The problem of obesity in Scotland has reached epidemic proportions and this reality is recognised at Scottish Government level. The financial impact of treating obesity and obesity-related disease is substantial and in Scotland the cost was estimated at £171×106 in 2001 but only a small proportion of this estimate included weight-loss interventions. The Scottish Intercollegiate Guidelines Network (SIGN) define clinical guidelines as ‘systematically developed statements to help practitioner and patient decisions’ that ‘provide recommendations for effective practice in the management of clinical conditions where variations in practice are known to occur and where effective care may be known not to occur’. The evidence base for successful interventions has progressed since the publication by SIGN of Obesity in Scotland: Integrating Prevention with Weight Management in 1996 and Management of Obesity in Children and Young People in 2003. In 2007 SIGN commissioned a review of these two publications. In 2006 the National Institute for Health and Clinical Excellence (NICE) published a comprehensive obesity guideline and to avoid duplication of effort SIGN used the ADAPTE guideline adaptation framework to utilise and update evidence tables produced by NICE (where appropriate) as a basis for considered judgement. The new SIGN guideline is due for publication in 2010 and addresses children, young people (<18 years old) and adults. It will provide evidence-based recommendations on primary prevention of obesity (defined as intervention when individuals are at a healthy weight and/or overweight to prevent or delay the onset of obesity) within the clinical setting and treatment by lifestyle measures, drugs and surgery.

In 2007, the estimated cost of disease-related malnutrition in the UK was in excess of £13×109. At any point in time, only about 2% of over 3 million individuals at risk of malnutrition were in hospital, 5% in care homes and the remainder in the community (2–3% in sheltered housing). Some government statistics (England) grossly underestimated the prevalence of malnutrition on admission and discharge from hospital (1000–3000 annually between 1998 and 2008), which is less than 1% of the prevalence (about 3 million in 2007–2008) established by national surveys using criteria based on the ‘Malnutrition Universal Screening Tool’ (‘MUST’). The incidence of malnutrition-related deaths in hospitals, according to government statistics (242 deaths in England in 2007), was also <1% of an independent estimate, which was as high as 100 000/year. Recent healthcare policies have reduced the number of hospital and care home beds and encouraged care closer to home. Such policies have raised issues about education and training of the homecare workforce, including 6 million insufficiently supported informal carers (10% of the population), the commissioning process, and difficulties in implementing nutritional policies in a widely distributed population. The four devolved nations in the UK (England, Scotland, Northern Ireland and Wales) have developed their own healthcare polices to deal with malnutrition. These generally aim to span across all care settings and various government departments in a co-ordinated manner, but their effectiveness remains to be properly evaluated.

Much interest has been focused on the relationship between glycaemic index and body-weight loss, some of which is fuelled by popular media. However, there is a number of potential mechanisms that could be triggered by reducing the glycaemic index of the carbohydrate consumed in the diet. For example, the effect of foods on the gastrointestinal tract and the effect on blood glucose both could lead to potential appetite effects. Acute meal studies seem to point to an effect of glycaemic index on appetite regulation. However, the results of longer-term studies of weight loss are not as clear. In the present review a possible reason for this variation in outcome from the weight-loss studies will be discussed. The present review focuses on the possibility that the fermentable fibre content of the low-glycaemic-index diet may be important in weight-loss efficacy. A novel receptor that binds SCFA, the products of carbohydrate fermentation, has recently been described on the enteroendocrine L-cell in the colon. This cell releases a number of anorectic hormones and could offer an explanation of the appetite suppressant effects of fermentable carbohydrates. It could also explain the variability in the results of glycaemic-index weight-loss studies.

It is well known that the consumption of dietary polyphenols leads to beneficial effects for human health as in the case of prevention and/or attenuation of cardiovascular, inflammatory, neurodegenerative and neoplastic diseases. This review summarizes the role of polyphenols from red wine in the immune function. In particular, using healthy human peripheral blood mononuclear cells, we have demonstrated the in vitro ability of Negroamaro, an Italian red wine, to induce the release of nitric oxide and both pro-inflammatory and anti-inflammatory cytokines, thus leading to the maintenance of the immmune homeostasis in the host. All these effects were abrogated by deprivation of polyphenols from red wine samples. We have also provided evidence that Negromaro polyphenols are able to activate extracellular regulated kinase and p38 kinase and switch off the NF-κB pathway via an increased expression with time of the IκBα phosphorylated form. These mechanisms may represent key molecular events leading to inhibition of the pro-inflammatory cascade and atherogenesis. In conclusion, according to the current literature and our own data, moderate consumption of red wine seems to be protective for the host in the prevention of several diseases, even including aged-related diseases by virtue of its immunomodulating properties.

Osteoporosis-related fractures have a major impact on health at the individual and societal levels, through associated morbidity and increased mortality. Up to 50% of women and 20% of men at age 50 years may have a fragility fracture in their remaining lifetimes. Nutrition is important throughout the life course. Thus, adequate Ca and vitamin D intake has been shown to reduce risk of fracture in old age. Other factors such as protein and vitamin K may also be important, although the evidence here is less strong. In childhood Ca or vitamin D supplementation trials have demonstrated modest short-term increases in bone mass, but the long-term implications have not been established. Over recent years it has become apparent that maternal nutrition may have critical and far-reaching persistent consequences for offspring health. Thus, reduced maternal fat stores and low levels of circulating 25-hydroxyvitamin D in pregnancy are associated with reduced bone mass in the offspring; placental Ca transport may be key to these relationships. Wider maternal dietary patterns have also been shown to predict offspring bone mass. These data suggest that an interventional approach aimed at specific micronutrients, such as vitamin D, should be complemented by general optimisation of the mother's diet and lifestyle in order to maximise intrauterine bone mineral accrual and postnatal skeletal growth and thus reduce the burden of osteoporotic fractures in future generations.

With the considerable cost of disease-related malnutrition to individuals and to society (estimated to be >£13×109 for the UK, 2007 prices), there is a need for effective and evidence-based ways of preventing and treating this condition. The wide range of oral nutritional supplements that may be prescribed for the dietary management of malnutrition and other conditions account for only about 1% (about £99×106, 2007 data) of the prescribing budget in England. Systematic reviews and meta-analyses consistently suggest that ready-made, multi-nutrient liquids which may be prescribed can improve energy and nutritional intake, body weight and have a variety of clinical and functional benefits in a number of patient groups. Meta-analyses have repeatedly shown that oral nutritional supplements produce significant reductions in complications (e.g. infections) and mortality, and a recent meta-analysis shows a reduction in hospital admissions (OR 0·56 (95% CI 0·41, 0·77), six randomised controlled trials). Such benefits suggest that the appropriate use of oral nutritional supplements should form an integral part of the management of malnutrition, particularly as there is currently a lack of evidence for alternative oral nutrition strategies (e.g. food fortification and counselling). As with all therapies, compliance to oral nutritional supplements needs to be maximised and the use monitored. To make sure that those at risk of malnutrition are identified and treated appropriately, there is a need to embed national and local policies into routine clinical practice. In doing so, the economic burden of this costly condition can be curtailed. As recently suggested by the National Institute for Health and Clinical Excellence, substantial cost savings could be made if screening and treatment of malnourished patients was undertaken.

Treatments to induce weight loss for the obese patient centre on the achievement of negative energy balance. This objective can theoretically be attained by interventions designed to achieve a reduction in energy intake and/or an increase in energy expenditure. Such ‘lifestyle interventions’ usually comprise one or more of the following strategies: dietary modification; behaviour change; increases in physical activity. These interventions are advocated as first treatment steps in algorithms recommended by current clinical obesity guidelines. Medication and surgical treatments are potentially available to those unable to implement ‘lifestyle interventions’ effectively by achieving losses of between 5 kg and 10 kg. It is accepted that the minimum of 5% weight loss is required to achieve clinically-meaningful benefits. Dietary treatments differ widely. Successful weight loss is most often associated with quantification of energy intake rather than macronutrient composition. Most dietary intervention studies secure a weight loss of between 5 kg and 10 kg after intervention for 6 months, with gradual weight regain at 1 year where weight changes are 3–4 kg below the starting weight. Some dietary interventions when evaluated at 2 and 4 years post intervention report the effects of weight maintenance rather than weight loss. Specific anti-obesity medications are effective adjuncts to weight loss, in most cases doubling the weight loss of those given dietary advice only. Greater physical activity alone increases energy expenditure by insufficient amounts to facilitate clinically-important weight losses, but is useful for weight maintenance. Weight losses of between half and three-quarters of excess body weight are seen at 10 years post intervention with bariatric surgery, making this arguably the most effective weight-loss treatment.