PUBLIC HEALTH
VITAMIN D IN THE UK: AN OVERVIEW Emma Berry Associate Nutritionist (Registered)
Vitamin D is an important vitamin which is unique due to its production from sunlight exposure.1 It plays an important role in maintaining calcium and phosphorus levels within the body.1
Emma is working in Research and Development and is a freelance writer of nutrition articles.
Although vitamin D is produced in the skin after being exposed to UVB rays, there are also ways for this vitamin to be extracted from dietary sources. Vitamin D is then converted into 25-hydroxyvitamin D (25(OH) D) by hydroxylation 25(OH)D, before undergoing a further hydroxylation reaction into 1,25 dihydroxyvitamin D (1,25(OH)2D).1 D3 and D2 are the main forms of vitamin D. They are structurally very similar, but D2 has an additional side chain1 which remains during metabolism. Vitamin D3 is produced from skin exposure to UVB rays and some dietary sources, whereas vitamin D2 is provided from dietary sources. 25(OH)D3 can also be found from some dietary sources.1 The richest sources include egg yolk and oily fish, but it can also be found in wild mushrooms, animal meat, animal fat, animal liver and animal kidney.1 In the UK, many foods can also be found fortified with vitamin D, such as some margarines, breakfast cereals and evaporated milks.1
REFERENCES For full article references please CLICK HERE . . .
DIETARY SOURCES
Dietary sources are highly important when sun exposure isn’t possible, for example, due to long office working hours, or if the UVB rays are not able to reach the skin during the winter months.1 The UVB rays can also be influenced by many factors, such as sunscreen use, time of day and season. In the UK, vitamin D can only be produced by sunlight available between late March until September.1 The geographical
latitude also influences vitamin D, so an individual in Scotland will have a different exposure than an individual in Southern England.2 So, the vitamin D produced from sunlight could vary substantially between individuals. The way that vitamin D is measured may also not be wholly accurate. Serum 25(OH)D is the main measure of vitamin D, as it is believed to reflect the vitamin and is widely used as a biomarker due to its long half-life of approximately two to three weeks.1 However, 25(OH) D concentration may be picked up differently by different assays.1 The measure of serum 25(OH)D concentration would represent a total of 25(OH)D3 and 25(OH)D2, and assumes a linear relationship between vitamin D and serum 25(OH)D.1 This relationship is not always so simple and a curvilinear relationship has been suggested instead.1 In 2016, the Scientific Advisory Committee for Nutrition (SACN) released a review of the vitamin D report originally published in 1991 by the Committee on Medical Aspects of Food and Nutrition Policy (COMA).1 This detailed the importance of vitamin D for health and the new recommended nutrient intake of 10 micrograms per day for all individuals aged over four years.1 This was developed to ensure the majority of the UK population could have an intake which would ensure musculoskeletal health all-year round regardless of location.1 This did not take into consideration the vitamin D produced from sunlight exposure, only intake from dietary sources or supplementation.1 www.NHDmag.com July 2018 - Issue 136
19
®
It’s all in the taste FruitiVits ® is a vitamin, mineral and trace element supplement specifically designed for children aged 3-10 years on restrictive therapeutic diets.
A great tasting orange flavour Soluble - dissolves easily Low volume - 1 sachet made up in a minimum of 60ml water All in one - A single 6g sachet meets micronutrient* Reference Nutrient Intakes (RNIs)1
Contains 15µg of Vitamin D and 804mg of Calcium per sachet Only 0.5g of carbohydrate per sachet (suitable for the Ketogenic diet)
For further product information or samples, please contact either your local Vitaflo® representative, or call Nutrition Support on: +44 (0)151 702 4937 or email vitaflo@vitaflo.co.uk
* excludes sodium, potassium and chloride.
FruitiVits® is a Food for Special Medical Purposes
REFERENCE: 1. Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. HMSO, London. NHD0718
Vitamin D is important for calcium and phosphorous regulation within the body. This means that it plays an important role for musculoskeletal health. VITAMIN D DEFICIENCY
Vitamin D is important for calcium and phosphorous regulation within the body. This means that it plays an important role for musculoskeletal health. Deficiency in vitamin D has been linked to numerous musculoskeletal health conditions, such as rickets, as well as other health risks including in pregnancy and cancer.1 Recently, there have been many news articles discussing vitamin D deficiency ranging from an increase in vitamin D deficiency cases in Kent,3 to deficiency awareness and foods to boost intake.4 There have also been articles focusing on a recent study which has linked vitamin D deficiency to an increasing level of abdominal fat.5 The study by Rafiq et al (2018),6 was presented at the 20th European Congress of Endocrinology in May 2018 and carried out a cross-sectional analysis from data collected in the Netherlands Epidemiology of Obesity study. This data contained information from both male and female participants who were aged between 45 to 65 years, with the data adjusted for any perceived biases. They found that there were differences in body fat and vitamin D concentrations with gender. Women were found to have total body fat and fat surrounding internal organs inversely related to vitamin D concentration, whilst, in men, the fat surrounding internal organs and liver fat were related to vitamin D. For both genders, the fat which surrounded internal organs had the strongest association to vitamin D.6 This abstract by Rafiq et al was not the only study to discuss the relationship between obesity and vitamin D levels. A study by Athanassiou et al (2018)7 also explored the relationship between vitamin D and obesity, but established that morbidly obese patients were shown to have lower levels of vitamin D. They found that as BMI rose, the vitamin D levels decreased. The relationship between obesity and vitamin D deficiency is well documented, with a recent
systematic review and meta-analysis having a similar finding.8 With reports of an increasing level of obesity since the 90s,9 is this something that needs to be investigated as a growing public health concern? HOW TO INCREASE VITAMIN D?
Although the relationship between obesity and low vitamin D levels hasn’t been fully researched, there are many groups which could benefit from increasing levels of vitamin D. From the SACN report,1 it is believed that the majority of adults will reach sufficient vitamin D levels. However, during the winter, all adults should consider taking a 10 microgram supplement of vitamin D.1 The report has also outlined that there are some special considerations: individuals who remain mostly indoors, or covered in clothes, should consider taking a supplement all-year round.1 Individuals from minority ethnic backgrounds with darker skin are also advised to take a supplement of vitamin D all-year round.1 Although supplementation is suggested for most people at some point during the year, these supplements can be costly. One high-street provider offers these supplements at a charge of over £8 for 250 x 10mg tablets (price correct as of 11th June 2018).10 Although there are some groups which could access the supplements for free, the majority of the public would have to pay. This creates an unbalanced health equality, as many might not be able to afford such supplements. Therefore, it would be beneficial to find a way to increase vitamin D levels without adding additional costs to the public. One suggestion of a way to increase vitamin D concentrations would be the fortification of foods. Although there are dietary sources of vitamin D, it would be very difficult to achieve the RNI through diet alone. However, there www.NHDmag.com July 2018 - Issue 136
21
PUBLIC HEALTH have been numerous studies discussing the fortification of food to increase vitamin D intake within the population. Margarines were at one point required to be fortified with vitamin D, but this is now no longer mandatory.11 Yet, fortification of margarine has the potential to be one of the major dietary contributors of vitamin D intake. A simulation study of the Netherlands, UK and Sweden found that fortified margarine could contribute up to 35% of daily vitamin D intake.12 In the UK, milk and milk products have been suggested as a food group which could be fortified with vitamin D, as it is in other countries. This may have a greater impact on vitamin D levels, as a large percentage of the UK population consume milk. However, this alone would not be enough to meet the recommended RNI.12 TOO MUCH D!
Although it is important to ensure that individuals are reaching the right levels of vitamin D, to reduce the risk of deficiency and associated diseases, it should be noted that there are risks to having too much vitamin D. It would be hard to overdose through diet or sunlight, but, nevertheless, taking too many vitamin D supplements for a long time could result in
NHD
CPD eArticles
• Continuing professional development • Answer questions
hypercalcaemia.1 We need to ensure that any fortification of foods and supplementation recommendations still keep the general population within a safe range of vitamin D. CONCLUSION
Vitamin D is an important micronutrient which has an impact on human health. Both excessive vitamin D and a lack of it can result in serious problems. However, individuals who are classified as obese are found to have a lower level of vitamin D. This requires further investigation to determine if this is a result of being obese, or if there are other factors involved. There are various groups within the population at a higher risk of deficiency. The recent SACN guidance encourages supplementation for all adults over the winter, but certain ‘at risk’ groups are advised to supplement all-year round. This guidance doesn’t take sunlight derived vitamin D into consideration, which seems appropriate given the variation that is likely between individuals. However, supplementation may not allow all individuals an equal opportunity for health. Food fortification may provide a better way to reach a larger range of the population, but this would need to be investigated further.
NHD CPD eArticle
icle eArt Although the adult level of obesity NHD CPD looks to still be increasing, childhood obesity seems to be holding steady.
NHD
CPD
eArt
Figur Volume 8.05 - icle 29th March 2018 e 1: Tiers of weigh t mana geme nt for
clinical
mana
NHD
geme
nt and
CPD
treatm sug ent 12 ges ts ind
Volum eA
e 8.05 rtic le
- 29th
March
ivid tha there uals t there 2018 with 29% of men and women und is - 29th March most may ergoin a red Volume 8.05 now classified as obese, be based on findings term sustainable determrecent variou g bar uced of the 2016 Scottish change through num Health Survey. 7 HEALT H DIGEST iatr engaging individuals, food s ine figures this NETWO RK and drink industries if the hav factors ic procedber of tren Although the adult communities to and re has e not for level of obesity risk ures, become healthier. Alt d. looks to action still be increasing, s Volu bee been this; Their in pop hough plan childhood obesity me add of com na the rele 8.05 seems to reformulation includes encouraging industry be holding steady. itio ularity these con plic ofte - 29th In England, 9% tinu ased to NHS. nal cos atio to reduce the sugar n of children all in Reception year Mar ns atio content in Fur reducelong-te over treatme ts foods and drinks ch 201 the were classified n in the by 20%, by means as at risk of sugar pos ther rese to the and to being obese in 2015/2016, 8 Often d abi rm side last nts hav t-op of the sweetened beverage alre compared to 10% lity effe erativeNEarc dec e ady avoid the tax. They will also TW h is 2006/2007. 20% been well nut in be recommitting add CONCL require cas of children in Year ritiona se ind to con cts due ade, the grown epidemic has to the Healthy h-strap ing Qu carOR K 6 were at to The World ivid risk of being obese suc to the The obesity Start sum re are years. d to Scheme Obesit USION Ty es e is HE ensure that all opt ual h as l defi in 2015/16, which for many e ensure ped families with low AL ima Emma Berry is slightly have pe tio report higher than the defi y is documented cien s can suf a nor patien TH UK income l. Du ns access cien tion’s (WHO) 17% who were Associate that DIG identified industries to nutritious food. Food and drink cies mping cies and fer frommal diet’s doc . Althou stillQ.a1 your re vita Health Organisa substantial rise in obesityas Nutritionist, ES ofte min n, being ‘at risk’ in 2006/07. However, ser an latin are also being encouraged the ument ghA t. Syn ting T preventio var for sw app E com believed Freelance the Wiou it is new, healthier documen n dro obe and to that this figures 1 ear. ed ers g to plic ious obehat s pro sity products for consumptiondevelop in place a strategy from 2006/2007 ble in pos Nutrit copper include me. 14 atio sityar decades ago. were and setting is stil for ma bem : Ob Emma is working work with the UK and to Nutrit ns, and in underestimated due to a poor almost two ny yea eepi Government to make thedemlowwites l of sur t-opera ional , but ma iron, differencesparticipation. 8 in NHS Research t hin level of labels star Englan was published nutrient Q.d. growin defi rs, themo ic , has to review the easier to understand tive ny oth thia ional do ity the ting ger since and Developmen looks UK 2 cien the g programm y per wn up min for individuals. They car obe st within This article In Scotland, Howe within lev As are also aiming and is a freelance e, sity toA be co loa nda form e ofte cies wh ers can el of bee childhood obesity obesity found most recent UK the eshelp seeHa looking to healthcare professionals furthe . Fut remained around nutrition writer. in scho ed. 14 n dep also the levels of has in encouraging the adud an te: wh ich n veinob ver, imp both mmon clas ure discusses the same level lt d end pre r and ols. sified number for prim to healthy creat lifestyles for the and children. es lev last decade. In rov Scotlan the report and to tackle obesity. They on the sent mainly reduce policie the wa with family sa ere abo e acementity 2015/16, em of as a d ary ve will req ys place s loo lev el of 10% of children healt food ent enc ar childr as Air-Displ mo type the peo uire ve) Scotland's Primary scho policies in hy ratin also be in our Q. healt k els The Department chi rgy X-ray is to de or pr e we obe methods such 1 Dual-Ene furthe ment increases rbidly ple wit school year agi 3 en hier. ofolsHealth prim eve g sity set risto atte ldhood were at the level of obesity, with to help int ter As well and will ary 1 outlined that ryo A ng Ou and to mak , the obe also sche r .4 The for the hin be me cal impe- risk working the same Plethysmography, mi enco for now? Public figure of hea ne. Ho a tlinhea familie levels,en sin mpt child withscho Bioelectri targe se pro re is se (BM having e scho t the thetha urag ne the The WHO report rising at a staggering recorded in metry, refo 2,3 Whilst been ren in ols, Health yo obes they England that healthy tingto ensure to e an 9 ce we e thelthy s, targ lthi ol at und ob re, inno a cha I of ced options will ityseprob ur more. t Absorptio 2006/07. was are look ind and Unfortunately be made the etin es it vativures 40 level of er life ver, whUK env whilst , there in healt of obesity easily children in reco no recent hy foodearly of overweigh are dance theerg analysis year lem. oing ivid all public used for ity statistics cou nce tha end Refe furtheWgHO not older ualThisis impe plan styles ilstgo Vo the Q. obe s’ setti ingavailable rise in level iron sector an men to supp are for locations. publ rds, in rence ofbarJanu children throu the lum rate. This orta toldtackl Furthermore, are me sity ngs has also seen in Scotland increa t mo A use4 ished the UKusGovernment and iatr arys cancons r rep ve 1 Worl an alone that of s these methods ultat in recei ort obesity but nt individuals e se e 8.0 or in a repo ic seen may hel rnenc ofWha willghbe deve our nt for ind d re proandremain iontoclose determine if this looking phys encourag measures would allow issues, such us to thethesuccess and obese ort pr ving lopinto repeat studies, 2000 Health ens p me ced results wit ing these ical ivi rt. population agefor Althoupopula bar t iatr group 5int of activ related health in upda tont’ ageme Orga the Change4life g revis academic is also remaining ures, heawill CLIN du 2 Mark . Avail lthy dure steady for obesity and various 20 nisat increase in used s 20uce nt Sugar Smart an r asnew ic sur hin the red ICAL 29 child able ity app al of the ed gh byteencouraging ion. to red the 00 s P, TREAat: be figures. how advanced afte d co cular diseases report put generally Fram th or a pu Obes Alth Van gery pop 16 the bio-i www ? Us development Earlythe guid t to note However, elines ren r trea Q. long-te this for agesis 2-15 overall technology as cardiovas bli ewor Ma meet uce MeelTMEN.who ough ity: mpe po oftonew importan ulation in Scotland, the how these The WHO mple furthe 5 ac T FOR Years Prev k.which could throu danc ma M, iss3/ .int/n rch g it pu the e sta rm could ctme outli entin tio, become andpercentage On e, and y Robi encourage A 39 (acce man OBES gh an preventin Foun healthier children utritio forms of cancer. lat 3 Gibbned effe hel healtnt for y bec g and nson at risk yofhas 20 te of body of decisions rem r Exres datio technolog Skinof the obesityprecision tis in individuals. ion strategy for 26th Gove the look J and n/puITY ssed h tec ind ome n pla Mana y JT, child 18 by ain plaearch cts and p ma blica tic In so doing, theyn Stag the is 14%, which is the that of levels and lowest recorded rnme : 13th forward a ? ivid Quanren to fold. ging Robi Njeru n on ny tions s in hea in Inter new ha hope e The the figure since .1998. 7 enco nt open October can increase development nson tifica the Dece UK proposed ual /obe DK, natio rise in obesity ind lthythe to ens bariatr hnolo nd 2017 tion:to this2017 the CL. polic sity/W Global mbe uragnal Cvet measures levels found a further new re ed of technology afte , 41(2 adul . ic die gyividual s. Body will produce A Compurs r 2017 e Jour ure koue , the of deter4 Bake UK UKr ies actio HO_Q. Epid du fami composition a current high docu way ST, art innovative nal the cons to ): comp emic Scott TRS_ ns laid ) healthier paris Hein s, cin t level t req solutions common oflies ment ber Obes302-308 FUTURE PLANS icle managing gosurger these ultation co . Tech Exer andositio 6 894/ most for tackling ish level, Amb on to y EL, childhood The TO files. C. incre g ch uire out in cise TACKLE a ve A Heal uld A ofHydrobes ind population Cree to parlia high 2016, ityasing lifestyles at OBESITY Scien n differ Wen/ (acce Rep Ser ition obesity. as a In rn y. Stati ivid hes the cons on the 5 indiv globally. r AR 2 ev Zanin idua thier ment ild me ). Being Weig Theys have the obesity One ostaticity UK government and uals lp on Diet, ls.uk/d stics. . Briefi ide . ce. 2015 enceha s by otto (kg/mpublished ho has been defined a mining t assessed: 13th 894. Worl thro outlinedFutu ultation Gibb meth Weigis class ughP, Head toocum ht. 11 a re . 8(3). ac redu nc guidance on number using BMI htingstill Obesity od to which has d Heal nt’s y WA. seen when Dece ng Pape od of which ssme tio proje bariaJ, is The how tissue aims through 6 ents/ ce e Actio Activ is and they of specifically Avail en obese aim plan to table ob Scot th Orga has l’s their r. Num of help ction ns nt meth mber yo proposed Stam SN03 docu target ity Air Disp Whole-Bo tric able n and and reduce co a four clinically tish primary childhood level of adipose on an individua es s of Q. lacem ur surg ataki ment 10 nisat 336/ body at: s for ing didhttps ods 2017) and schools. obesity.as Exec -tier Doc/ ur defined dy Com ity This guidance BMI is over to These 7 s ery. 4 SN03 ber weig an ion: obes actioencouraging utive preva impr include ag Heal 924/ . syste lence E, Ward The 336. 3336 ent the://dig such as sw plans over the to determine individual’s outlines report negative impact ns whic outliall . The their Thes htA is , 2017 prGeneva, ned childrenthyto7 Scottishity0021 e he do 60ove le H UKpdfcurr De Plethysmoputed Tomo coming minutes er. the level im WHO 055.wn Scot mtoin are many ways 2012 surg Gove(sho Sc italcommo DEXA, hydro a rang yearsthe n, an adult . UK of physical and (acce plac h activity to make e prop (acce ery pdf in Figu 2 4 sc tish ar coul . Jour alt When aoflonggrap health. There Parlia Mind grap ently e ott or populatio . ns.w ssed l adult (acce every to Heal rnme e whilst aiming is nt. y sc ssed d be of obes day, 8 optio hy. hie mark nal treat ell 30kg/m ment rib ku.ed static, individua osalsto improve 4th ssed re th Jour hy-Basedish of Epid J. 4th the 1 Surv e the 2000, 21.5% final eting taken NHS Trend clini . Hous over Dece Scot r de ity u/ijes sport index (BMI nal ho obesity of an Dece 2nd Digitns have ey (200 go were inclu cal leaf) released in emio in and tish tier, mbe s in of Com Body ab/v and food attac e of al. Stati Dece mbe body mass ols Scotlactivity vario ve obes de r cis Q.logy and Mass ol8/ 3). .Sum Baria not Com waist was hmen r 2017 Health takembe adve of adult women 5 In s, supp pute us stics these include been Surv n whe in 8 tric Com ity amon2017) fou mon ion and r rtisemen limiting and. 9 NHS t_dadiffe r Assisrnme r tie measurements, ortin on Obes ) men and 21.8% s Libra ey (201 2017n) all perfo the successfu 2 Natio ta/file rent in England. families, A mary g adult s in muni ted nt Body Fat of key g isdsc Su t rmed nal othe prev /613 the rs ry. kg/m ), skinfold waist:hip ratio, many as obese Tomo ity, 6). 26% ty Heal encourag fig s in Avail Servwith 532/ type otlan Findi l. 12Volum r mm entative of unhe 10 prgrap ind classified s of and men and food Engla of able ices in obes Phys ht ngs. th. d.org whic op hy. althy HMofGove e 1:e cli baria Ther down into ing ivi Scot the -phy ical Activ at: resea circumference 22% of adult be and drin ag ar 2005 2009, 63(2 nd from /Hea are Main os nic grou land. UK,s-ac bein du the reformeasures for-a ity tric ise and rnmeh . Edin lth-To further broken 1 To placeScotland, ain ks an ad or discusswere found to e in rchb ps the g pics/ nt. als ): 140- 1993 al to ti-die gastrBody Mass burg for11 The ctionsleev mosand Diet.surgery Report. 2017 the of which are riefin st your #hist e Child mula gures to encouragand work requiremen ifications. please of adult women more h. Avail Childic band t-engtPl ? 2004 146 we gs. 20 Engla hood com Scot ea mon ch ory gastr t recent fi ts -201 6 . AvailTie igh by age ty has call (acce ectom tish able 17 nd: Obes -Health/P Index ild se e local ing with tion of AvailableThe , gastr various obesity class able ratesopportun num Gove of Prim 7-rep in 2003. The mos obesity onlin ssed cons t r 4at: ? ity:y. 13 ho and .pdf ly2017. Avail ublic typ icarybypa e definition of obesi vario 12 NHSundeat:rgon supp ities rnmeber 4th e: www ma A ultat that the obese socia od (acce ation mawww.gov. https ort and us nt. A ofDece Plan for Whilst th e ss 1 able Com over time, and ion allow for healt l .gov. na demonstrated 27% of men ssed e://co this on the indiv ob mbe Actio s/2016-1 Childad at: miss na drastically ge scot/ scot/ rendit creat13 uk/wincre nsult Healthier r idua p-co ased can be have es ionin proposed ed indiv hy lifest 4 In , with ge in Scot 4th Dece www.gov. 2-13 Publ me Reso not changed .gov. procFutu 2017) ls n (201 e The baria nten g ity icatio 6). Avail /201 ion obese. me mbe yles. who adipose tissue urce/ scot/ edur have increased recen Natio t/upl inBoar Copyrig idua re nt. . plans 6-12 alland. Scho r 2017 uk/govern nt d. Clinic ns/2 eActio healt oads classified as Not have Regi ht © 2017 naltric proc advanced. t year able ways in which -13-P 017/ and suggls to commThe Baria no1-BM ol Year ) /201 steadily stry. n and ment al Coms.h-and-so has whic of/uplo 14 women now become moreCopyright 10/2 edur is NH Publishing stead at: www.gov. tric 6/05 In 2006 tes I-Rep 2015 h ndrose is also rising for reproductionNH Publishing on© 2018 970 ob ads/ ent Dagan SS,Seco Ltd - obesity Surg miss es All rights reserved. cial-c Ambitions ily est new /apptook measured have Not for reproduction Available for printing -2007 for publish Ltd - All ionin es syste /16. ndxfor publishing purposes are/a uk/g he ort.p to ery body compositi Gold Registry Regi and sharing for on Diet, g Polic ideas Adult How rights 6,384 2016 , 1,951 ity 6-poplace overn without written df -hea re use. ing of use of Scotland, the use m/up Baria ever, stry ensh reserve permission CPD activities purpos Repo Determining for personal lthier the from NH Publishing ment iny: Com loads . . /pub(accessed . Available , giv of the licy-sev-co droptric Surg luger figur d. Availabuse. Copy es withoutfor personal through the rt. 2014proc Engl of CPD activities Ltd. -futu Activity edur / . for the use plex Britis es sligh 4th ing le forNot right and, re/us and written licati erytly A, Glob e in now possible . Avail and sharing printing Dece at: www h Obes © 2018 inmp-o Heal Patie ons/ permis for printing us I, besit and Spec er_up for repro 2014 Ltd. 2013 able/15 to mbe and sharing . the thy sion from child nts: 6,032 loads ity and y-pd reserved. Available /14. Weig ialise r 2017 from NH Publishing Clinic Schw hood ducti NH Ltd - All rights appe NH Publish lon forPubli permission . 4 eiger at: http: Meta f.pdf (acce d Obes /0052654 ht. Cons the shing on for ) -obe al Prac //nbs ared use of 2018 NH Publishing purposes without written Co AlthC, gbolic ing Ltd. sity-a ough Kess ity Surg publi Ltd CPD 3.pd Copyright © r.co.u ssed ultati tice. to pyr ter for publishing Surg - Allactivitie shing -plan lerthis No f (acce on k/20 on the ery. igh Adva m Not for reproduction purpo rights st for nces Y, Sanddrop14-re ery Soci 2013 ssed Document for person t© 10th reser sid bank ses 2018
TE: OBESITY UPDA NOW? WE WHERE ARE
• Download & keep for your files
NH
D
D
www.NHDmag.com July 2018 - Issue 136
eA
rtic
dieteticJOBS.co.u k
01342 824 073 (local
rate)
ety. port/ al use. in Nutri 6th rep ved. 201 of Dece . Avail . 2017 The GK, Dece (acce rodAvaila8 able tion. ut writte Unite . mbe mbe uct ble NH 2017 Ben-Pora ssed d King r 2017 r 2017 at: www n perm 10th ion for , 8: Pu printi .eng dom ) Dece 382- t T and ission blis ng for land. ) Natio 394 Sinai mbe pub from hin and shari nhs. nal T. Nutri r 2017 Baria lish gNH LtdPubli ng for ) tiona tric ing the shing Surg l Reco pur - All Ltd. use of ery mme CPD pos righ ndat activi es ts res ions ties wit for perso for hou erved. nal use. t wri Ava tten ilab per le mis for sio prin n from ting and NH sha Pu blis ring hin for g Ltd the use . of CP D act iviti es for per son al
e eff
witho
ec
ts.
use
.
CLICK HERE . . . TO VIEW OUR LATEST NHD CPD eARTICLE 22
CP
le