26.
34. Jebb SA et al. Effect of changing the amount and type of fat and carbohydrate on insulin sensitivity and cardiovascular risk: the RISCK (Reading, Imperial, Surrey, Cambridge, and
Kings) trial. Am J Clin Nutr. 2010 Oct;92(4):748-58. doi: 10.3945/ajcn.2009.29096. Epub 2010 Aug 25. http://www.ncbi.nlm.nih.gov/pubmed/20739418
35. Wijndaele K et al. Television viewing time independently predicts all-cause and cardiovascular mortality: the EPIC Norfolk Study Int. J. Epidemiol. (2010) doi: 10.1093/ije/dyq105
36. The relationship of dietary patterns with adult lung function and COPD doi: 10.1183/09031936.00114709 ERJ August 1, 2010 vol. 36 no. 2 277-284
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39. 2 Harding S et al. Neighbourhood food and physical activity environments in England, UK: does ethnic density matter? International Journal of Behavioral Nutrition and Physical Activity 2012, 9:75 doi:10.1186/1479-5868-9-75
40. International Children’s Accelerometry Database: http://www.mrc-epid.cam.ac.uk/research/studies/icad
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41. Ekelund U et al. Moderate to Vigorous Physical Activity and Sedentary Time and Cardiometabolic Risk Factors in Children and Adolescents. JAMA. 2012;307(7):704-712. doi:10.1001/jama.2012.156
42. TwinsUK: http://www.twinsuk.ac.uk/
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45. EPIC-InterAct, funded by the EU.
46. Prospective associations between sugar-sweetened beverage intakes and cardiometabolic risk factors in adolescents The American Journal of Clinical Nutrition, 2013
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53. Cooper AJ, et al. Fruit and vegetable intake and type 2 diabetes: EPIC-InterAct prospective study and meta-analysis. Eur J Clin Nutr. 2012;66:1082–92.
54. Patel PS et al. The prospective association between total and type of fish intake and type 2 diabetes in 8 European countries: EPIC-InterAct Study. Am J Clin Nutr. 2012;95:1445–53
55. Sluijs I et al. The amount and type of dairy product intake and incident type 2 diabetes: results from the EPIC-InterAct Study. Am J Clin Nutr. 2012;96:382–90.
56. O’Connor L et al. Dietary dairy product intake and incident type 2 diabetes: a prospective study using dietary data from a 7-day food diary. Diabetologia. 2014 May;57(5):909-17.
57. Long G, Watkinson C, Brage S, Morris JN, Tuxworth W, Fentem PH, Griffin SJ, Simmons RK, Wareham NJ. Mortality benefits of population-wide adherence
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Investigation into Cancer and Nutrition Study (EPIC) American Journal of Clinical Nutrition; Published Online 14 Jan 2015
© Medical Research Council 2014
Physical activity and diet
Image Credits
Image 1: Healthy lifestyle concept. Copyright: Roman Prishenko, Shutterstock
Image 2: Walkers in Mickleden Valley, in summer, English Lake District. Copyright: Stewart Smith Photography, Shutterstock
Image 3: Salmon. Copyright: Gayvoronskaya Yana, Shutterstock
Image 4: Bowl of corn flakes. Copyright: ifong, Shutterstock
Image 5: Young family watching TV. Copyright: Andrey Popov, Shutterstock
Image 6: Pregnant woman cooking vegetables. Copyright: Martin Novak, Shutterstock
Image 7: Children on bikes. Copyright: Sergey Novikov, Shutterstock
Image 8: Older couple exercising. Copyright: Tom Wang, Shutterstock
© Medical Research Council 2014
Physical activity and diet
Physical activity and heart disease
Vintage style picture of a red London Bus
Until the Second World War, it was unknown that a lack of physical activity could contribute to coronary heart disease (CHD). It was only afterwards, when the rates
of heart disease started to rise, that this link was made by Professor Jeremy Morris in 1953. He found that the rate of CHD was higher in sedentary double-decker bus
drivers than in the presumably more active bus conductors. He found similar results when comparing postal workers who sat behind desks to roaming postmen.
Professor Morris considered that the protection against CHD granted to
Professor Morris believed that because occupations were becoming
Professor Jeremy Morris was an epidemiologist looking at patterns of
more active workers was a result of their larger amounts of energy
increasingly sedentary, any future role of physical activity in the
disease in a population and why some people suffered ill health and
expended, rather than a difference in nervous strain, as previously believed.
protection against heart disease would have to be related to leisure
not others. This methodology had so far only been used for infectious
time activity. He therefore set up various studies to investigate this link.
diseases and so his use of it in this field was ground-breaking. Professor
Further studies showed that ischaemic myocardial fibrosis — blockage
The first of these was the pioneering Whitehall study, which looked
Morris published a number of papers that set out the potential for
of the heart’s arteries — was four to five times more common in those
at the leisure activities of almost 17,000 civil servants. This research
epidemiological research, pioneering its use in a range of areas of
categorised as ‘light’ workers than in those classified as ‘heavy’ workers
demonstrated that vigorous aerobic exercise including running,
medicine and public health.
at 45–59 years of age, and two to three times more common at 60–69
swimming, cycling or brisk walking resulted in a lower incidence of heart
years. Clinical records showed that hypertension and hypertensive heart
attacks when compared to comparatively sedentary leisure activities
disease were more commonly found in the ‘light’ workers and appeared
such as gardening or DIY.
10 to 15 years earlier in them than in the ‘heavy’ workers.
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Image: Vintage style picture of a red London Bus. Copyright: Christian Mueller, Shutterstock
© Medical Research Council 2014
Physical activity and diet
Calcium and health in The Gambia
Bone structure
All living cells require calcium to remain viable. It is also required for specific functions in the body so it is crucial that people consume sufficient amounts in
their diet. Calcium is essential for bone growth as it is needed for the mineralisation of bone; the rate of bone growth is proportional to the rate of calcium
deposition in bone. Insufficient calcium intake may lead to a low bone mineral density, which has implications for bone health in later life, such as a risk of
osteoporosis. Calcium also plays a role in regulating muscle contraction (including the heart) and blood pressure, digestion and ensuring blood clots normally.
It is important for pregnant and breast-feeding women to obtain
or infant birth weight, growth or bone mineral status in the first year of
A separate study undertaken by these MRC researchers has however
sufficient calcium to assist the growth of their baby’s developing
life . This supports research showing that metabolic adaptations occur
demonstrated that calcium supplementation in Gambian children aged
skeleton. Studies have also shown that supplementing calcium-deficient
during human pregnancy and lactation to provide sufficient calcium for
8-12 years old may increase bone mineralisation and, ultimately, peak
pregnant women with calcium may reduce their risk of high blood
foetal growth and breast-milk production .
bone mass6.
1
2
pressure and pre-eclampsia.
These results were followed by a publication in 2013, which showed
However, recent results from long-term follow-up of these studies
The MRC has funded several studies to determine whether calcium
that calcium supplementation had no significant effect on a mother’s
have indicated that calcium supplementation of Gambian children and
supplementation in Gambian women — whose calcium intake is low and
blood pressure .
pregnant women causes unintended, potentially adverse, long-term
3
effects on growth and skeletal mineralisation, without the anticipated
whose infants experience poor growth and bone mineral growth is poor
These research groups also investigated whether there was an
benefits7, 8. This cautions against applying dietary recommendations
association between maternal calcium supplementation and offspring
based on Western populations to countries such as The Gambia without
In 2006 researchers from MRC Human Nutrition Research (HNR) and the
blood pressure at age five-10 years old . The researchers found no
supporting evidence
MRC International Nutrition Group showed in fact that supplementing
association between maternal calcium supplementation and offspring
pregnant Gambian women, accustomed to a low-calcium diet, with
blood pressure5.
compared to those in Western populations — would be beneficial.
calcium had no significant benefit for breast-milk calcium concentrations,
4
These findings have implications for nutrition policy in The Gambia and
other populations with low calcium intake.
© Medical Research Council 2014
Physical activity and diet
References
1. Jarjou LM et al. Randomized, placebo-controlled, calcium supplementation study in pregnant Gambian women: effects on breast-milk calcium concentrations
and infant birth weight, growth, and bone mineral accretion in the first year of life. Am J Clin Nutr. 2006 Mar;83(3):657-66.
2. Prentice A. Micronutrients and the bone mineral content of the mother, fetus and newborn. J Nutr 2003;133:1693S–9S.
3. Goldberg GR et al. Randomized, placebo-controlled, calcium supplementation trial in pregnant Gambian women accustomed to a low calcium intake: effects on
maternal blood pressure and infant growth. Am J Clin Nutr. 2013 Oct;98(4):972-82. doi: 10.3945/ajcn.113.059923. Epub 2013 Sep 4.
4. Hawkesworth S et al. Effect of maternal calcium supplementation on offspring blood pressure in 5- to 10-y-old rural Gambian children. Am J Clin Nutr. 2010 Oct;92(4):741-7. doi: 10.3945/ajcn.2010.29475. Epub 2010 Jul 28.
5. Prentice A. Maternal calcium metabolism and bone mineral status. Am J Clin Nutr 2000;71:S1312–6
6. Dibba B et al. Effect of calcium supplementation on bone mineral accretion in gambian children accustomed to a low-calcium diet. Am J Clin Nutr. 2000 Feb;71(2):544-9.
7. Landing MA Jarjou et al. Unexpected long-term effects of calcium supplementation in pregnancy on maternal bone outcomes in women with a low calcium intake: a follow-up study.
Am J Clin Nutr. 2013 Sep; 98(3): 723–730. Published online 2013 Jul 31. doi:10.3945/ajcn.113.061630 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743734/
8. Gail R Goldberg et al. Randomized, placebo-controlled, calcium supplementation trial in pregnant Gambian women accustomed to a low calcium intake: effects on maternal blood pressure and
infant growth. Am J Clin Nutr. 2013 Oct; 98(4): 972–982. Published online 2013 Sep 4. doi:10.3945/ajcn.113.059923 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778867/
Image Credits
Image: Bone structure. Copyright: zimowa, Shutterstock
© Medical Research Council 2014
Physical activity and diet
Food fortification and supplements
Fresh bread and wheat
In recent years, there has been increasing interest in micronutrient malnutrition. This is largely due to an increased understanding of its contribution to the global burden of
disease1. The 2000 World Health Report2 identified iodine, iron, vitamin A and zinc deficiencies as being among the world’s most serious nutrition-related health risk factors.
Micronutrient deficiency is responsible for a variety of non-specific physiological impairments which can lead to reduced resistance to infections, metabolic disorders and
impaired physical and psychomotor development in addition to the more obvious diseases caused by micronutrient deficiency. The best way to prevent micronutrient
malnutrition is consumption of a balanced diet sufficient in every nutrient. However, this relies on universal access to adequate food and appropriate dietary habits. Fortifying
food with micronutrients can deliver nutrients to large segments of the population without needing drastic changes in food consumption patterns.
The MRC has played an important role in demonstrating the benefits of
participants could receive folic acid supplements. Observational studies
acid supplement4. The Scientific Advisory Committee on Nutrition
food fortification leading to Government recommendations and national
indicate that a similar level of prevention can be achieved among
(SACN, Chair: Dr Ann Prentice from MRC Human Nutrition Research)
and international policies.
women who have not already had an affected pregnancy and that this
and the Food Standards Agency both recommend the mandatory
may be achieved with the currently recommended lower dose of folic
fortification of bread or flour with folic acid. The Government will finalise
After a number of studies suggested that folic acid might reduce
acid (400 microg/d). Encouraging women to consume a supplement
its decision on mandatory fortification of flour in 2015.
the risk of neural tube defects (NTDs), the MRC conducted a
however has limitations, particularly as folic acid should be taken in early
randomised controlled trial to determine the effectiveness of folic acid
pregnancy and according to data from an MRC-funded study, one in six
It was MRC-funded researchers Dr Elsie Widdowson and Professor
supplementation in the prevention of the recurrence of NTDs. The RCT
pregnancies in the UK are unplanned . However, a 2009 study from the
Robert McCance who, when analysing Second World War diet rations,
found that women with a previous history of a pregnancy affected by
MRC Epidemiology Resource Centre, using data from the Southampton
concluded that in a rationed diet with limited dairy, calcium fortification
an NTD reduced their recurrence risk by 70 per cent by taking 4000
Women’s Study, showed that women planning a pregnancy only
of bread would be beneficial. This led to the statutory fortification of
micrograms (µg) of folic acid daily. The study was halted so that all
marginally increased their compliance with health behaviours and folic
bread with calcium, which still continues today.
3
© Medical Research Council 2014
Physical activity and diet
As part of the Government’s Red Tape Challenge on ‘Hospitality, Food
The MRC has also shaped national and international guidance on vitamin
by environmental influences during intrauterine and early postnatal life.
and Drink’5 to reduce regulatory burdens on business, the Department
D supplementation. Vitamin D is essential for musculoskeletal health
One study linked maternal vitamin D insufficiency with poor offspring
for Environment, Food and Rural Affairs (DEFRA) was asked in 2013 to
as it promotes calcium absorption from the bowel, enabling bone
bone mineral accrual during childhood — likely to lead to an increased
review whether mandatory fortification of bread with calcium, iron,
mineralisation and preventing osteoporosis. Osteoporosis is a major
risk of fracture in late adulthood10. Data from the Southampton Women’s
niacin and thiamine should continue. The SACN demonstrated that
public health problem, affecting around three million people in the
Survey also showed a link between maternal vitamin D concentrations
removal of calcium and iron would adversely affect the intake among
UK7. 300,000 people receive hospital treatment for fragility fractures
during pregnancy and a reduced bone mass in their offspring’s
certain population groups . It was recognised that the current system
each year as a result of the condition, which is estimated to cost the
bone mass at birth11. This reinforced government recommendations
provided equal health benefits for all consumers and that flour should
NHS more than £1.73 billion each year8. In the early to mid-2000s, it
encouraging vitamin D supplementation during pregnancy to optimise
be preserved as a vehicle for population nutritional intervention. In
was thought that universal vitamin D supplementation in the elderly
skeletal development in offspring and to reduce the risk of osteoporosis
particular, flour was a particularly important source of calcium, especially
would help to prevent these fractures. However, studies led by Professor
in later life. The SACN is currently reviewing its advice on vitamin D
for those who do not consume dairy products. The Government has
Cyrus Cooper at the MRC Lifecourse Epidemiology Unit (LEU) at the
dietary recommendations for the UK, to be published in 2015. MRC-
since concluded that the mandatory fortification of bread with calcium,
University of Southampton showed that vitamin D supplementation
funded research has contributed to the evidence on which these
iron, niacin and thiamine should continue.
had no marked impact on fracture incidence . Professor Cooper’s team
recommendations will be based.
6
9
however demonstrated that the risk of osteoporotic fracture is modified
References
1. World Health Organization and Food and Agriculture Organization of the United Nations Guidelines on food fortification with micronutrients. http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf
2. World Health Report, 2000. World Health Organization.
3. Wellings K et al. The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes
and Lifestyles (Natsal-3). The Lancet. Volume 382, Issue 9907, 30 November–6 December 2013, Pages 1807–1816
4. Crozier SR et al. Do women change their health behaviours in pregnancy? Findings from the Southampton Women’s Survey. Paediatr Perinat Epidemiol. 2009 Sep;23(5):446-53. doi: 10.1111/j.1365-3016.2009.01036.x.
5. http://www.redtapechallenge.cabinetoffice.gov.uk/themehome/hospitality-food-and-drink/
6. http://www.sacn.gov.uk/pdfs/sacn_uk_bread_and_flour_regulations_position_statement.pdf
7. www.nhs.uk
8. National Osteoporosis Guideline Group (NOGG), 2010.
9. Grant AM et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet. 2005 May 7-13;365(9471):1621-8.
10. Javaid MK et al. Maternal vitamin D status during pregnancy and childhood bone mass at age 9 years: a longitudinal study. Lancet 2006;367:36-43.
11. Harvey NC et al. Paternal skeletal size predicts intrauterine bone mineral accrual. J Clin Endocrinol Metab 2008;93:1676-1681.
Image Credits
Image: Fresh bread and wheat. Copyright: Scorpp, Shutterstock
© Medical Research Council 2014