The older population is increasing worldwide and in many countries older people will outnumber younger people in the near future. This projected growth in the older population has the potential to place significant burdens on healthcare and support services. Meeting the diet and nutrition needs of older people is therefore crucial for the maintenance of health, functional independence and quality of life. While many older adults remain healthy and eat well those in poorer health may experience difficulties in meeting their nutritional needs. Malnutrition, encompassing both under and over nutrition increases health risks in the older population. More recently the increase in obesity, and in turn the incidence of chronic disease in older adults, now justifies weight management interventions in obese older adults. This growing population group is becoming increasingly diverse in their nutritional requirements. Micro-nutrient status may fluctuate and shortfalls in vitamin D, iron and a number of other nutrients are relatively common and can impact on well-being and quality of life. Aging presents a number of challenges for the maintenance of good nutritional health in older adults.

Despite improving evidence-based practice following clinical guidelines to optimise drug therapy, Type 2 diabetes (T2DM) still exerts a devastating toll from vascular complications and premature death. Biochemical remission of T2DM has been demonstrated with weight loss around 15kg following bariatric surgery and in several small studies of non-surgical energy-restriction treatments. The non-surgical Counterweight-Plus programme, running in Primary Care where obesity and T2DM are routinely managed, produces >15 kg weight loss in 33 % of all enrolled patients. The Diabetes UK-funded Counterpoint study suggested that this should be sufficient to reverse T2DM by removing ectopic fat in liver and pancreas, restoring first-phase insulin secretion. The Diabetes Remission Clinical Trial (DiRECT) was designed to determine whether a structured, intensive, weight management programme, delivered in a routine Primary Care setting, is a viable treatment for achieving durable normoglycaemia. Other aims are to understand the mechanistic basis of remission and to identify psychological predictors of response. Cluster-randomised design with GP practice as the unit of randomisation: 280 participants from around 30 practices in Scotland and England will be allocated either to continue usual guideline-based care or to add the Counterweight-Plus weight management programme, which includes primary care nurse or dietitian delivery of 12-20weeks low calorie diet replacement, food reintroduction, and long-term weight loss maintenance. Main inclusion criteria: men and women aged 20-65years, all ethnicities, T2DM 0-6years duration, BMI 27-45 kg/m2. Tyneside participants will undergo Magnetic Resonance (MR) studies of pancreatic and hepatic fat, and metabolic studies to determine mechanisms underlying T2DM remission. Co-primary endpoints: weight reduction ≥ 15 kg and HbA1c <48 mmol/mol at one year. Further follow-up at 2 years. This study will establish whether a structured weight management programme, delivered in Primary Care by practice nurses or dietitians, is a viable treatment to achieve T2DM remission. Results, available from 2018 onwards, will inform future service strategy. Current Controlled Trials ISRCTN03267836 . Date of Registration 20/12/2013

AIM: METHODS: RESULTS: CONCLUSIONS:

As a population subgroup, older people are more vulnerable to malnutrition especially those who are institutionalised. Recognition of deteriorating or poor nutritional status is key in reversing the effects of undernutrition and reinforces the value of regular weight checks and/or the use of screening tools. Commercially produced supplements are often the first option used to address undernutrition in both acute and community settings. They can be expensive and, although regularly prescribed, have undergone only limited evaluation of their effectiveness in community settings. An alternative but less researched approach to improve the nutritional status of undernourished people is food fortification. This approach may be particularly useful for older people, given their often small appetites. The ability to eat independently has been significantly related to decreased risk of undernutrition. Assisting people who have difficulty feeding themselves independently should become a designated duty and may be crucial in optimising nutritional status. Lack of nutrition knowledge has been identified as the greatest barrier to the provision of good nutritional care. Education and training of care staff are pivotal for the success of any intervention to address undernutrition. The development of undernutrition is a multi-factorial process and a package of approaches may be required to prevent or treat undernutrition. Nutrition must be at the forefront of care if national care standards are to be met.

Fear of weight gain is a barrier to smoking cessation and significant cause of relapse for many people. The provision of nutritional advice as part of a smoking cessation programme may assist some in smoking cessation and perhaps limit weight gain. The aim of this study was to determine the effect of a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation.

Background: Excessive gestational weight gain is associated with adverse infant, childhood and maternal outcomes and research to develop interventions to address this issue is ongoing. The views of women on gestational weight gain and the resources they would consider helpful in addressing this are however largely unknown. This survey aimed to determine the views of newly pregnant women, living in areas of social disadvantage, on 1) their current body weight and potential gestational weight gain and 2) the resources or interventions they would consider helpful in preventing excessive gestational weight gain. Methods: A convenience sample of overweight and obese pregnant women living in Fife, UK, were invited to complete a short anonymised questionnaire at their 12 week booking visit. Results: 428 women, BMI>25 kg/m², completed the questionnaire. Fifty-four per cent of respondents were obese (231) and 62% were living in areas of mild to moderate deprivation. Over three-quarters of participants felt dissatisfied with their current weight (81%). The majority of women (60%) expressed some concern about potential weight gain. Thirty-nine percent were unconcerned about weight gain during their pregnancy, including 34 women (19%) who reported having retained weight gained in earlier pregnancies. Amongst those concerned about weight gain advice on physical activity (41%) and access to sports/leisure facilities were favoured resources (36%). Fewer women (12%) felt that group sessions on healthy eating or attending a clinic for individualised advice (14%) would be helpful. “Getting time off work” was the most frequently cited barrier (48%) to uptake of resources other than leaflets. Conclusions: These data suggest a lack of awareness amongst overweight and obese women regarding excessive gestational weight gain. Monitoring of gestational weight gain, and approaches for its management, should be formally integrated into routine antenatal care. Barriers to the uptake of resources to address weight gain are numerous and must be considered in the design of future interventions and services.