How diet and nutrition impact health

“It’s important to get diet right first before we go down the route of nutrient supplements”, Ms Jamieson emphasises. There are few randomised controlled trials to support the value of food supplements. One problem is that early observational studies were based on whole diets – such as fish-containing diets but later studies were based on single ingredients such as fish oil.  “When you take just one element of that food out and then put it into a capsule to … try to replicate what you’ve seen in the observational studies, there may be confounding factors [that] are often not taken into account in intervention studies”, she says.

In fact, it is possible to demonstrate causality from observational studies – as, for example, with smoking and cancer. The Bradford-Hill criteria are widely used to assess whether and observed association is likely to be casual, she explains.

Is magnesium a forgotten nutrient?

Magnesium is critical for more than 600 different processes in the body involving the musculoskeletal, cardiovascular, respiratory and neurological systems and yet we hear much less about it than iron and calcium. Magnesium deficiency can be associated with a wide range of non-specific effects. There is no simple blood test for magnesium because 99% of body magnesium is in bone and other tissues.

The typical Western diet is deficient in magnesium and so supplements are often needed. However, it is important to be aware that the bio-availability of magnesium is better from products containing amino-acid linked magnesium than from those based on magnesium oxide. “You may not necessarily get the dose that’s on packet – depending on which product you take”, says Ms Jamieson.

One approach to the management of non-specific, possible magnesium deficiency  symptoms might be to try a magnesium supplement.

Why the omega-3/omega-6 fatty acid balance is critical 

Ideally the diet should contain similar amounts of omega-3 and omega-6 fatty acids. However, the modern Western diet contains abundant quantities of omega-6 fatty acids, and lesser amounts of omega-3 fatty acids.

The human body needs both omega-3 and omega-6 fatty acids. They are essential fatty acids that cannot be made by the human body and must be consumed as part of the diet. Although EPA (eicospentaenoic acid) and DHA (docosahexaenoic acid) can be made in the body, recent research shows that it is better to obtain them from fish and seafood in the diet.

Omega-6 fatty acids are precursors of inflammatory mediators and omega-3 fatty acids are precursors of anti-inflammatory mediators. “A diet that’s richer in omega-3 fatty acids will be a much more anti-inflammatory diet whereas a diet that’s very rich in omega-6 fatty acids will be a more pro-inflammatory diet”, says Ms Jamieson.

A balanced intake of omega-3 and omega-6 fatty acids may reduce the need for anti-inflammatory medication.  A good way to increase the amount of omega-3 fatty acids in the diet is to adopt a Mediterranean diet that is rich in vegetables, fish and seafood.

How much vitamin D do you really need?

Vitamin D is classed as a vitamin and as a nutrient. The main source of vitamin D is through the action of ultraviolet light on the skin and in the UK there is only sufficient sunlight for this to occur between the months of April and September. Currently vitamin D supplementation is recommended for everyone during the winter months. People who cover their skin, those with dark skin tones and people who are indoors all day are at high risk of vitamin D deficiency.

Dose recommendations for vitamin D vary considerably. Vitamin D receptors are found in many tissues and it is important for bone health and immune function. Vitamin D deficiency is associated with many conditions that are affected by the immune system, for example, multiple sclerosis.

One important consideration is that magnesium is needed for the enzymes that metabolise vitamin D in the body. “So, if an individual is magnesium deficient, they may take a vitamin D supplement but their body won’t be able to access the active form of vitamin D”, explains Ms Jamieson.

Vitamin D is a fat-soluble vitamin and ideally it should be taken with a fat-containing meal. Currently the recommended dose is 10 micrograms (400 i.u.) . Some people have found through a process of trial and error that they respond better to larger doses, Ms Jamieson acknowledges.

Could a good diet and supplements reduce the need for medication?

Healthcare professionals should always consider whether nutritional factors are at play when a person presents with new symptoms, even if they do not look malnourished at first glance. Some nutrient deficiencies can increase the propensity to develop indigestion or nausea, for example, a magnesium deficiency can lead to nausea. Medication may also play a role. For example, a proton pump inhibitor (PPI) may be given for indigestion but PPIs can also reduce the absorption of magnesium, iron, vitamin C and various other nutrients. Changing the diet to tackle the root cause of some of the symptoms might reduce the need for the medication, Ms Jamieson explains.

When people present with new symptoms or what appears to be a new condition it is important for frontline clinicians to consider the possibility of nutrient deficiencies which may be amenable to correction either through diet or supplements.

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.

When people present with symptoms the potential causes need to be considered, bearing mind that nutritional deficiencies may be contributory factors says Lisa Jamieson. Taking as an example somebody presenting with dyspepsia or indigestion, she notes that some nutrient deficiencies can increase the propensity to develop indigestion or nausea, for example, a magnesium deficiency can lead to nausea.  Furthermore, medication may also play a role. “So, for example, a proton pump inhibitor may be given for indigestion and a proton pump inhibitor can also reduce your absorption of various nutrients. Proton pump inhibitors reduce absorption of magnesium, iron, vitamin C and various other nutrients so whilst you’re taking a proton pump inhibitor you may be – downstream – … influencing your nutritional status. If you were to change the way you eat and try and tackle the root cause of some of those symptoms you then may be able to reduce the need for the medication”, she explains.

Ms Jamieson has personal experience of this situation. “For the last decade I’ve been managing a plethora of different types of symptoms and conditions with a nutritional approach – so much so that I’ve been able to massively reduce my need for medication”, she says.

Food insecurity and malnutrition

Healthcare professionals do not always make the link between food insecurity or food poverty and medically unexplained symptoms. Typically, “this affects mothers who may prioritise their children in terms of their own food insecurity. They may then present to a pharmacist or a GP with symptoms which may be perceived as medically unexplained”, says Ms Jamieson. Moreover, they may at first glance appear to be well-nourished. “Traditionally, we’ve thought that malnutrition looks like somebody who is very underweight and starving and actually in a modern-day diet scenario you can have a lot of calories within your diet but not very much nutrition. You can have a lot of high-calorie low-nutrient density foods and therefore on the surface you may look well-nourished because you’re of a normal weight, but actually you may be  … because of the poor nutrient content of those foods,  actually be very malnourished. So, we do need to consider that people who are presenting to healthcare professionals within the UK may actually be malnourished even though they may not look malnourished at first glance”, she adds.

Ms Jamieson emphasises that when people present with new symptoms or what appears to be a new condition it is important for frontline clinicians to consider the possibility of nutrient deficiencies which may be amenable to correction either through diet or supplements.

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.

Vitamin D is classed as a vitamin and as a nutrient. However, “our main source of vitamin D is through the action of ultraviolet light on the skin and in the UK we can only make vitamin through the action of sun on our skin between the months of about April to September, because that’s when the sun is at the right angle”, explains Lisa Jamieson. Other factors that reduce the ability to make vitamin D include living at northerly latitudes and skin colour, because the pigmentation in skin acts as a natural sunscreen.  “So, people with darker skin tones who live very far north within the UK … will struggle to make vitamin D to reach the optimal levels throughout the winter”, she says. Currently vitamin D supplementation is recommended during the winter (October – March) for everyone “especially those people who are more at risk – people who cover their skin, people with darker skin tones, people who are indoors all day [such as those] in Care Homes”, says Ms Jamieson.

Dose recommendations for vitamin D vary considerably. (The NICE recommendation is 400i.u. (10mcg) per day).  Vitamin D receptors are found in many tissues suggesting that it is important for more than bone health.  “Vitamin D is really important for how the immune system functions and vitamin D deficiency is associated with lots and lots of different conditions that are affected by the immune system. So, for example, …. you’re at much higher risk of developing multiple sclerosis if you’ve had a vitamin D deficiency”, she says.  Moreover, the prevalence of multiple sclerosis is greater in areas that are further north. “So, it’s important that we consider vitamin D beyond just bone health”, she emphasises.

Another important factor is that magnesium is needed for the enzymes that metabolise vitamin D in the body. “So, if an individual is magnesium deficient, they may take a vitamin D supplement but their body won’t be able to access the active form of vitamin D”, explains Ms Jamieson. This could be a confounding factor in research studies that may have been overlooked in the past. “When you look at the SACN report for vitamin D calcium is mentioned throughout that report – over 300 times – magnesium is not mentioned once. So, it is really important to consider that magnesium is needed and we need to be replete in magnesium in order for us to be able to actually access the vitamin D from a vitamin D supplement – and that’s potentially why we’ve got these wide variations and response in various different intervention studies for vitamin D”, she says.

Taking vitamin D supplements

Vitamin D is a fat-soluble vitamin and ideally it should be taken with food, if possible, a fat-containing meal. Currently the recommended dose is 10 micrograms (400 i.u.) but larger doses are available. Some people have found through a process of trial and error that they respond better to larger doses, Ms Jamieson acknowledges.

“We do find, as well, when people become deficient, they do need quite large supplemental doses and a lot of the prescribed doses are of the orders of … more than 10,000 units in order to get somebody back [to a satisfactory level], so it depends where you start from. …  I think what’s important is to know what your own level is, to consider magnesium alongside, … and then consider what dose may be needed for you as an individual to get you up to a good, optimal blood level.

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.

Ideally the diet should contain similar amounts of omega-3 and omega-6 fatty acids. However, the modern Western diet contains abundant quantities of omega-6 fatty acids, from vegetable oils, nuts, seeds, grains, meat, eggs and dairy products and lesser amounts of omega-3 fatty acids, which are derived from green leafy vegetables, fish, seafood and some nuts, explains Lisa Jamieson.

A person may not get the benefit of omega-3 supplements if their diet is “awash with omega-6 fatty acids”, she says.

The human body needs both omega-3 and omega-6 fatty acids. They are essential fatty acids that cannot be made by the human body and must be consumed as part of the diet. Unlike plants, humans cannot convert omega-6 fatty acids to omega-3 fatty acids. “We can metabolise both types of the shortest chain fatty acids into longer chain fatty acids but we’re not very efficient at that and there are increasing amounts of research that show that it is better to get some of these longer chain polyunsaturated fatty acids directly from the diet. So, for example, the EPA (eicospentaenoic acid) and the DHA (docosahexaenoic acid) directly come from fish and seafood”, explains Ms Jamieson. (See figure 1)

Figure 1

Importantly, the metabolic products of omega-6 fatty acids are inflammatory mediators whereas the metabolic products of omega-3 fatty acids are less inflammatory or anti-inflammatory mediators. “So, the balance of these substances within our diet can increase or decrease our propensity towards inflammation. A diet that’s more rich in omega-3 fatty acids will be a much more anti-inflammatory diet whereas a diet that’s very rich in omega-6 fatty acids will be a more pro-inflammatory diet”, she says. (See figure 2)

Figure 2

A number of drugs block the effects of inflammatory mediators including, aspirin and  non-steroidal inflammatory drugs (e.g. ibuprofen) which interfere with the action of cyclo-oxygenase (COX) to reduce the production of inflammatory mediators (see figure 3). Similarly, leukotriene receptor antagonists are used to counter inflammation in respiratory conditions, explains Ms Jamieson. “It is important for us to consider that what we eat can influence our propensity towards inflammation and, actually, if we get the balance better with omega-6 and omega-3 within our diet we may create a less inflammatory state and we may reduce the need for some of these medicines. If you can reduce the inflammation in a person’s body, they may reduce their symptoms and reduce the need for these medicines”, she says.

Figure 3

Turning to the advice that might be offered to someone who wishes to increase the amount of omega-3 fatty acids in their diet, Ms Jamieson suggests adoption of a Mediterranean diet. Typically, this would be “a diet that’s high in fish and seafood balanced with vegetables – taking the beige out of your diet”, she says. This involves removing all the pre-packaged supermarket foods, because they tend to be the ones that are high in seed oils and grains, and switching to a diet that is richer in vegetables, fish and seafood “There is some research that shows that you can change the balance within your cells of omega-3 and omega-6 within a week of changing”, she explains. Of course, this is no different from the advice that has long been offered to people who have had heart attacks. “I think it’s important to tell people to eat more vegetables, more fish and seafood, particularly oily fish, like salmon or mackerel or sardines”, she concludes.

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.

Magnesium has been described as ‘the forgotten nutrient’.  “Certainly when I qualified as a pharmacist ….. I would have heard about the need for iron and calcium but magnesium didn’t really feature as part of my training and I’ve spoken to lots of pharmacists for whom that is the same”, says Ms Jamieson. Magnesium is required for more than 600 processes in the body and so magnesium deficiency can have wide-ranging effects. These can include muscle spasms, back pain, migraine headaches, sleep disturbances,  arrhythmias, palpitations, gastrointestinal disturbances and worsening of asthma, she adds.

One problem is that magnesium status cannot easily be measured. Less than 1% of total body magnesium is in the blood and 99% is in bone and other tissues. Furthermore, the symptoms of magnesium deficiency tend to be non-specific and are often described as ‘medically unexplained’.  “Magnesium is something that should in some scenarios be given as a supplement. I think we need to increasingly look to symptoms as markers of a possible deficiency”, says Ms Jamieson. Another important factor is food quality – “the typical Western diet is quite deficient in magnesium”, she says.

Magnesium supplements

When looking at magnesium supplements it is important to be aware that many over-the-counter products are based on magnesium oxide which is less bio-available than magnesium that is attached to an amino-acid. Such products may be called ‘chelated magnesium’. “You may not necessarily get the dose that’s on packet – depending on which product you take”, says Ms Jamieson.  Many will remember being taught that magnesium salts cause diarrhoea. “Magnesium sulphate, otherwise known as Epsom salt, is actually used as a laxative for that purpose because magnesium sulphate is an osmotic laxative”, she says.

The prescribable forms of magnesium tend to be those that are attached to amino-acids and they are less likely to cause gastrointestinal disturbances. Moreover, the dose can be adjusted on an individual basis, Ms Jamieson explains.

One approach to the management of non-specific symptoms might be to try a magnesium supplement although people with renal dysfunction would need to be cautious. “A lot of people have given me anecdotal feedback that they feel quite different after taking a magnesium supplements and various symptoms that were previously considered to be unexplained have reduced or diminished – and I have personal experience of the same effect as well”, says Ms Jamieson

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.

After working in the NHS for more than 10 years, first as a primary care pharmacist and then in a commissioning role, Lisa Jamieson embarked on studies for a master’s degree in nutritional medicine. During this time her research led her to realise that optimal diets, including supplements, if necessary, could reduce the need for prescribed medication.

“It’s important to get diet right first before we go down the route of nutrient supplements.  I think as pharmacists we often think of nutrient supplements as being a key way to manage nutrition but I think it’s really important to stress that diet needs to be addressed first”, Ms Jamieson emphasises. However, even with a good diet the quality of food available can also be an important factor. A case in point is magnesium intake. “Over the last 60 years or so the content of magnesium in our fruits and vegetables has reduced by about 20 to 30%, so even with a really good diet that’s full of … nutritious fruits, vegetables, nuts [and] other good sources of magnesium, we still may not be getting enough”, she explains. Moreover, food processing can lead to further losses of magnesium, she adds.

Sceptics will point out that  there are few randomised controlled trials to support the value of food supplements. There are good examples where the hypothesis seems sound, for example, fish oils and omega-3 fatty acids for eczema, but randomised trials and meta-analyses of randomised trials then return equivocal results. Ms Jamieson points out that the observational studies that generated the original hypotheses were based on whole diets or whole foods such as fish in the diet. “We then try and apply the pharmaceutical model to that. We take fish oil out of the fish and put it in a capsule but when you eat fish you get much more than just fish oil,  you get lots of other nutrients in there as well. You get protein, you get zinc, you get iodine, you get various other nutrients ….. so when you take just one element of that food out and then put it into a capsule to … try to replicate what you’ve seen in the observational studies, there may be confounding factors”, she says. Furthermore, trials may include participants with both good and poor diets. Such factors are often not taken into account in intervention studies, she notes.

Another important issue is the idea that observational studies are only hypothesis-generating and do not establish causality. “We need to start to think beyond that. So, for example, when we say that smoking causes cancer, we know that only from observational research – we haven’t done randomised controlled trials to look at whether smoking can cause cancer but we still use that word ‘cause’ and you can prove causality from observational research”, says Ms Jamieson.  The Bradford-Hill criteria are widely used to assess whether an observed association is likely to be causal. The criteria include points such as consistency of findings, strength of association, and biological plausibility.  “Looking at the whole diet can be quite tricky because obviously there are many different factors …. people are starting to be a little bit more open-minded about the fact that if we have lots of observational studies that look for these elements of causality, if it’s reproduced time and time again across lots of different studies ….. then that could potentially show us that eating a certain way is causal”, she says.

About Lisa Jamieson

Lisa Jamieson BPharm (Hons), MSc (Clin Pharm), MSc (Nutr Med), MRPharmS

Lisa Jamieson currently works as a pharmacist consultant from her own company, Enucleo Ltd. She has a portfolio career with two main roles – first, as a senior consultant in a market access consultancy, working at the interface between the pharmaceutical industry and the NHS and second, as a pharmacist consultant in nutritional medicine. This latter role  involves educating pharmacists and other healthcare professionals either in writing or as a speaker at conferences.

Read and watch the full series on our website or on YouTube.