NHD October 2015 issue 108 by NH Publishing Ltd

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NHDmag.com

Issue 108 October 2015

gluten-free diet Dr Mabel Blades p11

ISSN 1756-9567 (Online)

crohn’s disease and dietary treatment. . . p19

Julie Thompson Specialist Dietitian, The IBS Network & NHS Dietitian

malabsorption Growth faltering omega oils probiotics

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References 1. WHO World Health Organisation. Report of a Joint WHO/FAO/UNU Expert consultation. WHO Tech Rep Ser 2007(935): 1-265. 2. Clarke SE et al. J Hum Nutr Diet 2007; 20: 329-339. 3. Van Waardenburg DA et al. Clin Nutr 2009; 28: 249-255. 4. de Betue CT et al. Arch Dis Child 2011; 96: 817-822. 5. Bueno AL et al. Euro J Clin Nut 2010; 64(11): 1296-1301. 6. Black RE et al. Am J Clin Nut 2002; 76: 675-680. 7. Greer FR, Krebs NF Pediatrics 2006; 117(2): 578-585. 8. Leach JL et al. Am J Clin Nut 1995; 61: 1224-1230. Nutricia Ltd White Horse Business Park, Newmarket Avenue, Trowbridge, Wiltshire, BA14 OXQ, UK Tel 01225 711677 | Fax 01225 711972 | nutricia.co.uk

from the editor

Chris Rudd NHD Editor Chris Rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCT Medicines Management Team, as a Dietetic Advisor.

Recently, I attended the Seventh Annual Sheffield Gastroenterology Symposium, an interesting and informative event organised by Professor David Sanders. He sets his speakers the challenge of giving their presentations within 15 minutes and each speaker has a clock counting down as they present. What pressure to perform and inform the audience! It is truly a speed-dating event and how privileged we were to hear such talented speakers. There was a presentation by a dietitian on ’Recent evidence for dietary management of irritable bowel syndrome’, which was a concentrated journey through various papers, probiotics, prebiotics and FODMAPs. It was excellent and well done Kevin. The day also offered the opportunity to network with other healthcare professionals and meet up with dietetic colleagues, both old and new. This month’s NHD does have a GUT theme. One of our contributors was at the above event and I am pleased to share with you, Crohn’s disease and dietary treatment, where are we now? by Julie Thompson. Access to a dietitian is vital in the treatment of patients with Crohn’s disease, as malnutrition is common and there are several factors to take into account. Find out what the latest inflammatory bowel disease audit showed and how many dietetic approaches need to be considered. Gluten-free diet is covered by Mabel Blades and she concludes that dietitians are uniquely placed to provide advice to those individuals with, not just coeliac disease, but other types of non-coeliac gluten sensitivity. We also have our Gluten-Free Guide this month, providing you with useful information and resources. More on the gut on page 28, as Dr Mayur R Joshi informs us of the importance of infant gut microflora in health

and disease and how the function of the microflora can be influenced using probiotics. Emma Coates gives us an overview on malabsorption on page 23, reporting on causes, symptoms and treatment. Interested in finding out more about the main causes behind growth faltering alongside key studies that look into nutritional approaches to this problem? Then let me guide you to Emma Derbyshire’s article on Nutritional approaches to growth faltering. But you may also be fascinated by omega fatty acids and their health benefits too. Michèle Sadler’s account on the Health benefits of oils rich in omega-3, omega-6 and omega-9 fatty acids makes for a good read. What athletes eat and when may be key to how they perform. Turn to page 44 for Benefits of iron for sport and exercise by Carrie Ruxton and Rin Cobb. For something different again, we all reflect on our practice and within our practice and One chance to get it right recommends how people’s experience of care in the last few days and hours of life should be considered, planned and delivered. Elaine Lane shares with us her Reflections on nutrition and ‘One Chance to Get it Right’, a government review as part of her CPD activity. NHD invites more of you to send us your reflections, so that we can share these with the readers. If you are interested in doing so, please email me at info@networkhealthgroup.co.uk. NHDmag.com October 2015 - Issue 108

Contents

COVER STORY

Gluten-free diet & resource guide 6

News

CPD reflections

Latest industry and product updates

‘One Chance to Get it Right’

19 Crohn’s disease

Dietary treatment: where are we now?

23 Malabsorption

Causes, symptoms and treatment

28 Probiotics

Microflora and the infant gut

33 Growth faltering

A nutritional approach

38 Omega oils

Omega-3, -6 and -9 fatty acids

43 Subscribe to NHD Magazine It’s easy online

44 Iron for sport

Benefits in sport and exercise

48 dieteticJOBS

Latest career opportunities

50 Events and courses

Upcoming dates for your diary

51 The final helping

The last word from Neil Donnelly

36 Web watch

Online resources and updates

Editorial Panel Chris Rudd, Dietetic Advisor Neil Donnelly, Fellow of the BDA Ursula Arens, Writer, Nutrition & Dietetics Dr Carrie Ruxton, Freelance Dietitian Dr Emma Derbyshire, Nutritionist, Health Writer Emma Coates, Senior Paediatric Dietitian Elaine Lane, Freelance Dietitian Dr Mabel Blades, Freelance Dietitian and Nutritionist Julie Thompson, Specialist Dietitian Dr Mayur Joshi, Medical Advisor, Probiotics International Ltd Michèle Sadler, Registered Nutritionist Rin Cobb, Freelance Sports Dietitian

NHDmag.com October 2015 - Issue 108

Editor Chris Rudd RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dawson Design Heather Dewhurst Advertisement Sales Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk @NHDmagazine www.NHDmag.com www.dieteticJOBS.co.uk All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

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news

Cholesterol low down

Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd

Cholesterol in the past has been given a hard time, with it mainly being linked to heart disease. Now, two new meta-analysis studies show that the effects of cholesterol on health may not be as bad as we thought. One meta-analysis of 40 studies using healthy adults did not find any significant associations between dietary cholesterol and coronary artery disease, ischemic or hemorrhagic stroke. It was, however, concluded that cohort studies (17 were analysed in this paper) lacked scientific rigour. A second meta-analysis looked at trends between cholesterol and breast cancer risk. Interestingly, a modest, but negative, association between total cholesterol and risk of breast cancer was found, with high-density-lipoprotein cholesterol thought to be contributing to this. For more information see: Berger S et al (2015). American Journal of Clinical Nutrition Vol 102, no 2, pg 276-94 and Touvier M et al (2015). British Journal of Nutrition Vol 114, Issue 3, pg 347-57.

Lab studies: don’t watch me eat

Typically, laboratory environments are used to study human energy intake. However, until recently, few studies have looked into how these settings could affect energy intake. Now, a systematic review of nine studies has looked into this. Most studies used young women and looked at the energy intake of energy-dense snack foods. From these, it was found that heightened awareness of being watched eating led to reduced energy intakes when compared with control conditions. These are important findings showing that future lab-based studies may consider putting measures into place, so that their participants do not feel that their eating behaviours are being measured, which could ultimately affect results. For more information see: Robinson E et al (2015). American Journal of Clinical Nutrition Vol 102, no 2, pg 324-37.

Vitamin D, miscarriage risk and how much?

Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

Two new studies have been published looking at vitamin D’s role in pregnancy. Using data from the Danish Odense Child Cohort, scientists have looked into whether vitamin D status was related to miscarriage risk. The prospective cohort study recruited 1,683 pregnant women. Amongst women who donated serum before week 22 of pregnancy, vitamin D (25(OH)D) levels were analysed and associations with miscarriage risk (n=58) studied. Overall, it was found that 25(OH)D levels <50nmol/L were associated with a twofold increased risk of miscarriage in the first trimester. However, such associations did not exist for the second trimester. These are important findings suggesting links between vitamin D status and miscarriage risk. Randomised studies are now needed to test possible effects of vitamin D supplementation in relation to miscarriage risk. A second study has also looked at how

NHDmag.com October 2015 - Issue 108

different doses from vitamin D taken in pregnancy could affect infants’ vitamin D status. A sample of 226 pregnant women were randomised to receive 10, 25 or 50µg vitamin D3 from weeks 13 to 24 of pregnancy until eight weeks after birth. Maternal and infant blood samples were then taken. Results showed that taking 50µg vitamin D3 in pregnancy helped to protect unsupplemented breastfed infants from vitamin D deficiency, defined as blood levels <30nmol/L up to eight weeks after birth. In contrast, 10 or 25μg vitamin D3 daily, only protected 57% and 84% of infants. These findings highlight the importance of vitamin D supplementation in pregnancy, particularly in women who intend to breastfeed their babies. For more information see: Andersen LB et al (2015.) American Journal of Clinical Nutrition Vol 102, no 3, pg 633-8 and March KM et al (2015). American Journal of Clinical Nutrition Vol 102, no 2, pg 402-10.

news

Olive oil or butter?

Caffeinated soft drinks and early menarche

Early menarche has been linked to a higher risk of certain chronic diseases, including Type 2 diabetes and cardiovascular disease. As caffeine is thought to modulate the female reproductive axis, new research has looked into links between the two. Using data from the US National Heart, Lung and Blood Institute Growth and Health Study, data was analysed from 1,988 girls aged nine to 10 years, followed over a period of 10 years. Results showed that early menarche occurred in 8.3% of the girls. After making data adjustments, it was found that greater consumption of caffeine drinks was associated with a higher risk of early menarche. A similar trend was also found for aspartame. On the whole, it appears that young girls with greater intakes of caffeinated and artificially sweetened drinks could be at risk of early menarche. Now further studies are needed to reconfirm these findings. For more information see: Mueller NT et al (2015). American Journal of Clinical Nutrition Vol 102, no 3, pg 648-54.

Olive oil is renowned for its heart health benefits, but how it affects the risk of Type 2 diabetes does not seem to have been examined until now. Using data from the US Nurses’ Health Study, comprised of 85,157 initially healthy women aged 26 to 45 years, scientists have now looked into this. After 22 years of follow-up, it was found that the risk of Type 2 diabetes was modestly lower in women consuming more than one tablespoon (>8 grams) of olive oil daily when compared to those who never had olive oil. Clearly more studies are needed, but, in theory, swapping other types of fats and salad dressings, e.g. mayonnaise with olive oil, may go some way towards lowering Type 2 diabetes risk. For more information see: Guasch-Ferré M et al (2015). American Journal of Clinical Nutrition Vol 102, no 2, pg 479-86.

Erratum Please note that the Dysphagia Product Update by Alison Smith that appeared in the Aug/Sept issue of NHD has since been updated with an amendment to Table 1: Starch based thickeners: Thixo-D Original. The amended version of this article can be viewed here: https://create-cdn.net/sitefiles/27/1/5/271513/Dysphagia_article_revised.pdf

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cpd

Reflections on nutrition and ‘One chance to get it right’1

Elaine Lane Freelance Dietitian (Partnership in Nutrition)

Elaine offers professional dietetic expertise to funded developmental nutritional care projects, to improve the health and wellbeing of the nutritionally vulnerable. She is a member of the BDA Freelance Dietitians, Public Health Network, Older People and Food Service specialist interest groups

I undertook a continuous professional development (CPD) activity to update my professional practice in line with the government review ‘One chance to get it right’1 and its recommendations on improving people’s experience of care in the last few days and hours of life. The review was commissioned by the Department of Health following media concerns and criticism on the use of the Liverpool Care Pathway for those in the last days of life.2 The two main criticisms made in the Neuberger report2 were that fluids were inappropriately withheld from dying patients and painkillers were given as a matter of course rather than for symptom control. From the ‘One chance to get it right’1 recommendations, I learnt about the changes in terminology. ‘End of life’ is the term to be used when patients are likely to ‘die within the next 12 months’ of life. This report, however, is about ‘Priorities for care’, i.e. care planning in the ‘last days of life’, i.e. ‘Dying’, with guidance for GPs, nurses and Allied Health Professionals. The report covers all aspects in the last days of life, including nutrition and hydration. The five priorities for care focus on: 1. recognising that someone is dying; 2. communicating sensitively with them and their family; 3. involving them in decisions; 4. supporting them and their family; 5. creating an individual plan of care that includes nutrition and hydration. From reflections on clinical experience of working with patients in the last 12 months of life and the ongoing challenges faced, there is support for an appropriate person-centred nutritional care plan. For some patients, the practical little-and-often food fortification

NHDmag.com October 2015 - Issue 108

approach can be put in place; for others, with anorexia/cachexia syndrome (a complex metabolic process found in many end stage illnesses), the assessment is much more than the patient’s calorific intake versus their body weight and the ongoing loss of lean body mass may occur with or without loss of fat mass. The latter can be challenging, as it is characterised by the loss or absence of appetite (anorexia) with weight loss and muscle wasting (cachexia). It impacts significantly on quality of life and can cause anxiety and distress for patients, but often more so for carers. This is a reminder that each assessment should be individualised, taking the patient’s condition and stage of illness into consideration and looking for any reversible problems that may exacerbate anorexia. These palliative care symptoms may include; pain, breathlessness, depression, ascites, delayed gastric emptying causing early satiety and vomiting of undigested foods that relieve nausea, constipation, dysphagia, heartburn, gastritis, anxiety, medication, oral problems (i.e. dry mouth, ill-fitting dentures, ulcers, candidiasis), odours from incontinence, or fatigue which is commonly associated with anorexia/cachexia syndrome. The CPD activity I underwent, also reinforced the importance of ensuring that decisions are not made in isolation and that we are working together,

cpd

The CPD activity I underwent, also reinforced the importance of ensuring that decisions are not made in isolation and that we are working together i.e. communicating with residents, carers, family, other healthcare professionals, particularly for those patients who lack mental capacity. An increased awareness is required amongst all concerned, that patients may now be in the ‘dying phase’, communicating being one of the five priorities for care.1 Reflections from further reading were gained from a model known as Ellyn Satter’s Division of responsibility in feeding.3 It is used with children who are refusing food and is based on the responsibilities of parent or child. The parent’s responsibility is for the ‘what’ of eating (i.e. the provision, structure and feeding if age/skill appropriate) and the child’s is ‘how much’ (eating). This could be paralleled to the carer and vulnerable adult. For those patients who are struggling with their eating and drinking as their condition deteriorates into the last days of life, the focus for carers often switches from nutritional adequacy to a focus on access to food and drink and assistance as informed by assessment. Part of the carer’s role is to ensure that, if a patient is hungry or thirsty at any stage in the day, they can access food or drink and have the support and assistance to do so, i.e. prompting or physical help as indicated. An explanation, based on carers’ responsibility for ‘what’ food is provided or available, may help some with the rejection that they often express when food is not fully eaten. For those with Dementia, the approach based around five mini meals/snacks daily may also be helpful.4 A final learning was a reminder to ensure that we ask patients and carers about their

perspectives on weight, body image, nutrition and dietary intake. In nutritional support, the emphasis is also based upon eating within the limits of the patient’s condition and capability. We must encourage patients and their carers to focus on enjoying food and the social interaction associated with eating and drinking and that a gradual reduction in oral intake is a natural part of the last days of life. The use of oral nutritional supplements, therefore, at this stage, are neither cost effective nor consistent with these care planning goals. In conclusion, we can use the learning from this CDP to promote: 1 a greater awareness of the interpretation that significant unintentional weight loss can be complex, remembering that what is important is to ensure the underlying reasons for poor dietary intake are assessed and care planned for; 2 an increasing recognition that another one of the many reasons why patients may have a reduced oral dietary intake and lose weight is that they may indeed be in the ‘dying phase’ and to include awareness of this within clinical assessments and nutrition training sessions; 3 people’s experience of care by improving our understanding, knowledge, skills and experience of recognising minimal dietary intake and weight loss linked to the recognition of ‘dying’, when reversible treatments of deteriorating health have been explored and treated for, as we only have ‘One chance to get it right’.1

References 1 Leadership Alliance for the Care of the Dying People (2014a). One chance to get it right. www.gov.uk/government/One_chance_to_get_it_right 2 Neuberber J (2013). More Care, Less Pathway: a Review of the Liverpool Care Pathway. www.gov.uk/government/publications/review-of-liverpoolcare-pathway 3 Satter E (2015). Ellyn Satter’s Division of responsibilty in feeding. www.ellynsatterinstitute.org/dor/divisionofresponsibilityinfeeding 4 CWT (2011). Eating well: supporting older people with dementia. www.cwt.org.uk/EW-Old-Dementia-Practical-Resource

NHDmag.com October 2015 - Issue 108

E C R I P E EfiW ! N w i n o l s , a e t r u b r a ted h in

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Gluten-free diet Coeliac disease and other conditions related to gluten sensitivity.

Dr Mabel Blades RD, PHD, MBA, DMS, MIFST, RSPH Freelance Dietitian and Nutritionist

Mabel is a Registered Dietitian, a member of the BDA and NAGE, Food Counts and Freelance Dietitians Specialist Groups. All aspects of nutrition enthuse her and she is passionate about the provision of nutritional information to people to assist their understanding of any diet.

Coeliac disease and dermatitis herpetiformis are the most commonly known manifestations of intolerance to gluten. Both are autoimmune disorders which are caused by a response to gluten in the diet and both are lifelong conditions.1 Coeliac disease causes gastrointestinal symptoms while dermatitis herpetiformis causes an itchy rash particularly on the knees, buttocks, elbows and face, which can form blisters. In the UK and North America (US: celiac disease), the prevalence of coeliac disease is approximately 1.0% of the populations, while in mainly rice eating communities such as found in Asia, the prevalence is much less. Those with diabetes and an autoimmune condition have an increased risk of developing the disorder, while those with a first degree relative, such as a sibling or parent, have a tenfold increase.2 Dermatitis herpetiformis is much less common, affecting only one in 3300 people.3 However, there are a number of other conditions which are caused by sensitivity to gluten which are much less well recognised. Sensitivity to gluten has long been quoted by various individuals who claimed to have experienced improvements in the symptoms of various types of gastrointestinal problems as well as other disorders, including neurological ones, after they had removed gluten from the diet. Often, such considerations from individuals are not always favourably supported by healthcare professionals. In 2012, at a second International Expert Meeting on Gluten Sensitivity, the matter of gluten sensitivity was debated by a group of interested consultants and it was decided to recognise and classify the condition as non-coeliac gluten sensitivity (NCGS) to differentiate it from coeliac disease.4

On investigation, sufferers were not found to have the intestinal involvement of flattened villi which is characteristic of coeliac disease. On blood testing, sufferers were also found to have had no antigens to gluten. In general, people with non-coeliac gluten sensitivity improve on a gluten-free diet, but some researchers suggest that some of the improvements may be due to a placebo effect. At this meeting it was considered that NCGS • is a wide-spread condition; • is presumed to be linked to dysfunctional innate immunity; • reacts positively to a gluten-free diet; • has behavioural effects including as anxiety and depression; • is clinically variable. At a third International Expert Meeting on Gluten Sensitivity held in 2014, the focus was to examine the subject of coeliac disease, plus other gluten sensitivities, further.5 Coeliac disease

This is a well-known and recognised condition where an autoimmune response occurs when gluten from wheat, rye or barley is eaten. The standard for the diagnosis of coeliac disease is villous atrophy which is seen in a biopsy of the duodenum provoked when gluten has been eaten. Additionally, antibodies to gluten are found in the blood, therefore, blood tests are often used to give an indication of the disorder. This damage to the villi of the small intestine means that the body cannot properly absorb nutrients from food and, thus, the most common symptom of coeliac disease is diarrhoea due to malabsorption: stools can contain high levels of fat and be pale NHDmag.com October 2015 - Issue 108

gluten-free diet in colour, as well as foul smelling and difficult to flush away. People can also suffer from bloating and abdominal pain, plus flatulence and a gurgling stomach. The malabsorption of nutrients can result in weight loss and anaemia due to a lack of iron or folate. Consequently, people may suffer from tiredness and lethargy.6 The only treatment is a lifelong adherence to a strict gluten-free diet. The National Institute for Health and Care Excellence (NICE) has clear guidance on both the diagnosis and management of celiac disease. It is recommended that groups with the following symptoms are assessed for coeliac disease7: • Chronic diarrhoea • Persistent or unexplained gastrointestinal symptoms such as nausea and vomiting • A persistent feeling of tiredness or fatigue • Persistent or recurrent abdominal pain or cramping • Sudden or unexpected weight loss • Unexplained iron deficiency anaemia Due to the links of coeliac disease with other conditions, NICE recommends that the following groups are offered blood (serological) tests:

• • • • •

Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome Type 1 diabetes First degree relatives

Wheat allergy

Wheat allergy is a reaction to proteins found in wheat, triggered by the immune system and usually occurs within seconds or minutes of eating. This reaction can be with skin involvement such as hives or urticaria, or more serious anaphylaxis symptoms.8 Irritable Bowel Syndrome (IBS)

The IBS Network supports people with this condition by giving help and advice on various strategies to assist them in managing symptoms. According to the IBS network, many people with IBS are going on a gluten-free diet. ‘It’s not just the fact that coeliac disease is more common in people initially diagnosed with IBS, it’s also that the concept of gluten sensitivity is gaining credibility.’9 Many people with IBS are also advised to follow a low-fodmap diet which reduces fructans found in bread.10

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gluten-free diet NCGS and wheat allergy has been described to be a factor in IBS in various studies of people diagnosed with IBS. In one study of 920 subjects 276 were found to be wheat intolerant.11 Bread

In a section on the NHS Choices website entitled: Should you cut out bread to stop bloating, Dr Isabel Skypala, Specialist Allergy Dietitian at the Royal Brompton and Harefield NHS Foundation Trust, says, “Probably one-third of patients in my allergy clinic complain of symptoms such as bloating, diarrhoea, vomiting and stomach pain after eating bread.” She also says that, “allergy is unlikely to be the culprit, but bread-related symptoms are real and wheat could be to blame.” Dr Skypala goes on to discuss, “Is it wheat intolerance or sensitivity?” and suggests that if you are sensitive to wheat, or you have trouble digesting it, “the main way to relieve your symptoms is to embark on a wheat-free or partially wheat-free diet,”.12 Undiagnosed cases of coeliac disease

Coeliac UK quote that the condition affects at least one in 100 people in the UK and in Europe; however, only about 24% of people with the condition are clinically diagnosed. Also, the average length of time taken for someone to be diagnosed with the disease from the onset of symptoms is a staggering 13 years.13 While there is much debate on the numbers of people affected by gluten sensitivity, the Gluten Intolerance Group estimates that it may affect up to 10 times more people than coeliac disease.14 Certainly, there are many more gluten-free products now available and in North America, marketers estimate that 15 to 25% of the population want gluten-free products. Other conditions related to gluten

Gluten sensitivity has been well documented in various other disorders, including neurological conditions with one well documented report from 1996 of a girl suffering hallucinations since childhood. Her symptoms totally abated when, in her twenties, she followed a gluten-free diet.15 Additionally, other neurological conditions have been described and the rationale postulated, which appears not to be due to an effect on the digestive tract or immunological factors.16

A form of ataxia (the term for neurological disorders where balance, gait and speech can be affected), related to the ingestion of gluten, has been described in some individuals as resolving when gluten is removed from the diet.17, 18 Schizophrenia and also autism have been linked with gluten.19 Many parents with children suffering from autism spectrum disorders and the chronic behavioural issues that these disorders can cause, wish to try such diets in order to assist their children. Some workers have postulated that excess levels of peptides from gluten (and also casein) cross into the brain from the blood with a resultant alteration of neurotransmission. Others have suggested that there is a degree of malabsorption which allows the passage of gluten and other proteins and peptides directly into the blood. However, there is little well validated research on the topic. Due to pressure from parents for Registered Dietitians to provide advice, the British Dietetic Association has provided guidelines: • Advise parents about the lack of research. • Examine the current nutritional adequacy of the diet. • Advise on the introduction of both casein and gluten after a period when the behaviour is monitored.20 The law and gluten

To assist those with allergies and intolerances, the Food Standards Agency (FSA), along with DEFRA and in line with EU legislation, introduced new allergen labelling laws which came into effect from 13th December 2014. These are the Food Information Regulations EU1169/2011 (FIR Regs).21 These new regulations mean that producers of pre-packed foods must emphasise allergenic foods in the ingredients list and all information must be in a manner which makes the allergenic food easily seen; for example, the use of bold print, underlined type or a different colour font. Food producers will still be able to state ‘may contain’ on products, but any such products will require a thorough analysis of the level of risk. For those producing non-packaged food, such as cereals, biscuits, sweets, etc, information must be available for customers who ask what is in the product. Similarly, for caterers, they need to know what is in the food they provide and must be able to NHDmag.com October 2015 - Issue 108

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gluten-free diet provide this information to diners. Signs to remind people of this can be helpful in all dining areas. Information can also be placed on menus and order sheets. Caterers will also need to obtain information on the allergen contents of food and incorporate this into information on the dishes produced. This information can be obtained from packaging and electronically from manufacturers. There are 14 items which are required to be highlighted in ingredients lists: • Peanuts, sometimes known as ground nuts • Tree nuts such as walnuts, hazelnuts, Brazil nuts etc • Milk/lactose • Eggs • Fish • Shellfish • Molluscs • Soya • Cereals containing gluten, such as wheat, rye and barley • Sesame seeds • Mustard • Celery, found in items such as salads, celery salt • Sulphur dioxide • Lupin Gluten-free products should contain no more than 20ppm and thus require analysis by laboratory methods. Therefore, if this isn’t the case, ‘no gluten-containing ingredients’ should be printed on menus. All this useful information will, of course, be helpful to those with any allergy or intol-

erance, especially coeliac disease sufferers or those who are sensitive to gluten. Conclusions

While many individuals have considered gluten to be a factor in the causation of their symptoms for conditions, other than coeliac disease and dermatitis herpetiformis, this is a fairly new area and there is a need for more research to understand the condition and who is at risk. NCGS is now being recognised as a problem in many countries across the world. It is regarded as a disorder which can only be properly diagnosed after ruling out other gluten-related disorders, such as coeliac disease and wheat allergy, when symptoms appear after consuming foods which contain gluten. From research, it is increasingly being recognised that, in sensitive individuals, gluten can lead to not only coeliac disease but also a variety of other symptoms including gastrointestinal, psychiatric and neurological ones. From the meetings of the Expert Meeting on Gluten Sensitivity it was considered that for some individuals with various health issues dietary elimination of gluten may lead to complete symptom resolution and health practitioners are advised to consider gluten elimination in patients with otherwise unexplained symptoms. It is, therefore, essential that registered dietitians are involved in providing advice to those with, not just coeliac disease, but other types of NCGS, as they are uniquely placed to do so.

References 1 Coeliac UK (2015). www.coeliac.org.uk/coeliac-disease/about-coeliac-disease-and-dermatitis-herpetiformis [accessed July 15th 2015] 2 Gujural N et al (2014). Celiac disease prevalence, diagnosis, pathogenesis and treatment. World Gastroenterol. Nov 14 18 (42) 6032-6059 3 Coeliac UK (2015). www.coeliac.org.uk/coeliac-disease/about-coeliac-disease-and-dermatitis-herpetiformis [accessed July 14th 2015] 4 International Expert Meeting on Gluten Sensitivity (2012). Munich 1-2 December 5 International Expert Meeting on Gluten Sensitivity (2014). Salerno 5-7 October 6 NHS (2014). accessed 6 Oct 2014 www.nhs.uk/Conditions/Coeliac-disease/Pages/Symptoms.aspx 7 NICE (2009). Coeliac disease recognition and assessment. www.nice.org.uk/guidance/cg86 [accessed July 13th2015] 8 Anaphylaxis Campaign (2014). www.anaphylaxis.org.uk/what-is-anaphylaxis/knowledgebase/wheat-allergy--the-facts?page=12 [accessed 6 Oct 2014] 9 IBS network (2014). www.theibsnetwork.org/the-self-care-plan/diet/is-it-food-intolerance-or-the-intolerant-gut/gluten-sensitivity/ [accessed 6 Oct 2014] 10 Low-fodmap diet (2014). www.ibsgroup.org/brochures/fodmap-intolerances.pdf [6 Oct 2014] 11 Holmes G (2013). Non Coeliac Gluten Sensitivity. Gastroenterol Hepatol Bed Bench. Summer 6 (3) 115-119 12 Skypala I (2014). www.nhs.uk/Livewell/digestive-health/Pages/cutting-out-bread.aspx [accessed 6 Oct 2014] 13 Coeliac UK fact sheet (2014). www.gluten.net/resources/gluten-sensitivities/ [accessed 6 Oct 2014] 14 Statistics (2014). http://glutenintoleranceschool.com/gluten-intolerance-statistics/ [accessed 6 Oct 2014] 15 Genuis SJ, Lobo RA (2014). Gluten sensitivity presenting as a neuropsychiatric disorder Gastroenterol Res Pract. 2014:293206 16 Sapone A et al (2012). Spectrum of gluten-related disorder: consensus on new nomenclature and classification. BMC Medicine 2012; 10:13 www.biomedcentral. com/1741-7015/10/13 17 Ataxia UK (2015). https://www.ataxia.org.uk/ataxia-types1 [accessed 15th July 2015] 18 Hadjivassiliou M et al (2010). Gluten sensitivity from gut to brain. Lancet Neurology Vol 9 no 3 March 2010 318-330 19 Catassi C et al (2013). Non-Celiac Gluten Sensitivity: The New Frontier of Gluten Related Disorders. Nutrients. 2013 Oct; 5(10): 3839-3853. Published online 2013 Sep 26 20 Isherwood E, Thomas K, Spicer B (2011). Professional Consensus Statement Dietary Management of Autism Spectrum Disorder. Dietitians working in Autism supported by the British Dietetic Association 21 Food Information Regulations (2011). Food Standards Agency www.food.gov.uk/enforcement/regulation/fir

NHDmag.com October 2015 - Issue 108

gluten-free guide Brands that are readily available in supermarkets/retailers Supplier Email / Tel / Website Main Categories Almondy

almondy.com/en

Cheescakes, mousse and tarts

Amsia

amisa.co.uk

Pasta, Pizza base mix, crisp breads, crackers

Big Oz

www.bigoz.co.uk

Breakfast Cereals, flakes and puffs

Bounce

bouncefoods.com

Bounce healthy snack bars

Easy Bean

easybean.co.uk

One pot meals, crispbreads

Feel Free

feelfreeforglutenfree.co.uk

Breads, Christmas, Eastern, Italian, sausages, sweets & savouries

Genius Gluten Free

geniusglutenfree.com

Granovita

granovita.co.uk

Hale and Hearty

halenhearty.co.uk

Heinz Deliciously Gluten Free range heinz.co.uk/Products/Gluten-Free

Bakery, frozen pies, pastry Granola, juices, snacks, oils, quinoa, oils, condiments, sauces, paté, puree Syrup, pasta, crisps, rice, snacks, mixes, cereals, breaded cod fillets, stuffing, christmas pudding, porridge oats Pasta, pasta sauces

Honey Buns

honeybuns.co.uk

Flapjacks, cookies, shortbreads, brownies, savoury tarts

Meridian Foods

meridianfoods.co.uk

Sauces, pestos, jams, spreads, juice concentrates

Mrs Crimble's

mrscrimbles.com

Biscuits, ricecakes, mixes, sweet and savoury snacks

Munchy Seeds

munchyseeds.co.uk

Seeds, seed mixes

Nairn's

nairns-oatcakes.com

Oatcakes, crackers, biscuits, fruit bars, muesli, porridge

Nestle

nestlecereals.co.uk

Cornflakes and honey cornflakes

Newburn Bakehouse by Warburtons newburnbakehouse.com Orgran orgranglutenfree.co.uk Primrose Kitchen

primroseskitchen.com

Rizopia

rizopia.co.uk

Bread, rolls, wraps, sandwich thins, crackers, baguettes, muffins Pasta, Snacks Baking, Breakfast, Kids snacks muesli, nut and seed butters, sprinkles, superfood smoothie boosters, hampers and granola Gluten-free organic pasta

Udi's Gluten Free

udisglutenfree.co.uk

Breads, bagels, crisps, granola, snacks, baking mixes, sweet treats

Online retailers (not including supermarkets) Abel & Cole Ltd Baked To Taste Better Life Bakery BFree foods Clives Pies Doves Farm Foods Ltd Schär Freego Gluten Free Kitchen Goodness Direct Green's Beers Hambleton Breweries Ilumi Lovemore Free From Foods Mandy's Gluten Free Morley's of Swanland Natural Grocery

abelandcole.co.uk 08452 626262 organics@abelandcole.co.uk bakedtotaste.co.uk 01404 47904 g-free@tiscali.co.uk betterlifebakery.com 01254 610895 bfreefoods.com 00353 1 7790500 info@bfreefoods.com clivespies.co.uk 01364 642279 sally@clivespies.co.uk dovesfarm.co.uk 01488 684880 mail@dovesfarm.co.uk schar.co.uk 0800 161 5838 share@schar.co.uk freego.com 0844 692 1333 hello@freego.com glutenfreefood.info 01969 622222 info@theglutenfreekitchen.co.uk goodnessdirect.co.uk 0871 871 6611 info@GoodnessDirect.co.uk glutenfreebeers.co.uk 0161 456 4226 info@glutenfreebeers.co.uk hambletonales.co.uk 01765 640108 office@hambletonales.co.uk ilumiworld.com 0800 505 3232 shop@ilumiworld.com lovemorefoods.com 01685 813545 lovemore@welshhills.com glutenfreefoodproducts.co.uk 01388 661334 admin@glutenfreefoodproducts.co.uk glutenfreebutcher.co.uk 01482 634225 gf@glutenfreebutcher.co.uk. naturalgrocery.co.uk 01242 572 323 orders@naturalgrocery.co.uk

NHDmag.com October 2015 - Issue 108

Various - online store inc meals, snacks, sauces, pasta, noodles, sweets Pasties, pies, sausage rolls, quiches, tarts, cakes, bread, pastry, scones Biscuits, cakes, puddings, pastry, savoury pies and sweet pies Online bakery - bread, rolls, wraps and fajita kits Pies, pasties, rolls, cakes, flapjacks, dips Various products - online store Various - online store, bread, snacks, biscuits, pizzas, frozen ready meals Various products - online store Online bakery - sweet and savouries Various - online store Beers and ales Gluten and wheat-free ale Indian, Chinese, Mediterrranean dishes, hampers, porridge, pasta, rice noodles, gravy, bread mix, brownie mix, oat cakes Bread, cakes, biscuits, savouries. Pies, tarts, scones, muffins Sausages, pies, savouries, specialities Various inc Amaranth, muesli, spaghetti - online store

gluten-free guide Naturally Good Food Oakhouse Foods Simply Free Wellfoods

naturallygoodfood.co.uk 02476 541990 Various - online store orders@naturallygoodfood.co.uk A large selection of frozen ready meals - you need to select by diet oakhousefoods.co.uk 0845 643 2009 on the home page Brands, mixes, flour, stuffing, pasta, crackers, condiments, gravy, simply-free.co.uk 01582 840502 spreads, snacks enquiries@simply-free.co.uk wellfoods.co.uk 01226 381712 Loaves, rolls, buns, flour, pizza, prescriptions janet@wellfoods.co.uk

Prescription/NHS suppliers drossa.ltd.uk 020 3393 0859 orders@drossa.co.uk countrywidehealthfoodsltd.co.uk Countrywide Health Foods Ltd. 01685 810058 info@countrywidehealthfoodsltd.co.uk drossadirect.co.uk 020 3393 0859 Drossa Limited orders@drossa.co.uk finaxglutenfritt.se/ 46 042-29 51 50 Finax info@finax.se generaldietary.com 0203 044 2933 General Dietary info@generaldietary.com geniusglutenfree.com 0845 874 4000 Genius Gluten Free info@geniusglutenfree.com glutafin.co.uk 0800 988 2470 Glutafin glutenfree@glutafin.co.uk glutenfree-foods.co.uk 020 8953 4444 Gluten Free Foods Ltd info@glutenfree-foods.co.uk juvela.co.uk 0800 783 1992 Juvela info@juvela.co.uk livwellfoods.co.uk 0845 874 4000 Livwell livwell@geniusglutenfree.com nairns-oatcakes.com 0131 620 7000 Nairn's info@nairns-oatcakes.com newburnbakehouse.com 0800 243 684 Newburn Bakehouse by Warburtons talk2us@warburtons.co.uk Bialimenta

Oakhouse Foods

oakhousefoods.co.uk 0845 643 2009

Orgran

orgranglutenfree.co.uk 020 8208 2966 proceli.com/eng 0034 93 784 83 82 info@proceli.com pureglutenfree.co.uk 01706 746713 info@pureglutenfree.co.uk rizopia.co.uk 01992 581715 info@pgrhealthfoods.co.uk tobiateff.co.uk 0207 018 1210 sales@tobiateff.co.uk wellfoods.co.uk 01226 381 712 janet@wellfoods.co.uk wiltshirefarmfoods.com 0800 077 3100 info@wiltshirefarmfoods.co.uk

Proceli Pure Gluten Free Rizopia Tobia Teff Wellfoods Wiltshire Farm Foods

Pastas Ready meals and desserts: dysphagia, allergy, vegan, home delivery Wide range of products inc biscuits, breads, pizza, pasta, mixes, sauces, pickles, marinades Flour and mixes Breads, rolls, cookies, snacks, cheeses, communion wafers, pasta, baking products, prescriptions Bakery, frozen pies, pastry Gluten-free prescription products, including breads, rolls, mixes, pasta, crackers, breakfast cereal Various - online store Essential gluten-free foods on prescription, including bread, flour, breakfast cereals, pasta & crackers Breads, rolls, cakes, prescriptions Oatcakes, crackers, biscuits, fruit bars, muesli, porridge Bread, rolls, wraps, sandwich thins, crackers, baguettes, muffins A large selection of frozen ready meals - you need to select by diet on the home page Bread Mix, Pizza pastry mix, flour Breads, rolls, buns, muffins, cookies, croissants, pasta, wafers Flours and baking ingredients including prescription Gluten-free organic pasta Brown and white teff flour Loaves, rolls, buns, flour, pizza, prescriptions Ready meals inc breakfasts, desserts and pureed meals, home delivery

Resources and information BDA Gastroenterology Special Interest Group (GSG) bda.uk.com 0121 200 8080 info@bda.uk.com. Coeliac UK www.coeliac.org.uk 0845 305 2060 dietetics@coeliac.org.uk British Society of Gastroenterology r.gardner@bsg.org.uk

bsg.org.uk 020 7935 3150

Live Gluten Free liveglutenfree.co.uk 01738 23 70 70 info@liveglutenfree.co.uk Gluten Free for RDs glutenfree.com customerservice@glutenfree.com Food Finder

foodfinder.org

Food Intolerance Network food-intolerance-network.com officeuk@food-intolerance-network.com CORE - fighting gut and liver disease corecharity.org.uk 020 7486 0341 info@corecharity.org.uk Schär www.dsglutenfree.com/en/ 0800 954 1981 info@dsglutenfree.co.uk

Dr Schar Institute drschaer-institute.com 0800 988 8470 professionals@drschaer.com Glutafin glutafin.co.uk 0800 988 2470 glutenfree@glutafin.co.uk Juvela – supporting healthcare professionals juvela.co.uk/hcp 0800 783 1992 hcp@juvela.co.uk Nutrition Society nutritionsociety.org 020 7602 0228 office@nutritionsociety.org.uk Patient UK patient.co.uk Primary Care Society of GB pcsg.org.uk secretariat@pcsg.org.uk Celiac Central (US) celiaccentral.org 215-325-1306 info@celiaccentral.org Uni of Chicago Celiac Disease Centre cureceliacdisease.org 773-702-7593 Celiac Disease and GF diet Information (US) celiac.com Celiac Disease Awareness Campaign (US) celiac.nih.gov 1-800-891-5389 celiac@info.niddk.nih.gov NHDmag.com October 2015 - Issue 108

Cow’s Milk Allergy Management

THE UNIQUE RANGE FOR ALLERGIC CHILDREN 0-10 YEARS

The uniq u of nutr it e sole source io children n for allerg ic from 1 to 10 years

allergenic The unique hypo use as a milk for t en lem pp su ildren from substitute for ch s ar ye 1 to 10

The unique spoo that can be us nable produc t ed as a dairy replacement for allerg ic ba bies and children from 6 month s+

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a .1 amino The Normula in the UK based fo th from bir

Working together for better paediatric care

Crohn’s disease and dietary treatment: where are we now?

Julie Thompson Specialist Dietitian, The IBS Network and NHS Dietitian

For article references please email info@ networkhealth group.co.uk

Julie is a Registered Dietitian with interest in IBS. She is Diet Advisor to The IBS Network and works in NHS and private practice (www. calmgutclinic. co.uk). Julie provides dietary advice on IBS, Crohn’s disease, coeliac disease, ulcerative colitis and food intolerance.

Since my last article for NHD on dietary treatment of Crohn’s Disease (CD)1, we have had an update in the dietary guidelines from the BDA and research has moved on at a pace in the area of the gut microbiome. This article discusses current treatment of adult CD with dietary therapy. CD is a chronic inflammatory autoimmune condition, exhibiting transmural skip lesions, affecting any area of the gastrointestinal tract. The aetiology of CD is poorly understood; there is a genetic component, an inappropriate immune response to microbiota and environmental causes including diet. Patients have significant morbidity, 70-80%2 will have surgery and this has considerable effect on nutritional status, particularly if resections are substantial. Access to a dietitian is vital in the treatment of patients with CD, as malnutrition is common. Along with protein energy malnutrition, there has been reported inadequate intake of micronutrients3. The latest inflammatory bowel disease (IBD) audit4 highlighted that, whilst dietetic access has improved, the importance that standards escalate the level of care in areas where change is challenging was emphasised. The audit showed 23% of patients have no access to specialist dietetic input, only 67% of services have 0.5 WTE dietitian and only 61% of services reported a 90% level of nutritional risk screening during inpatient admission. No less than 100% of assessment with a validated tool (e.g. MUST) is the standard; the authors report that services should implement a business case to improve dietetic accessibility. However, BMI has been

suggested to be falsely reassuring and grip strength has been proposed as a better predictor of lean mass, presence of sarcopenia and osteoporosis risk.5 Exclusive enteral/liquid diets

Enteral or oral liquid diets have been provided as treatment to reduce inflammation and induce remission. Theories suggest that the mechanism is avoidance of presumed dietary antigens or alteration of the bowel microbiota profile. A major paper in CD was published in 20076 and suggested that, whilst evidence was clear that enteral diets induce remission, corticosteroids were more effective in this regard. Evidence was unclear that steroids were more effective; some of the studies reported concomitant additional drug therapy and exclusion of these studies showed a lack of superiority of steroids over diet, but exclusion reduced the power of the research. A recent meta-analysis suggested that enteral nutrition is more effective in inducing and maintaining remission in combination with infliximab (a medical anti TNF treatment) compared with infliximab treatment alone.7 Liquid diets remain a secondary consideration in adults, where palatability and adherence are still sited as major drawbacks in NHDmag.com October 2015 - Issue 108

crohn’s disease

Bacteria is associated in the pathogenicity of CD, so the theory suggests that altering gut microbiota will be beneficial. treatment. Liquid diet therapy can maintain nitrogen balance and reduce the risk of development of osteoporosis in the long term in adult females when compared with steroids8 and has also been found to maintain remission.9 The liquid diet ideally needs to be followed for a minimum of four to six weeks to allow for mucosal healing, although benefits have been shown from 10 days onwards10 and reintroduction needs to be commenced once inflammation has resolved. Food elimination/reintroduction diets

LOFFLEX (or LOw Fibre, Fat Limited EXclusion diet,) researched by a team at Addenbrooks Hospital11, is recommended by guidelines.10 Liquid diet can be continued as nutrition support during food reintroduction when needed, particularly during the first restricted stage. The LOFFLEX diet is used for two weeks and then foods are reintroduced to tolerance. The initial phase can be increased to four weeks if needed.10 Standards state that when compared with elimination diets, there is limited weak evidence that the LOFFLEX diet is of similar efficacy to elimination diets and patients are more compliant and prefer LOFFLEX as a reintroduction diet option. The specific carbohydrate diet

This diet eliminates disaccharides, oligosaccharides, polysaccharides and fruits and vegetables containing a higher ratio of amylopectin to amylose. Some patients are following this diet as a self-care approach. Individual case reports have been published and a case series report has recently been published of 50 IBD patients (36 with CD) choosing this diet.12 Currently, there is no randomised control trial (RCT) level evidence for its efficacy as a treatment. The average case in this publication followed the diet for three years, the longest 13 years, but the concern is that this diet has not been investigated for adequate nutrient pro20

NHDmag.com October 2015 - Issue 108

vision. A reintroduction protocol is provided to reintroduce some foods, how many foods people reintroduce again remains unclear. It allows fructose and, therefore, fructose malabsorption is not considered as a possibility of symptom causation in CD. Patient intake of dietary inulin type fructan has been studied.13 Fructans are fermentable carbohydrates. Patients with active CD have lower intakes of fructans and oligo-fructans than patients with CD in remission, but again, the consequences of low fructan intake is unknown. Patients appear to be manipulating their diet to self-treat perceived symptoms from food. Research is urgently needed to investigate how effective a treatment the specific carbohydrate diet is, what nutritional limitations it provides and the long-term consequences, with a diet potentially low in prebiotics in a disease where the microbiome is implicated and higher intakes of calcium are required. Probiotics, prebiotics and synbiotics

Bacteria is associated in the pathogenicity of CD, so the theory suggests that altering gut microbiota will be beneficial. Some patients with IBD use probiotics to try to manage their disease, but less than half of users discuss this use with their healthcare provider.14 There is still lack of evidence that these products have any effects in induction15 or maintaining remission16 in CD, therefore, probiotics are not supported by the new IBD standards.10 Caution needs to be used with prebiotics and synbiotics as these products may be poorly tolerated; the patient should be informed that their use may increase risks of bloating, diarrhoea and gas, due to them containing fermentable carbohydrates.10 Research showed that FOS inclusion in active CD did not show clinical benefit and 19% of participants in the CD arm withdrew due to worsening symptoms.17

crohn’s disease

Evidence has shown that reduction of fermentable carbohydrates (FODMAPs) may be successful in treating functional symptoms such as gas, bloating and pain during remission.

Functional symptom therapy

A major change in CD testing is use of the faecal calprotectin test, which delineates between active disease and remission. Some patients do go on to experience functional gastrointestinal symptoms during disease remission. It is important to review disease status for patients referred for dietary treatment of functional symptoms, or IBS, as self-reported symptoms during both stages may be similar. Low FODMAP diet

Evidence has shown that reduction of fermentable carbohydrates (FODMAPs) may be successful in treating functional symptoms such as gas, bloating and pain during remission. A study18 has shown that lowering the dietary fermentable carbohydrates resulted in symptomatic improvement in half of participants with IBD, this paper had a higher number of participating CD patients. In the absence of strictures/inflammation, the Low FODMAP diet could be considered as treatment. High fibre diets

High fibre diets, including wheat bran consumption, to maintain remission in CD is included as a result of searches revealing poor quality studies with small numbers of participants. One single blinded paper19 that had very few par-

ticipants reported a wide difference between the treatment and control group; this is likely to be a consequence of very low participant numbers and not strong clinical effectiveness. This is an area that needs a good understanding of the effects of foods on the digestive system at each stage of the patient’s clinical condition. Inclusion of a high fibre diet to maintain remission is potentially dangerous in the presence of stricturing and wheat bran consumption may result in functional symptoms. Current guidelines10 state that there is weak limited evidence to suggest that high fibre diets are effective in maintaining remission in CD. Conclusion

Dietary self-care may be considered by patients as a consequence of poor access to dietetic services and is completely understandable when patients desire a solution to ameliorate symptoms from food. If this is the case, then the solution is to increase dietetic access to increase availability to evidenced-based care. Dietary research is challenging due to the complex nature of diet, but dietary treatments are an important adjunct in treatment. What is clear is that where randomised control trials exist, the evidence is usually limited and weak. Further research is urgently needed, to ensure that we have evidenced treatments in our dietetic care.

Stricturing disease Reducing fibre or utilising low residue diets to reduce symptoms or prevent bowel obstructions in CD remains an area that has little evidence base, or clear demarcation as to what constitutes low fibre or low residue.10 It is important to differentiate between strictures due to fibrotic scarring and those due to inflammation. Inflammatory strictures can resolve with liquid diets and medical treatment and may require a reduction in fibre in the short term. Symptom resolution with reducing fibre is reported anecdotally by patients; this may be due to global reduction of fermentable carbohydrates and, without research, it remains an area of controversy. It is advisable to follow guidelines or protocols with stricturing CD and UK guidelines suggest that fibre is contraindicated in stricturing disease, due to the risk of obstruction.10 NHDmag.com October 2015 - Issue 108

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Malabsorption

Malabsorption: An overview Malabsorption is a clinical term to describe any defects occurring during the digestion of food and the absorption of nutrients. Depending on the cause, the digestion or absorption of single or multiple nutrients can be affected.

Emma Coates Metabolic Dietitian, Dr Schar UK

In lactose intolerance and the digestion of a single nutrient, lactose, is affected. However, for example, in coeliac disease, the digestion and absorption of several nutrients are affected.

There are a wide range of symptoms related to malabsorption, with abdominal discomfort, bloating, flatulence, diarrhoea and weight loss being commonly reported by patients. Nutritional intervention

Table 1: Causes of malabsorption (adapted from Ruiz Jr AR)12 Dysmotility, e.g. inadequate gastric mixing, rapid emptying, or both

Digestive enzyme or bile deficiencies

Abnormal intestinal environment

Acutely abnormal epithelium

Chronically abnormal epithelium

Short bowel syndrome Emma has been a Dietitian for almost 10 years, working within the NHS in both adult and paediatric care for eight years. She is now Metabolic Dietitian at Dr Schar UK.

Impaired transport of nutrients during the postabsorptive stage

Gastrectomy Gastrojejunostomy Gastroparesis Vagotomy Biliary obstruction and cholestasis Cirrhosis Chronic pancreatitis Cholestyramine-induced bile acid loss Cystic fibrosis Lactase deficiency Pancreatic cancer Pancreatic resection Sucrase-isomaltase deficiency Abnormal motility secondary to diabetes, scleroderma, hypothyroidism, or hyperthyroidism Bacterial overgrowth Diverticulitis Zollinger-Ellison syndrome (lowered duodenal pH) Acute intestinal infections Alcohol Antibiotic therapy, e.g. neomycin Amyloidosis Coeliac disease Crohn’s disease Ischemia Radiation enteritis Tropical sprue Whipple disease Intestinal resection, e.g. for Crohn’s disease, NEC in neonates Jejunoileal bypass for obesity Abetalipoproteinemia or Bassen-Kornzweig syndrome (rare autosomal recessive disorder that interferes with the normal absorption of fat and fat-soluble vitamins) Addison’s disease Blocked lacteals due to lymphoma or TB Intrinsic factor deficiency found in pernicious anaemia Lymphangiectasia Chylothorax NHDmag.com October 2015 - Issue 108

malabsorption Table 2: Common symptoms found in malabsorption Symptom Diarrhoea

Steatorrhoea

Flatulence and abdominal distention

Weight loss/faltering growth

Anaemias

Oedema

Clotting disorders Bone complications

Neurological presentations

Comment Abdominal2-5 Very common complaint. Frequent loose stools as a result of the osmotic load present within the intestine. A consequence of fat malabsorption. Patients experience pale, bulky, and offensive stools, which are difficult to flush away. Commonly observed in pancreatic insufficient cystic fibrosis patients when PERT (Pancreatic Enzyme Replacement Therapy) is not effectively managed or taken by the patient. Unabsorbed food is subject to bacterial fermentation. Gaseous products such as hydrogen and methane cause flatulence. Abdominal distention and cramps caused by excess wind within the intestine. Other areas of the body Prevalence of weight loss may vary but can be significant. Some patients may have an increased calorie intake which may mask weight loss from malabsorption. Iron deficiency anaemia often is a manifestation of coeliac disease6. Microcytic (iron deficiency) or macrocytic (vitamin B-12 deficiency)1. Crohn’s disease or ileal resection can cause megaloblastic anaemia due to vitamin B-12 deficiency. Peripheral oedema caused by hypoalbuminemia when there has been chronic protein malabsorption or from loss of protein into the intestinal lumen. Protein losses can be caused by extensive obstruction of the lymphatic system, seen in intestinal lymphangiectasia and HIV. Ascites can develop when there is severe protein losses. Vitamin K malabsorption and subsequent hypoprothrombinemia can lead to complications in blood clotting. Vitamin D deficiency may lead to osteopenia or osteomalacia. Easy fracture of bones and bone pain. Secondary hyperparathyroidism can be caused by the malabsorption of calcium. Malabsorption of vitamins B5 (pantothenic acid) and D can cause generalised motor weakness. Peripheral neuropathy due to B1 (thiamine), B6 (pyridoxine) and B12 (cobalamin) malabsorption. Other complications can include night blindness (vitamin A), seizures (biotin). Loss of sensations such as vibration and position may be due to B12 (cobalamin) deficiency. B12 deficiency also causes breathlessness and fatigue. Hypocalcemia and hypomagnesemia, due to electrolyte malabsorption can lead to tetany.

is often required to manage malabsorption, including the use of exclusion diets, nutritional support and use of specialist nutritional products and/or supplements. In some cases, pharmaceutical intervention is also required. The intervention will depend on the definitive cause of the malabsorption. Common causes of malabsorption are listed in Table 1. It is important to understand the mechanism of malabsorption in order to realise the impact it may have on the health of the patient. There are various stages of malabsorption depending 24

NHDmag.com October 2015 - Issue 108

on which point it occurs in the normal process of digestion and absorption within the gastrointestinal tract. In the normal digestion and absorption process there are 3 stages1: Luminal - where digestive enzymes and bile break down dietary fats, proteins and carbohydrates; Mucosal - where the brush border membrane, found within the epithelial cells of the intestine, transport digested matter to the body’s cells from the intestinal lumen; Postabsorptive - here nutrients are transported around the body to its cells via the circulatory and lymphatic systems.

malabsorption Table 3: Examples of underlying diseases and treatment in malabsorption Disease/condition

Treatment

Coeliac disease

Gluten-free diet +/- vitamin and mineral supplementation, e.g. calcium, iron. Secondary lactose intolerance may occur and can be addressed with a temporary exclusion diet.

Lactose intolerance

Lactose exclusion diet with appropriate dairy replacements, e.g. lactose-free baby formulas in infants, suitable dairy alternatives and weaning advice for young babies. Appropriate calorie and calcium intake should be monitored across the lifespan.

Pancreatic insufficiency, e.g. in cystic fibrosis (CF) or pancreatic cancer

Protease and/or lipase replacement therapy. Advice and guidance regarding their use and dietary considerations should be provided. High calorie supplements may be required.13 In CF patients fat soluble vitamins are routinely prescribed. Enteral nutritional support is sometimes required.

Inflammatory bowel disease, e.g. Crohn’s disease, ulcerative colitis or pouchitis

Elemental feeds or liquid diets may be used to promote bowel rest and remission, administered orally or via enteral feeds. Vitamin and mineral supplementation may be necessary, e.g. regular vitamin B12 injections and iron supplementation. Corticosteroids and/or anti-inflammatory agents, such as mesalamine. Immunosuppressants, e.g. azathioprine and Infliximab. Probiotics may be considered but there is limited evidence for their use, however, they may be useful in the management of pouchitis and ulcerative colitis.14

Short gut syndrome

If there has been extensive intestinal disease or resection, parenteral nutrition may be necessary. High calorie supplements may be useful for some patients along with vitamin and mineral supplements, e.g. fat soluble vitamins, electrolytes, B12, iron. Antibiotics may be prescribed for bacterial overgrowth.

Liver disease, e.g. biliary atresia15

MCT (medium-chain triglycerides) based feeds and oil are used in patients experiencing poor weight gain as a consequence of fat malabsorption. MCTs are more easily absorbed and don’t require the body’s usual process for fat metabolism, e.g. micelle formation is not required for absorption and they are transported via the portal route rather than via the lymphatic system. Fat-soluble vitamin supplements are required for patients with fat malabsorption. Oral and/or enteral nutritional support may be required.

Chylothorax16

60-70% of fat flows through the lymphatic system after digestion in the intestinal lumen. In chylothorax a fistula between the thoracic lymph duct and the plural cavity means that chyle is transferred in to the pleural cavity rather than to body’s cells. Minimal LCT feeds and/or diet with MCT are given. High calorie juice based supplements are used in older children and adults.

Disruption of the digestive or absorption process and/or capability during any of these stages leads to malabsorption. If the intestine’s ability to absorb certain nutrients is disrupted an osmotic load leads to presenting symptoms. Diagnosis

There is a vast array of tests which are performed to diagnose malabsorption and its underlying causes. A good general overview can be found at: British Society of Gastroenterology: Tests for malabsorption.10

Management and treatment

When treating a patient who is experiencing malabsorption, there are two approaches to consider: • Treat the underlying disease, e.g. coeliac disease; • Provide nutritional support to correct deficiencies, encourage adequate growth in children and prevent weight loss in adults.

For article references please email info@networkhealthgroup.co.uk NHDmag.com October 2015 - Issue 108

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REFERENCES: 1. Huynh DTT et al. J Hum Nut Diet. DOI 10.111/jhn.12306 Published online 25th March 2015. 2. Data on fi le. Abbott Laboratories Ltd., 2007 (PaediaSure Plus & PaediaSure Plus Fibre taste testing). 3. Data on fi le. Abbott Laboratories Ltd., 2013 (PaediaSure Fibre taste testing). 4. Data on fi le. Abbott Laboratories Ltd., 2013 (PaediaSure & PaediaSure Peptide vs. Peptamen Junior Powder). *Independent, head-to-head taste testing for PaediaSure, PaediaSure Plus, PaediaSure Fibre, PaediaSure Plus Fibre and PaediaSure Peptide vs. Fortini or Frebini Energy or Peptamen Junior Powder Date of preparation: July 2015 RXANI150119

probiotics

Probiotics and the Infant Gut

The human gut bacterial population (or microflora/microbiota) is a complex ecosystem that plays a critical role in many physiological functions within the body.

Dr Mayur R Joshi Medical Advisor, Probiotics International Ltd (Protexin)

For article references please email info@ networkhealth group.co.uk

Its influence on early development and its subsequent impact on long-term health into adulthood has recently become a focus of much attention within probiotic circles. The gut flora has been shown to have an important role to play in infant nutrition, immune system development, behavioural development and the development of chronic conditions such as obesity, diabetes and other metabolic disorders. In this article, we will discuss the importance of the infant gut microflora in health and disease, discuss how we can influence the function of the microflora using probiotics and look at some of the clinical evidence available to support their use in maintenance of health and prevention and treatment of disease. INFANT GUT MICROFLORA

Dr Mayur Joshi is Medical Advisor for the Human Health Care division at Probiotics International Ltd (Protexin), manufacturers of Bio-Kult and Lepicol. Dr Joshi is a fully registered doctor and has spent most of his clinical work in colorectal surgery, before spending time within industry as a Medical Advisor.

Up to 1,000 bacterial species inhabit the adult bowel, with concentrations increasing further down the intestinal tract.1 There are approximately 10 times more microbial cells inhabiting the body than there are cells making up the human body itself2; with the mass of bacterial cells within the colon weighing up to 1.5kg, similar in weight to the human liver.3 In addition, the collective genetic information of the gut bacteria (the microbiome or microbiota), contains over 100 times the number of genes in the human genome.4 Consequently, the metabolic function of this microbial ‘organ’ is comparable to the liver and, as such, is as important to normal functioning.

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In utero, the foetus is presumed to be almost sterile, with little to no microbial colonisation. The mode of delivery is an important factor in the exposure of the body to microorganisms, with a natural vaginal delivery being the most desirable. When the foetus is born via the vaginal canal, the bacterial exposure is representative of the microbes present in the mother’s vagina, a rich and diverse ecosystem; when the foetus is born via caesarean section, the bacterial exposure is representative of the mother’s skin and is less diverse.5 The differences between these exposures can have a significant impact on infant development as a more diverse microflora is associated with more beneficial effects.6,7 An early example of this difference can be seen in the evidence that suggests that up to 80% of MRSA infections in infants occur following a C-section birth.8 Epidemiologic evidence has shown a correlation between caesarean birth and obesity, asthma, coeliac disease and Type 1 diabetes.9 In addition, breastfeeding is associated with a lower risk of obesity, diabetes and diarrhoeal diseases. When analysed further, these correlations seem to be as a result of differences between the respective microbiomes that result after vaginal and caesarean deliveries. Whilst there is no definition of a ‘normal’ gut bacterial population, there are indications of the types of bacteria that dominate in infant bowel and it takes approximately three years for the infant microbiota to mature into a more adult type. In that time, the infant

probiotics Figure 1

microbiota has profound influences on many physiological functions, in particular immune system development. MICROFLORA AND THE IMMUNE SYSTEM

The human gastrointestinal tract contains the largest mass of immune tissue in the body; in fact, gut-associated lymphoid tissue (GALT) is responsible for 60% of antibody secretion in the body.10 The microflora of the gut has a complex relationship with the immune system and is able to exert local and systemic effects.11 The importance of the microflora to our immune system is considered so significant that it has been postulated that we are 200,000 times more prone to infection without our microbiota.12 The intestinal microflora plays an integral part in host defence, both through direct interactions with pathogenic organisms as well as modulation of the immune system. Particularly in early life, the composition of the gut flora profoundly influences the development of the gut lining and the corresponding immune system, supporting it to work effectively and offer protection against common infections. After birth, the microbial population of the gut ‘primes’ the local immune tissue which in turn has systemic effects on overall immune development. The mechanisms by which this oc-

curs are very complex and are the focus of much ongoing research. The hygiene hypothesis proposed by Strachan in 1989 suggests that the increase in the prevalence of atopic disease and autoimmune disease is related to reduced exposure to microbes at an early age as a result of improved sanitation and living conditions, vaccines, antibiotic therapy and smaller family sizes (in developed countries).13 These changes result in less diverse microbial populations resulting in altered microbiomes and immature immune system development. This in turn is associated with an increased incidence of allergic diseases (such as eczema, asthma and hay fever), autoimmune disease and increased susceptibility to infection. PROBIOTICS

Probiotics represent a potentially excellent aid to early infant development. The accepted definition of a probiotic is a live microorganism that, when administered in adequate amounts, confers a health benefit on the host.14 These beneficial microbes can be used to support the bowel microflora and exert their beneficial protective effects. The mechanisms by which probiotics work are numerous and complex, but can broadly be categorised into three main functions as I have summarised in Figure 1. NHDmag.com October 2015 - Issue 108

probiotics Even in the brief summary Figure 1 it is clear to see that the functions of probiotics and their relationship with the human body are extremely complex. In addition, the nature of probiotics means that they are also extremely difficult to study in vivo. This is why randomised controlled trials remain the gold standard for probiotic research. CLINICAL EVIDENCE

Gut related disorders The use of probiotics to help prevent and manage diarrhoeal diseases in children is well established with much good research published in the area. There have been excellent trials that have demonstrated the benefits of specific probiotics in preventing nosocomial gastroenteritis, acute infectious diarrhoea, antibiotic associated diarrhoea and traveller’s diarrhoea.15 In addition, the use of specific probiotic formulations to help manage and prevent functional constipation is also well documented.16, 17 There has also been promising research in the use of probiotics in the prevention and management of infantile colic. One systematic review identified six excellent clinical trials that have shown benefit with the use of probiotics in colic.18

These studies are in single strain formulations, but a more recent study looked at the benefits of a multi-strain mixture and found excellent results in the management of colic with treatment success seen after only seven days of use.19 Immune system related disorders An extensive meta-analysis of data available for the use of probiotic supplementation in reducing risk of developing atopic dermatitis (AD, also known as eczema) in children was performed in 2012.20 This was able to show that the use of probiotics significantly reduced the occurrence of atopic dermatitis (AD), particularly in children administered with probiotics perinatally. Other studies have shown improvements in the Severity Scoring of Atopic Dermatitis (SCORAD) index.21, 22 The evidence overwhelmingly supports the use of probiotics perinatally to prevent the development of atopic dermatitis in later life.23, 24, 25 A number of studies have demonstrated that probiotics can have a beneficial effect in the treatment and prevention of allergic rhinitis (or hayfever) in children and adults.26, 27 They found evidence to show that probiotics improved the

NHDmag.com . . .

. . . Your essential resource 30

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probiotics nasal symptoms of allergic rhinitis. They also found that these improvements correlate to improvements in blood markers of inflammation and allergy, suggesting a systemic effect. Acute Infections (non-gut related) A study in 2009 looked at the incidence of acute infection in 81 infants comparing a probiotic to placebo.28 The infants were followed up for their first year of life and those taking probiotics were found to have a reduced incidence of otitis media and recurrent respiratory infections during that time. A 2001 study by Hatakka et al looked at 571 children aged between one to six years old and the effect of probiotics on general illness and acute infections.29 They found that the probiotic group had fewer days of absence from day care. They also found a relative reduction in acute respiratory tract infections (and subsequent complications), as well as a reduction in the number of episodes requiring antibiotics. CONCLUSION

There is a large, growing body of evidence supporting the use of probiotics to help ben-

efit infant health and we have only touched the surface above. There is ongoing research in mental health, liver disorders, metabolic conditions, as well as other gut related disorders such as irritable bowel syndrome and inflammatory bowel disease. There are, however, limitations to the research. Studies and claims are strain and formulation specific, so research is not applicable across all probiotics. Even strains of the same species will have significantly different properties making even metaanalyses of research papers controversial. Historically, there has also been a large variability in the quality of research, but with more stringent regulatory controls, this is improving. In addition, the quality of products is variable and the extensive types of formulations available (powder, capsule, yoghurt, liquid) will impact on the choice of probiotics for specific conditions. As pre-clinical research techniques become more sophisticated and accurate and clinical research in specific formulations becomes more prevalent, we will see the use of probiotics in infant health become routine.

Look after your child’s immune system* with Bio-Kult Infantis! Bio-Kult Infantis is a research-based, multi-strain formula for infants with Omega 3 and Vitamin D3. *Vitamin D3 contributes to the normal function of the immune system.

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Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. www.nutramigen.co.uk †Studied before the addition of LGG®. Calculated using data on allergic reactions after oral food challenge with an eHF from table 3 of Dupont C et al. 2012, as judged by the Committee on Nutrition of the French Society of Paediatrics. ‡vs an eHF based on casein, rice hydrolysate, soy and amino acid formulas. CMA, cow’s milk allergy; eHF, extensively hydrolysed formula; LGG®, Lactobacillus rhamnosus GG. References: 1. Dupont C et al. Br J Nutr 2012;107:325–338. 2. Nermes M et al. Clin Exp Allergy 2010;41:370–377. 3. Baldassarre ME et al. J Pediatr 2010;156:397–401. 4. Canani RB et al. J Pediatr 2013;163:771–777. 5. Data on file, 2014. IMPORTANT NOTICE: Breastfeeding provides the best nutrition for babies. *Trademark of Mead Johnson & Company, LLC. © 2015 Mead Johnson & Company, LLC. All rights reserved. LGG® is a registered trademark of Valio Ltd, Finland. This material is for healthcare professionals only. EU15.572/09–15.

Growth faltering

Nutritional approaches to growth faltering

Dr Emma Derbyshire PhD, RNutr (Public Health) Independent Consultant, Director of Nutritional Insight Ltd

For article references please email info@ networkhealth group.co.uk

Dr Emma Derbyshire is a nutrition consultant who writes regularly for academic and media publications. Her specialist areas are maternal nutrition, public health nutrition and functional foods. www. nutritional-insight. co.uk

Growth is central to later health and wellbeing, with the first two years of life being a particularly important window of growth. While validated screening tools are available to identify growth faltering, it is less clear what nutritional strategies could be put into place once identified. This article discusses the main causes behind growth faltering alongside key studies looking at the nutritional approaches to this problem. Growth faltering can be concerning for both families and health professionals. Healthy growth, particularly during the first two years of life is needed to support immune function and physical health, along with neurological and cognitive development.1 For example, growth faltering in early life, as well as during the pubertal years has been associated with poorer cognitive and schooling outcomes.2 With regard to human growth itself, this occurs in different stages. For example, prenatal growth is the most rapid period of growth followed by infancy.3 On average, an infant gains around 20cm a year during the early months of life. This is usually followed by another 10-20cm by the age of one year.3 Following on from this, pubertal growth is the next period of rapid growth when nutritional needs are again high.4 Subsequently, for these reasons, the first two years of life and puberty are often referred to as the ‘rendezvous’ of growth; a period of growth that should not be missed.3 Determining growth

As shown in Table 1, the causes of growth faltering are multifaceted, which can be divided into general reasons, or medical causes. Amongst low income countries, poverty, food insecurity, highly infectious environments and poor understanding of nutrition and hygiene, are some of the main factors contributing to growth faltering.5 Prematurity is another risk factor for reduced infant growth, with postnatal growth failure being inversely associat-

ed with gestational age, i.e. longer pregnancies tend to lower the risk of this.6 Other work has shown that medical conditions, such as coeliac disease, may contribute to growth faltering amongst children identified as having this.7 Table 1: Causes of growth faltering General: Inadequate intake of energy and protein Inadequate intake of micronutrients Poor appetite regulation Delayed introduction of solid foods Fear of new foods (neophobia) Oral-motor dysfunction Medical/disease-related: Prematurity Reduced gestational age Reduced dietary intakes Increased nutritional requirements Increased nutritional losses Sources: Sullivan & Goulet (2010)4; Poindexter (2014)6

It is important to monitor growth from birth, whatever the clinical situation or country, to make sure this is on track. The World Health Organisation (WHO) has developed a set of growth standards using data collected from the WHO Multicentre Growth Reference Study. These are based on how children should grow in all settings, i.e. derived from a worldwide sample of children, rather than being limited to a specific setting and time.8 These Standards were published in 2006 and are based on infants and children from Africa, Asia, Europe, Latin and North America who were fed according to international NHDmag.com October 2015 - Issue 108

growth faltering nutritional standards and whose mothers were adequately nourished.9 A series of validated charts have since been developed by the WHO for measuring the growth of children from birth to five years and are available through their website (www.who.int/nutrition/media_page/ en/). As growth is one of the most sensitive indicators of health and wellbeing it is important that health professionals use validated growth charts, like these, to give better interpretations of children’s growth patterns. This, in turn, then enables suitable intervention strategies to be put into place.10 Nutritional approaches

A PubMed search was undertaken to identify studies published over the last 10 years investigating links between nutrition and growth faltering. Main findings from randomised controlled trials and key epidemiological studies are shown in Table 2. Based on the studies identified, three looked at the effects of different protein supplementation programmes. One found that providing extremely low birthweight babies (<1000g) with higher protein intakes had significantly improved growth velocity over the first 30 days after regaining birth weight.11 Other work which involved randomising 92 preterm infants to receive fortified breast milk (with 1.4 or 1.0g protein per 100ml) from birth until their due or discharge date, showed that higher levels of protein led to significant improvements in infants’ body weight.12 In an Ethiopian study, growth faltering lessened amongst children eating quality maize protein (maize biofortified with higher lysine and tryptophan).13 Other randomised trials have investigated whether lipid-based supplements could reduce growth faltering, although no improvements were seen.14,15 One study looked at the potential effects of glutamine supplementation (0.25mg/ kg body weight, taken twice daily) although findings were insignificant when tested over a period of five months amongst a sample of Gambian infants.16 Several studies have researched the effects of multi-micronutrient supplements, with somewhat mixed findings. Vietnamese research has shown that growth faltering was partly reduced when infants were provided with complementary foods fortified with micronutrients over a six-month period17, with daily multiple micro34

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nutrient supplements also being found to reduce growth faltering in a similar population and study time-period.18 Other studies, however, have found that zinc and iron supplementation19 and multi-micronutrient interventions have not prevented, or reduced growth faltering.20,21 Earlier work found that increasing the energy content of infant formula led to reductions in length z-scores.22 Subsequently, authors of this work advised that the energy content of infant formulas should not be increased without also increasing the protein and micronutrient levels for infants with growth faltering.22 In line with this epidemiological evidence from Willows and colleagues (2011) showed that diets higher in protein, fat, iron and vitamin appeared to improve the growth of Chinese children.23 More recently, emerging work suggests that certain gut microflora, particularly an abundance of Acidaminococcus could also be associated with growth deficits.24 Discussion

Growth in early life is central to the development of a healthy immune system, neurological and cognitive function, organ formation and overall physical wellbeing.1 Clearly, the underlying causes of growth faltering are multifactorial, although gestational age is one determining factor.6 Unfortunately, once growth faltering tends to be recognised, nutritional deficits tend to have already occurred and can be difficult to recover.6 Subsequently, improved screening programmes are needed to identify expectant mothers whose infants may be at risk of growth faltering, so suitable strategies can be put into place early on. In terms of nutritional approaches, protein supplementation programmes look most promising at present.11,12,13 Now, further research is needed to determine ‘how much’ in relation to different levels of growth faltering. Unfortunately, findings from other nutritional interventions which have included energy supplements, multi-micronutrients, fatty acids and glutamine, have been less consistent, although the emerging role of gut microflora warrants further investigation. Other factors, such as aflatoxin exposure should also be considered, as strong effects on growth have been observed amongst Gambian women exposed to this in pregnancy.25

growth faltering Table 2: Nutrition and growth faltering: key studies Author

Area of interest

Gough et al (2015)24

Microflora

Maleta et al (2015)14 Cormack & Bloomfield (2013)11 Van der Merwe (2013)15

Lipid-based supplements

Methods Secondary analysis of twin cohorts Randomised single-blind trial

Main Findings Reduced microbiota diversity was associated with stunting and increased Acidaminococcus sp. was associated with growth deficits No benefits were seen in relation to length gain or reduced stunting between 6 and 18 months of age Babies fed higher protein intakes in the first month of life had a significantly greater growth velocity (p<0.0001)

Protein

Prospective cohort study

Long-chain PUFA supplements

Randomised double-blind trial

Miller et al (2012)12

Protein content of a milk fortified

Randomised controlled trial

Pham VP et al (2012)17

Micronutrientfortified complementary food

Willows et al (2011)23

Dietary adequacy

Village randomised controlled trial Observation study of 172 children aged 1 to 5 years in rural China

Akalu et al (2010)13

Quality protein maize (QPM)

Two randomised controlled studies

Dijkhuizen et al (2008)19

Iron and zinc supplementation

Williams et al (2007)16

Glutamine supplementation

Four randomised double-blind trials Double-blind placebocontrolled trial

Clarke et al (2007)22

Energysupplemented formula

Hop et al (2005)18

Multiple micronutrient supplementation

Lopez de Romana et al (2005)20 Untoro et al (2005)21

Multiple micronutrient supplementation Multiple micronutrient supplementation

No improvements in linear growth were seen

Open, parallel randomised study Double-blind placebocontrolled randomised trial Double-blind masked controlled trial Four double-blind placebo-controlled randomised trials

Equally, on the other side of the coin, whilst growth faltering is clearly an important issue, further study is needed to look into interventions for rapid early weight and fat gain. Interestingly, it has been found that attenuation of protein supply in these cases can help to normalise the risk of this.26 Thus, it seems that protein has a key role to play in both growth faltering and rapid weight gain. It now seems to be a question of what balance of protein is needed to support ‘healthy’ growth.

Infants in the higher-protein group achieved a greater weight at study end (mean difference: 220g; p= 0.03) Growth faltering stopped partly in Vietnamese infant but it is possible that benefits may only be short-term Consuming more protein-, fat-, zinc-, iron- and vitamin A-rich foods may improve growth and reduce anaemia Children eating conventional maize faltered in their growth, whereas children consuming QPM did not change significantly in height-for-age and had marginal increases in weight-for-age Neither iron nor zinc supplementation prevented growth faltering during infancy Glutamine supplementation failed to improve the growth of malnourished Gambian infants Increasing the energy content of normal infant formula without increasing protein and micronutrients should not be practiced in infants with faltering growth The length-for-age Z-score decreased significantly amongst the daily multi micronutrient group compared with the placebo or weekly multi micronutrient group No effects on growth faltering during infancy were observed Growth faltering was not prevented

Conclusions

Healthy growth, particularly during the first two years of life is central to a child’s later health and wellbeing. With regard to nutritional approaches protein interventions look to be most promising at present. That said, roles of multi-interventions that include protein warrant further investigation, as does the role of gut microflora. There is also potential to look at infant feeding and weaning practices in relation to infant growth. NHDmag.com October 2015 - Issue 108

web watch

web watch Online resources and useful updates. Increase in number of people with diabetes The number of people living with diabetes in the UK has increased by 59.8% in a decade, according to a new analysis by Diabetes UK. The new figures, extracted from official NHS data, show that there are now 3.3 million people diagnosed with diabetes, which is an increase of more than 1.2 million adults compared with 10 years ago when, in 2005, there were 2.1 million people diagnosed with the condition. This figure doesn’t take into account the 590,000 adults estimated to have undiagnosed diabetes in 2013-2014. www.diabetes.org.uk/About_us/ News/diabetes-up-60-per-cent-inlast-decade-/ Funding for eating disorder services NHS England has announced details of how it intends to distribute £30m of funding to improve eating disorder services aiming to achieve 95% of patients being seen within four weeks or one week for urgent cases by 2020. NHS England has issued guidance to CCGs on submitting their Local Transformation Plans (LTPs) to improve mental health care for children and young people, including how they will develop eating disorder services. www. england.nhs.uk/2015/08/03/cypmh-prog-launch/ NICE Quality Standards drug allergy/nutrition NICE has published two new quality standards, Drug allergy:

diagnosis and management (QS97) www.nice.org.uk/guidance/ qs97 covering the diagnosis and management of drug allergy in adults, young people and children. Treatment of the acute phase, including anaphylaxis, will be covered by a separate QS. Nutrition: improving maternal and child nutrition (QS98), www.nice. org.uk/guidance/qs98 covers improving nutrition before, during and after pregnancy (up to a year after birth). It particularly focuses on low-income and other disadvantaged households. NICE guidance: coeliac disease NICE has published guidance on Coeliac disease: recognition, assessment and management (NG20) covering the recognition, assessment and management of coeliac disease in children, young people and adults. It updates and replaces NICE guideline CG86 and includes recommendations on referral of people with suspected coeliac disease; information, support and advice. www.nice.org.uk/ guidance/ng20 Diabetes prevention programmes: evidence review Public Health England has published A systematic review and meta-analysis assessing the effectiveness of pragmatic lifestyle interventions for the prevention of Type 2 diabetes mellitus in routine practice. This document updates and extends a previously conducted systematic review and metaanalysis assessing the effectiveness

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of ‘real-world’ interventions for the prevention of Type 2 diabetes mellitus (T2DM) in high risk populations. The review supports previous research, demonstrating that diabetes prevention programmes can significantly reduce the progression to T2DM and lead to reductions in weight and glucose compared with usual care. It concludes that those developing prevention programmes should adhere to the NICE and/or IMAGE guidelines to increase efficacy. www. gov.uk/government/publications/ diabetes-prevention-programmesevidence-review NHS Diabetes Prevention Programme: non-diabetic hyperglycaemia The National Cardiovascular Intelligence Network has published NHS Diabetes Prevention Programme - non-diabetic hyperglycaemia. Non-diabetic hyperglycaemia refers to raised blood glucose levels, but not in the diabetic range. People with non-diabetic hyperglycaemia are at increased risk of developing Type 2 diabetes. This analysis uses a population representative sample of people with valid measurements to indicate nondiabetic hyperglycaemia. The accompanying spreadsheet outlines the number of people in each local authority who are estimated as having non-diabetic hyperglycaemia. www.gov.uk/ government/publications/nhsdiabetes-prevention-programmenon-diabetic-hyperglycaemia

Omega Oils

Health benefits of oils rich in omega-3, omega-6 and omega-9 fatty acids Use of the term ‘omega’, or ‘n-x’ when signifying a particular unsaturated fatty acid, refers to the position of the first double bond from the methyl (-CH3) end of the fatty acid molecule. For example, omega-9 or n-9 means that the double bond is located at the ninth carbon atom from the -CH3 group. Michèle Sadler Registered Nutritionist Rank Nutrition Ltd

Of the main fatty acids in the diet, polyunsaturated fatty acids (PUFA) are subdivided into omega-6 (n-6), omega-3 (n-3), and omega-3 long-chain or very long chain (n-3 LC) PUFA. The monounsaturated fatty acid (MUFA) oleic acid is classified as cis-omega-9, while two of the main trans-MUFA are classified as omega-9 and omega-7 (Table 1). Roles in the body

Michèle is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry. Michèle has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

Omega-3, omega-6 and cis-omega-9 fatty acids have important roles in the diet. Cis-omega-9 MUFA can be oxidised to provide energy, incorporated into tissues or converted into other fatty acids. Since they can be synthesised in the body, there is no specific dietary requirement for these fatty acids. In contrast, the parent omega-3 fatty acid (alpha-linolenic acid) and the parent omega-6 fatty acid (linoleic acid) are defined as essential. They are precursors of biologically active substances such as prostaglandins, prostacyclins and leukotrienes which are important, for example, for immunological reactions and the regulation of blood pressure. LC PUFA are important for the structure of cell membranes and help to control membrane functions such as fluidity and permeability. Requirements

In Europe, requirements for fatty acids were assessed by EFSA in 20101. No Dietary Reference Values were set for total PUFA, total MUFA or for oleic acid specifically. For adults, daily requirements for Average Intakes for linoleic

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acid were set at 4.0% energy, for alphalinolenic acid at 0.5% energy, and for EPA + DHA at 250mg/day, with an additional 100-200mg DHA/day required for pregnancy and lactation. In the USA, a recent development is that the 2015 Dietary Guidelines Advisory Committee Report2, a systematic review of the literature that provides evidence-based recommendations to inform revision of the Dietary Guidelines for Americans, has not recommended an upper limit on total fat consumption. The Committee concluded that dietary advice should emphasise optimising the types of fat in the diet rather than reducing total fat intake. This may result in more prominence being given to replacing saturated fats with PUFA rather than with carbohydrate in the American diet, the Committee concluding that for every 1.0% energy from saturated fat that is replaced with PUFA the incidence of coronary heart disease is reduced by 2.0-3.0%, whereas replacing total fat with overall carbohydrates does not lower cardiovascular disease risk. Health benefits

The evidence for health benefits of fatty acids has been assessed in recent years as part of the exercise of authorising nutrition and health claims in Europe3. The list of authorised health claims provides a good summary of the generally accepted health benefits for omega-3, -6 and -9 fatty acids and the required amounts to achieve the claimed effects (Table 2).

This demonstrates that most of the authorised health claims in Europe are for omega-3 LC PUFA, with other claims mostly recognising the physiological benefits of the essential fatty acids. The approved claim for oleic acid (omega-9) recognises the benefit of replacing saturated fats with unsaturated fats in order to maintain normal levels of blood cholesterol. The list also demonstrates the wide range of beneficial effects of these fatty acids including benefits for markers of heart health, heart function, blood pressure, the development and maintenance of normal vision and brain function, development of the eye and for growth and development in children. Further, it shows that the target groups that can benefit from omega-3 oils include the foetus, infants, children, pregnant and lactating women as well as the general population. For some of the claims, the required intakes are higher than the DRVs set for adults in Europe. For example, the claim that DHA and EPA intake contributes to the maintenance of normal blood pressure requires a daily adult intake of 5.0g EPA and DHA combined. Main dietary sources

Linoleic acid is found in oils, particularly corn, soybean and sunflower-seed oils, alpha-linolenic

acid in walnuts, linseeds and rapeseed oil, while LC omega-3 PUFA are mainly found in fish oils. Oleic acid is found in seeds and nuts and in olive, high-oleic sunflower-seed and rapeseed oils. A further source of these fatty acids is dietary supplements, which provide concentrated amounts in different combinations and from varying sources. These can make a useful addition to the diet, particularly where high intakes are required to achieve the health benefit and for people who do not like, or who do not frequently consume, oily fish.

Table 1: The main omega-3, -6, -7 and -9 fatty acids in the diet Common name

Systematic Name Monounsaturated fatty acids (MUFA) Cis-monounsaturated fatty acids (cis-MUFA) Oleic acid (Octadecenoic acid) Trans-monounsaturated fatty acids (trans-MUFA) Elaidic acid (Octadecenoic acid) Trans-vaccenic acid (Octadecenoic acid) Polyunsaturated fatty acids (PUFA) n-6 Polyunsaturated fatty acids (n-6 PUFA) Linoleic acid (Octadecadienoic acid) (Octadecatrienoic acid) γ-Linolenic acid

Abbreviation

Arachidonic acid n-3 Polyunsaturated fatty acids (n-3 PUFA)

20:4 (omega-6)

(Eicosatetraenoic acid)

(Octadecatrienoic acid) α-Linolenic n-3 Polyunsaturated long chain fatty acids (n-3 LCPUFA) EPA (Eicosapentaenoic acid) DPA (Docosapentaenoic acid) DHA (Docosahexaenoic acid)

18:1 (omega-9) 18:1 (omega-9) 18:1 (omega-7)

18:2 (omega-6) 18:3 (omega-6)

18:3 (omega-3) 20:5 (omega-3) 22:5 (omega-3) 22:6 (omega-3)

NHDmag.com October 2015 - Issue 108

omega oils Table 2: Authorised EU health claims for omega-3,-6 and -9 fatty acids Fatty acid type

Fatty acid

Claim wording

Conditions of use

Article 13.1: ‘General function claim’

ALA contributes to the maintenance of normal blood cholesterol levels

Foods bearing this claim must meet the conditions to make a nutrition claim for ‘Source of ALA’, as referred to in the claim ‘Source of omega 3 fatty acids’, and consumers are to be informed that the beneficial effect is obtained with a daily intake of 2.0g ALA.

DHA and EPA contribute to the maintenance of normal blood pressure

Foods bearing this claim must provide a daily intake of 3.0g EPA and DHA, and consumers are to be informed that the beneficial effect is obtained with a daily intake of 3.0g EPA and DHA. When used on food supplements and/or fortified foods, consumers are to be informed not to exceed a supplemental daily intake of 5.0g EPA and DHA combined. The claim is not for use on foods targeting children.

Omega-3

Docosahexaenoic acid and eicosapentaenoic acid

DHA and EPA contribute to the maintenance of normal blood triglyceride levels

Foods bearing this claim must provide a daily intake of 2.0g EPA and DHA, and consumers are to be informed that the beneficial effect is obtained with a daily intake of 2.0g EPA and DHA. When used on food supplements and/or fortified foods, consumers are to be informed not to exceed a supplemental daily intake of 5.0g EPA and DHA combined. The claim is not for use on foods targeting children.

Omega-3

Docosahexaenoic acid

DHA contributes to maintenance of normal brain function

Foods bearing this claim must contain at least 40mg DHA per 100g and per 100kcal, and consumers are to be informed that the beneficial effect is obtained with a daily intake of 250mg DHA.

Omega-3

α-Linolenic acid

Docosahexaenoic acid and eicosapentaenoic acid

Omega-3

Docosahexaenoic acid

DHA contributes to the maintenance of normal blood triglyceride levels

Foods bearing this claim must provide a daily intake of 2.0g DHA and must contain DHA in combination with EPA. Consumers are to be informed that the beneficial effect is obtained with a daily intake of 2.0g DHA. When used on food supplements and/or fortified foods, consumers are to be informed not to exceed a supplemental daily intake of 5.0g EPA and DHA combined. The claim is not for use on foods targeting children.

Omega-3

Docosahexaenoic acid

DHA contributes to the maintenance of normal vision

Foods bearing this claim must contain at least 40mg DHA per 100g and per 100kcal. Consumers are to be informed that the beneficial effect is obtained with a daily intake of 250mg DHA.

EPA and DHA contribute to the normal function of the heart

Foods bearing this claim must meet the conditions to make a nutrition claim for ‘Source of EPA and DHA’ as referred to in the claim ‘Source of omega-3 fatty acids’. Consumers are to be informed that the beneficial effect is obtained with a daily intake of 250mg EPA and DHA.

Omega-3

Eicosapentaenoic acid and docosahexaenoic acid

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omega oils

Omega-6

Omega-9

Omega-3, -6, -9

Linoleic acid

LA contributes to the maintenance of normal blood cholesterol levels

Foods bearing this claim must provide at least 1.5g LA per 100g and per 100kcal. Consumers are to be informed that the beneficial effect is obtained with a daily intake of 10g LA.

Oleic acid

Replacing saturated fats in the diet with unsaturated fats contributes to the maintenance of normal blood cholesterol levels. Oleic acid is an unsaturated fat.

To bear the claim, foods must be high in unsaturated fatty acids, as referred to in the nutrition claim ‘High unsaturated fat’.

Monounsaturated and/or polyunsaturated fatty acids

Replacing saturated fats with unsaturated fats in the diet contributes to the maintenance of normal blood cholesterol levels [MUFA and PUFA are unsaturated fats].

To bear the claim, foods must be high in unsaturated fatty acids, as referred to in the nutrition claim ‘High unsaturated fat’.

Article 14.1(b): ‘Children’s development and health claim’ Docosahexaenoic acid

DHA intake contributes to the normal visual development of infants up to 12 months of age

Consumers must be informed that the beneficial effect is obtained with a daily intake of 100mg DHA. To bear the claim, follow-on formula must contain at least 0.3% of the total fatty acids as DHA.

Docosahexaenoic acid

DHA maternal intake contributes to the normal brain development of the foetus and breastfed infants

To bear the claim, foods must provide a daily intake of at least 200mg DHA. Information to be given to pregnant and lactating women that the beneficial effect is obtained with a daily intake of 200mg DHA in addition to the recommended daily intake for omega-3 fatty acids for adults, i.e. 250mg DHA and EPA in total.

Omega-3

Docosahexaenoic acid

DHA maternal intake contributes to the normal development of the eye of the foetus and breastfed infants

To bear the claim, foods must provide a daily intake of at least 200mg DHA. Information to be given to pregnant and lactating women that the beneficial effect is obtained with a daily intake of 200mg of DHA in addition to the recommended daily intake for omega-3 fatty acids for adults, i.e. 250mg DHA and EPA in total.

Omega-3

α-Linolenic acid & linoleic acid, essential fatty acids

Essential fatty acids are needed for normal growth and development of children

Consumers are to be informed that the beneficial effect is obtained with a daily intake of 2g ALA and a daily intake of 10g LA.

Omega-3

ALA: α-Linolenic acid; DHA: Docosahexaenoic acid; EPA: Eicosapentaenoic acid; LA: Linoleic acid.

Dietary intakes of LC PUFA

To achieve adequate intake of the LC omega-3 PUFA, it is recommended in the UK to eat one portion of oily fish (140g)/week. The latest NDNS survey results4 show consumption is well below this in all age groups, particularly in younger people, being equivalent to 11g/week for 11- to 15year-olds, 21g/week for 16- to 24-year-olds, 47g/

week for 25- to 49-year-olds, 76g/week for 50- to 64-year-olds and 90g/week (103g for men and 81g for women) for 65+-year-olds. While adults aged 65 years and over have the highest consumption of oily fish, this still fell below the recommended one portion/week. As well as intake increasing with age, intake also increases from the lowest to highest quintile NHDmag.com October 2015 - Issue 108

omega oils

The age group with the highest percent of oily fish consumers over the four-day recording period was older adults (aged 65+ years) of which 38% were consumers of income for men and women aged 19 to 64 years. The age group with the highest percent of oily fish consumers over the four-day recording period was older adults (aged 65+ years) of which 38% were consumers, followed by adults aged 19 to 64 years of which only 23% were consumers. Only 8.0 to 12% of children consumed oily fish over the recording period. Comparing mean intakes of oily fish consumption for years 1 and 2 of the NDNS rolling programme with years 3 and 4, shows that intakes were similar in all age and sex groups. This indicates that there has been no trend towards increasing intakes over this time period. Novel sources of LC omega-3s

Given that oily fish is the richest source of LC omega-3 fatty acids and, given that intakes remain stubbornly low, the search is on for novel sources that can be used to increase supplies of these fatty acids in the diet. Also, concerns have been raised about lower levels of LC omega-3 fatty acids in farmed fish, which is mainly due to the use of a combination of fish and vegetable oils in fish feeds due to the lack of availability and increasing costs of pure fish oils. After many years, a collaborative research project between the University of Stirling and Rothamsted Research has resulted in the development of genetically modified (GM) plants that can produce up to 20% of EPA. In this research programme, five microalgal and fungal genes were transferred to Camelina plants (Camelina sativa) in order to generate a renewable terrestrial sustainable source

of omega-3 oils. The oil extracted from these plants was then tested in fish feeds for farmed Atlantic salmon. In the study5, three diets were fed to (contained) fish for seven weeks, one containing standard fish oil, one containing oil from Camelina plants that were not been genetically modified, and one containing oil derived from the GM plants. The results showed that oil derived from the GM plants was an effective substitute for fish oil in salmon feed with growth performance, feed efficiency, fish health and nutritional quality for the human consumer unaffected by the oil from the GM plants. Clearly GM technology is controversial, but its use to deliver a direct consumer benefit may be more acceptable to consumers than previous uses of the technology. Conclusions

Omega oils are important for human health, particularly the omega-3 and omega-6 series of fatty acids for which a number of health benefits have been defined at varying levels of intake and for various sub-groups of the population. The importance of using PUFA as opposed to carbohydrate to replace saturated fats to reduce CVD risk has been given more emphasis by the latest review that will inform revision of the Dietary Guidelines for Americans. In the UK, dietary intakes of oily fish, the main source of LC omega-3 PUFA, remain low and coupled with concerns about the content of omega-3 fatty acids in farmed fish, sustainable ways to maintain high levels of omega-3 are being investigated.

References 1 EFSA (2010). Scientific Opinion on Dietary Reference values for fat including saturated fatty acids, polyunsaturated fatty acids, monounsaturated fatty acids, trans fatty acids and cholesterol. EFSA Journal 8(3) 1461 2 Dietary Guidelines Advisory Committee; Scientific Report of the 2015 Dietary Guidelines Advisory Committee (2015). www.health.gov/ dietaryguidelines/2015-scientific-report 3 Community list of claims: http://ec.europa.eu/nuhclaims 4 Public Health England, Food Standards Agency, 2014. National Diet and Nutrition Survey: Results from Years 1, 2, 3 and 4 combined of the rolling programme (2008/9-2011-12) 5 Betancor et al (2015). A nutritionally-enhanced oil from transgenic Camelina sativa effectively replaces fish oil as a source of eicosapentaenoic acid for fish. Scientific Reports. 5: 8104 | DOI: 10.1038/srep08104

NHDmag.com October 2015 - Issue 108

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iron for sport

Benefits of iron for sport and exercise Iron has several essential functions in the body for both health and sport, but despite our increased knowledge and understanding of the benefits and sources of iron, it is still the most common nutrient deficiency across the globe.

Carrie Ruxton PhD, Freelance Dietitian

Rin Cobb, Freelance Sports Dietitian, PND Consulting

In the UK, women and teenage girls often do not meet their daily iron requirements and obtain most of their iron from less bioavailable sources. The requirement of endurance sports puts athletes at an increased risk of iron deficiency, which in turn can affect their sporting performance in a number of ways. Female and vegetarian athletes are also at an increased risk as they struggle to meet their basic daily iron needs, let alone any increased requirements that they may have for their sport. Role of iron in health

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. Rin’s years of experience working as a dietitian in the NHS and her love of the outdoors culminated in a unique sports nutrition service PND Consulting. Rin has practiced in weight management, nutrition support and has specialised in kidney disease, childhood nutrition and eating disorders.

Minerals, like vitamins, are classified as micronutrients and as such are only required in small amounts, but are, nonetheless, essential for normal body function1. Iron is one such mineral and has a number of roles within the human body. These include haemoglobin synthesis, oxygen transport within haemoglobin in blood and in muscle myoglobin, and enzyme production for the citric acid cycle and DNA synthesis2. The role of iron in the body is summarised in Figure 1. Due to the toxicity of iron and limited options for excreting any excess, iron homeostasis is primarily regulated through iron absorption with this being up-regulated when iron stores are low. Of the total dietary iron consumes, less than 10% is absorbed in the upper intestine, with bioavailability being three times greater for haem iron (found in red meat) compared with non-haem iron (found in fortified foods and plant sources). Iron not immediately required for metabolic

NHDmag.com October 2015 - Issue 108

processes is stored temporarily by epithelial cells in the gastrointestinal tract but, due to their high turnover, both cells and their iron can then be lost in faeces.3 Once iron is absorbed, it is distributed by the protein transferrin to fulfil its bodily functions, with any surplus stored in the liver, spleen or bone marrow as ferritin. Ferritin levels can be affected by infection and inflammation, so this should be taken into account when interpreting biochemical tests, as these can raise ferritin levels even in the presence of an underlying deficiency.4 Iron levels can become low through blood loss, impaired absorption or inadequate dietary intake. Early symptoms such as fatigue, pallor, breathlessness and palpitations can be subtle and go unnoticed, but prolonged iron deficiency can ultimately lead to a reduction in red blood cell production and, in turn, low haemoglobin levels, resulting in iron deficiency anaemia. This is defined as haemoglobin (Hb) <13g/100ml in men and <12g/100ml in non-pregnant women4. However, it should be noted that cut-offs vary according to local reference ranges. Whilst low Hb is indicative of anaemia, it does not confirm whether it is due to iron deficiency, so additional tests, including ferritin and transferrin, should be requested. Certain groups in the UK population are at an increased risk of iron deficiency, such as infants over the age of six months; toddlers, particularly those from low income families; women with high menstrual losses; pregnant women who already have low

iron for sport Figure 1: Iron absorption and metabolism3

iron stores on conceiving; vegetarians and vegans; and endurance athletes.1, 5 This is reflected in the most recent National Diet and Nutrition Survey (NDNS)6 which reported that only 1.5% of adult men were anaemic while 10% of women aged 19-64 years had Hb <12g/100ml. Iron and performance

The two primary factors that determine exercise performance are the exercising muscles oxidative capacity and the body’s maximum oxygen consumption, also known as VO2max.7 These are particularly important for endurance exercise where the body is working more aerobically and the demand for oxygen is greater. As iron is multifunctional in the body, iron deficiency will influence exercise performance in multiple ways. Primarily, it limits the oxygen carrying capacity of the blood to exercising muscles including the heart, thus reducing VO2max. As iron is essential for oxidative energy metabolism, a deficiency will reduce energy production via this process and in response, anaerobic glycolysis will increase, thus further increasing the demand

on carbohydrate for fuel.8 The other processes to which iron contributes will also be impaired and can lead to mental dysfunction, poor temperature control and weakened immunity.9 There is no doubt that iron deficiency anaemia will have a negative impact on athletic performance since ‘iron is the key to most physiological variables of athletic performance’7; however, what is less clear is the point at which iron deficiency is detrimental to an individual athlete. Peeling et al5 suggested iron deficiency can be categorised into three stages of severity for athletes as shown in Table 1. Endurance and female athletes appear to be at increased risk of iron deficiency in some form or another10 and, whilst Stage 3 is still reported to be rare amongst athletes and not dissimilar to the general population, a summary of surveys reported that 35% of female athletes had a ferritin <12ųg/L and up to 60% <30ųg/L.11 To test the effect that iron deficiency has on performance, most studies have performed an exercise test before and after iron supplementation. Despite some conflicting results, iron supplementation of non-anaemic iron deficient athletes (both men and women) has generally had a positive impact on endurance capacity, including VO2max, 15km time trial performance, work rate and lactate threshold.7,10,12 The American College of Sports Medicine (ACSM)13 acknowledges that iron deficiency with or without anaemia can have negative effects on both health and exercise performance. Since, reversing anaemia can take three to six months, prevention strategies are a more practical option. Whilst ACSM recognises that the iron requirements of endurance athletes can be increased by as much as 70%, there are no specific recommendations above and beyond the US RDA for this group. A review by Zourdos et al12 suggests that iron supplementation should be based on blood tests and commenced if ferritin is <35mg/L NHDmag.com October 2015 - Issue 108

iron for sport Table 1: The three stages of severity for athletes Stage 1: Iron depletion

Iron stores in bone marrow, liver and spleen are depleted

Ferritin <35ųg/L Hb >11.5g/100ml Transferrin saturation >16%

Stage 2: Iron deficient erythropoiesis

Erythropoiesis diminishes as iron supply to erythroid marrow is reduced

Ferritin <20ųg/L Hb >11.5g/100ml Transferrin saturation <16%

Stage 3: Iron deficient anaemia

Haemoglobin production falls resulting in anaemia

Ferritin <12ųg/L Hb <11.5g/100ml Transferrin saturation <16%

Table 2: Examples of iron-rich snacks and meals Iron rich meals

Iron rich snacks for exercise

Spaghetti Bolognese using lean mince with added carrots and spinach

Dried fruit

Baked beans on wholegrain toast

Fortified milk drinks

Pork chops, mashed potato and peas

Recovery drinks

Mackerel salad with tomatoes, peppers, baby spinach and potatoes

Peanut butter on wholegrain toast

Mixed bean stew

Bowl of fortified breakfast cereal

Lamb and apricot stew

Fortified breakfast biscuits

using a dose of 100mg/day of haem iron and continuing until ferritin is approximately 60mg/L, which may take two to three months. There is currently no evidence to support any performance enhancing effects of supplementation in athletes who have a normal iron status. Dietary sources of bioavailable iron, such as that found in red meat, should be optimised to prevent iron deficiency. A study by Lyle et al14 demonstrated that meeting iron requirements (American RDA 18mg/d) through diet, including extra red meat, was as effective as a 50mg/day iron supplement for protecting ferritin status in active women. Dietary interventions may also attract better compliance than supplementation. The role of meat in providing bioavailable iron was also noted by the European Food Safety Authority which is currently reviewing Dietary Reference Values for iron.15 Intake and sources

The Reference Nutrient Intake (RNI) for iron in the UK is 8.7mg/day for men and 14.8mg/ day for women aged 19-50 years14; however, only 78% of women meet the RNI through diet. More concerning is the fact that 23% of 46

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women have iron intakes below the lower RNI of 8.0mg/day which indicates a higher risk of deficiency in this group.6. As already discussed, whilst athletes, particularly endurance athletes, are likely to have increased iron requirements, no additional recommendation has been agreed. Results from the NDNS support US-led advice13 that female, endurance and vegetarian athletes should pay particular attention to their diet and have their iron status tested several times per year due to an increased risk of iron deficiency. The main sources of iron in the UK diet are bread and fortified cereals, providing 39% of our daily recommendation and meat, contributing 1821% for adults (11-13% for children). The bioavailability of iron from different food sources should be considered in addition to intakes, as haem iron is more effectively absorbed than non-haem iron sources. Fortified cereals, the largest contributor to daily iron intakes, contain non-haem sources, so that only up to 15% is absorbed, whereas red meat, which is a source of haem iron, allows up to 30% to be absorbed.2 Official guidelines recommend a daily average intake of 70g red and processed meat to ensure adequate iron intakes, but women and teenage girls, on average, consume

iron for sport

only 45-56g. Red meat intakes appear to be adequate for most males. Due to the impact of iron on health, several health claims have been approved in Europe, the most commonly used being that iron helps to reduce tiredness and fatigue, and supports normal immune function and normal cognitive function. To use these claims, foods and drinks must provide an official ‘source’ of iron, i.e. at least 15% of the EU RDA (1.2mg for men and 2.2mg for women). A claim has also been approved that ‘meat or fish contributes to the improvement of iron absorption when eaten with other foods containing iron’ with a condition that the meal must contain at least 50g meat or fish.17 Conclusion

At a minimum, athletes should ensure that their diets contain at least the RNI for iron. Other tips for active individuals are suggested below: • Athletes, particularly women and those participating in endurance events, should pay particular attention to dietary iron intakes and have iron status checked routinely. • Any iron deficiencies, such as ferritin <35mg/L, should be corrected to prevent iron deficiency anaemia.

• Increase foods high in iron, particularly haem sources, such as red meat. The weekly guideline is 500g cooked red and processed meat. • Vegetarian athletes should aim to eat ironrich plant foods, such as beans and pulses, on a daily basis and should consider a mineral supplement. Some examples of iron-rich snacks and meals are shown in Table 2. The main meal could include a 150ml glass of pure fruit juice to improve iron absorption. Acknowledgment Funding for this review was provided by the Meat Advisory Panel (MAP) which is a group of experts who provide independent and objective information about red meat and its role as part of a healthy, balanced diet. MAP is supported by an unrestricted educational grant from the Agriculture and Horticulture Development Board. For more information, visit www.meatmatters.com. For article references please email info@networkhealthgroup.co.uk NHDmag.com October 2015 - Issue 108

career

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk

BRAND MANAGER - METABOLIC NUTRITION £ Attractive basic salary + pension, private healthcare, Liverpool (Sefton Street). For over 20 years, Vitaflo International Ltd (a Nestlé Health Science company) has been developing innovative products for clinical nutrition. Our commitment and dedication to the changing requirements of this specialist sector has established us as a global leader in products for inherited metabolic disorders and disease related malnutrition. As part of our continued growth we are looking for an experienced dietitian with strong theoretical (and ideally practical) knowledge of metabolic disorders to join our marketing function. You will be responsible for the Brand Management of a specialised range of metabolic products within our metabolic team and wider marketing department, driving growth of both Paediatric Dietitian - Norfolk the Vitaflo UK and International Metabolic business. This is a fantastic opportunity for a dietitian like you, a new challenge working in industry while still applying your clinical knowledge! Prior marketing experience is desirable. Please contact our recruitment advisor Oliver Duke, quoting the reference number OD11775, by sending full career details to The Recruitment Management Group, Eleven Abbots Park, Preston Brook, Cheshire WA7 3GH. Closing date: 16th October 2015. Email: oliver.duke@rmguk.com, fax 01928 711884 or telephone 01928 711800 for an initial discussion. www.rmg-uk.com www.vitaflo.co.uk

CATERING DIETITIAN - £32,000 - Putney, London SW15 - 40hrs pw Mon-Fri Aramark is a food service and facilities management partner to organisations across a range of market sectors. Here at a prestigious hospital, specialising in the care and rehabilitation of people with brain injuries, we are working primarily to support the main patient feeding production kitchen as part of the Catering team. We would look to you to ensure that all patients are properly nourished and hydrated by working carefully to develop patient menus and complete nutritional analysis of recipes, whilst also ensuring that the texture modifying of dishes meets guidelines and patient dysphagic requirements. This will involve lots of interaction and liaison with the hospital Dietitian and Speech & Language Therapy teams as well as our own Catering team. You’ll also create bespoke individual patient menus where required, through discussions with patients and relatives. You should already be a registered Dietitian with the Health & Care Professions Council and preferably the British Dietetic Association and have experience in food service dietetics ideally within a hospital or care home environment. Send your CV and cover letter outlining why we should meet to: baker-mark@aramark.co.uk. For an informal discussion about the role please call Mark Baker on 07732 041325.

2016 GRADUATE PROGRAMME - NUTRITION - London/Trowbridge £28,500 + bonus + benefits Start date: 12/09/2016 Application deadline: 31/10/2015. At Danone you’ll be on a secondto-none graduate programme, undertaking two 12-month placements. One will be field-based, working closely with healthcare professionals to deliver education and training; the other will be based in one of our Head Offices in London or near Bath where you could be working with our Marketing department and supporting the production of new materials or packaging. Bridging the gap between science and industry you will be using your nutritional knowledge to ensure that our products are the ‘best in class’. The role is focused on delivering quality nutritional and medical expertise to our businesses, and assisting in the commercial proposition to healthcare professionals and retailers. You will have access to our first-class learning and development programme focused on building your leadership skills. You will have the opportunity to learn and network across all levels of our business; from your fellow graduates to our directors. To obtain a place on this highly competitive programme you’ll need to demonstrate evidence of your abilities to engage and align teams, create breakthrough results and take responsibility and risk to show the way forward. You will need a 2.1 degree in Nutrition or Dietetics, a minimum of 300 UCAS points and be available to start in September 2016 to apply for the scheme. If successful at the online application stage, you will be invited to complete our online verbal and numerical testing. The next stages will be a video interview and then an invitation to the Danone Leadership Academy on the 1st and 2nd December. To apply, visit our graduate careers website www.danone.co.uk/graduates.

NHDmag.com October 2015 - Issue 108

career

*5$'8$7(

352*5$0Ǯ( NUTRITION Salary £28,500 + bonus + beneﬁts A two-year programme where you will gain experience across two of our four businesses. Securing a place could see you working at the very hub of nutrition innovation, research, quality and education to guarantee that our products really are the ‘best in class’. You will undertake two placements with our Early Life Nutrition and Advanced Medical Nutrition divisions, in medical affairs, medical marketing, or healthcare nutrition solutions (sales).

Application Deadline - 31st October 2015

Apply at: Danone.co.uk/graduates

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28/09/2015 12:09

We urgently require dietitians for immediate vacancies To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk

• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health • Our aim is to find you the right person and the right job • We offer inpatient and community UK & NI coverage • Competitive rates

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career Dietary Role - Band 7 - Guy’s and St Thomas’ Evelina Children’s Hospital, London This role is to cover the period from 26th Oct 2015 to 15th Jan 2016. Hours are 9am to 5pm, covering paediatric inborn errors of metabolism. Applicants must have paediatric experience, preferably with metabolic experience too. Email your CV to registration@pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is a NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

contract, but this might be extended. It is an Actual role (nursing homes, home visits and GP clinics) and community experience is preferable. To be considered for this or other roles with Elite, please call 0800 023 2275 or 01277 849 649. Email hayley@eliterec.com. Please follow us on Twitter @elitedietitians, or visit our website www.elitedietitians.com for up-to-date Jobs.

Band 6 Child Weight Management - W london This role is to start ASAP for two months, visiting special schools and sports centres in the local area. Previous weight management experience is essential, as well as experience with paediatrics. Call Hayley at Elite for further information 0800 023 2275/01277 849649 hayley@eliterec.com www.elitedietitians.com

Band 6 Community Dietitian - Hertfordshire This role is for 30 hours a week covering community Neuro Rehab for a minimum of four months. The hospital in Hertfordshire is commutable from London, so applicants must either be a car driver or have a licence as we could hire a car for them. Please call Hayley at Elite for further information on 0800 023 2275 or 01277 849 649. Email hayley@eliterec.com or visit www.elitedietitians.com

Band 5 or 6 Dietitian - NHS Staffs Required for a NHS trust in Staffordshire covering a community role, so car driver and car required. The role covers two days per week (preferably Tues and Weds), around 16 hours per week. Immediate start. Accommodation can be arranged locally. Three-month

Band 6 or 7 Paediatric Diabetes Dietitian This is a part-time role for three months starting ASAP. Please call Hayley at Elite for further information on 0800 023 2275 or 01277 849649. Email hayley@eliterec. com or visit www.elitedietitians.com

Band 6 Acute role - Wales Starting ASAP for four weeks, this role covers gastro, surgical and pancreatic patients. Please call Hayley at Elite for further information on 0800 023 2275 or 01277 849649. Email hayley@eliterec.com or visit www.elitedietitians.com

events and courses Nutricia Paediatric Allergy Symposium 16th Oct 9.30am to 4.30pm Marriott Victoria & Albert Hotel, Manchester www.nutricia.co.uk/events/paediatric_allergy/

University of Nottingham - School of Biosciences

Modules for Dietitians and other Healthcare Professionals

• Diabetes 1 & 2 - 14th Jan, 2016 • Understanding Behaviour Change 9th & 10th Feb & 22nd March 2016 For further details please email marie.e.coombes@ nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/ biosciences and click on short courses then ‘for practising dietitians’.

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Gastroenterology Module - University of Nottingham School of Biosciences Modules for Dietitians and other Healthcare Professionals - 8th Oct www.nottingham.ac.uk/biosciences Introduction to Mental Health, Learning Disability and Eating Disorders - BDA Trainer - 13th Oct London Road Community Hospital, Derby www.ncore.org.uk Hot Topic Conference 2015: Obesity & Pregnancy 29th to 30th Oct - Charles Darwin House Conference Centre, 12 Roger Street, London WC1N 2JU www.worldobesity.org/ CODHy 2015 5th to 7th Nov - Istanbul, Turkey www.codhy.com/2015/Default.aspx

the final helping

Neil Donnelly

Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders.

Many of you will remember the time that you first became interested in a career in nutrition and dietetics. Perhaps it was through a suggestion of a relative, friend, teacher, or maybe through meeting someone who had a condition requiring an enforced dietary change. Or maybe it was a combination of a desire to help individuals and explore the underlying physiology/biochemistry of the human body and how it coped with food. My own interest in the link between food and health began when I was fortunate enough to obtain my first summer job at the age of 15 years in a factory near Coleford in the Forest of Dean. Friends at my Grammar school in Wales had made this 40-mile journey during the start of the summer holidays for the past couple of years and had returned after five weeks with what was then an exceptionally good wage packet. That year, the factory was taking on nearly 20 boys from our school, housing them in former prisoner of war huts and putting them to work in a variety of jobs on a very specific seasonal activity. That activity was the production of the blackcurrant cordial called Ribena. Virtually all the commercially grown blackcurrants in the United Kingdom were hand-picked and transported to the Beecham’s factory for processing. All this occurred over a period of around six weeks. I was loading boxes onto conveyor belts, making ‘cheeses’ which extracted the juice, cleaning the boards which pressed the pulp and, finally, graduated to the laboratory where we checked compositional details, including, of course, vitamin C levels. The original juice was then concentrated fivefold, which destroyed all the original vitamin C in the blackcurrants and ascorbic acid was then added when it was reconsti-

tuted. It was a fascinating insight into product development and a simple, but essential, nutrient that we all need. And so it began… Ribena, of course, is still with us today, except that now, as a result of the sugar lobby, Tesco have withdrawn it from sale from their shelves. Back then, no one knew about obesity. None of my friends were overweight. No one stayed in their bedrooms for hours except to sleep. We needed energy in our foods and drinks. The Co-op pop man came round on a Friday and my favourites were Dandelion and Burdock and Cream Soda. We played football endlessly in the school playground. No cars waited for us outside the school gates. We met with our friends face to face, not viewed them on a flat screen. Sure, times have changed and we all need to adapt, but removing one longstanding established nutritional product from sale in the belief that it is going to make a contribution to resolving the current childhood obesity crisis of the nation is to my mind unfortunate at best. I get the sugar message, but some kids are still kicking a ball around and need a drink with a calorie or two combined with a significant water soluble vitamin in it. I was going to talk about the furore relating to the amount the government spends in funding gluten-free products, but maybe that’s for another time! NHDmag.com October 2015 - Issue 108

Here’s to choice Only Nutricia offers the widest range of compact nutrition, including Fibre and Protein

Fortisip Compact also has the widest range of flavours, from banana to forest fruit, which may aid patient compliance.1 Reference 1. Hubbard GP et al. Clin Nutr 2012:31;293–312.

Date of preparation: 02/15

Still #1 when it comes to choice and flavour range

uk o. .c BS JO 09 tic 20 te e ie c .d in w S w w

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EXTRA

A DAY IN THE LIFE OF A RENAL DIETITIAN... Heather Alford Registered Dietitian, East & North Hertfordshire NHS Trust ISSN 1756-9567 (Online)

Issue 108 October 2015

THE FOOD THEORY OF EVERYTHING by Ursula Arens Dr Mabel Blades p11

NUTRITIONAL ASPECTS OF HIGH FIBRE CEREAL INGREDIENTS by Carrie Ruxton

EXTRA NHD ARTICLES FOR SUBSCRIBERS ONLY

NHD Extra - menu scoring

The (Food) Theory of Everything The susDISH analysis system for scoring menus

Review by Ursula Arens Writer; Nutrition & Dietetics

For article information sources please email info@network healthgroup.co.uk

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews

The celebrity physicist Professor Stephen Hawking may be trying to find the number or equation that defines ‘time’; but you do not have to understand physics to enjoy the insight into his professional and personal challenges as beautifully portrayed in the film The Theory of Everything. Dr Toni Meier of the Martin Luther University in Halle Wittenberg in Germany, has the more modest ambitions of developing a menu system that combines the criteria of both nutrition quality and environmental impacts. Can these chalks and cheeses be combined to form a single menu rating that is meaningful and something that every caterer will be able to use to traffic-light menus into red-no or green-yes decisions? The computer algorithm Dr Meier has developed is called susDISH (from the term sustainable dish). More than 1000 menus have been rated, and caterers in many public and private institutions in Germany will be doing trial runs. Canteens, such as those of the car production sites of BMW, or of the Universities of Berlin, already mandate nutrient scoring systems, and adding eco points or greenhouse gas emission scores is just further fine tuning. “Where’s the Beef?” is a well-known American catchphrase first used by the hamburger chain Wendy’s to promote its claims of more-meat than rival burgers, but now it’s a phrase used by politicians and others in debate wanting facts and detail. It may also be the question that German canteen users ask after a susDISH menu analysis. There are three aspects to the susDISH analysis. Firstly health points, which are based entirely on the nutrient content of the meal. There are 16 macro

and micronutrients included in the calculation, with minimum cut-offs calculated to provide one third of reference intakes (for, example, lunch), with margins of 5.0% over or under the cut-offs. For a few nutrients, there are maximum cut-offs (protein/fat/sodium/cholesterol). Only energy contents, which are based on figures of adult Physical Activity Levels (PALs) of 1.6, have the wider margin of 10% over or under cut-offs. The more nutrients there are within the cut-offs, the higher the health points, the top score being 16 for the attainment of all the nutrient and energy criteria. Health points analysed for sample menus score highest for menus that include meat and lowest for the vegan menus, although the span of about two points indicate minor differences over the full range of zero to 16 (see Table 1). Typical faults for menus are inadequate levels of calcium or vitamin B12, and excess levels of sodium. Meat-containing menus can maintain high nutrition scores with smaller meat portion sizes, so health point optimisation can be more a process of changing recipes rather than changing ingredients. The second aspect is the eco-point score. This method of analysis was developed and is widely used in Switzerland (Frischknecht, 2013) and uses measures of ecological scarcity. Criteria are based on national targets and capture field-to-fork analysis of a wide diversity of ecological aspects of food production and preparation, such as pesticide use, water use, air pollution, soil degradation, nitrate excess and loss of biodiversity. Eco-points vary very widely per kilo of product; Beef hits 1344 points, but other animal-source foods scatter less predictNHDmag.com October 2015 - Issue 108

NHD Extra - menu scoring Table 1: Sample scores for different menus Menu

Health points>=√

Eco points>= X

Greenhouse points >=X

Mixed menu

155

11.8

104

1.6

Beef dishes

12.7

273

4.1

Pork dishes

11.5

114

1.7

Poultry dishes

12.3

1.4

Vegetarian

11.7

1.1

Vegan

10.6

0.8

ably (butter 811, cheese 549, milk 131, pork 511, poultry 336, eggs 238 and fish 51-164). Of course the gradient of milk to cheese to butter reflects the concentration of the product from processing, and weight quantities of butter consumed are usually lower than those of milk, so recipe level scores are different (see Table 1). All plant-source foods score below 200 eco points per kilo. The third and final aspect included in the susDISH analysis method, is the calculation of greenhouse gas emissions that can be attributed to food products. Although carbon footprint data is only one component in the assessment of environmental impacts, it has a defined methodology of assessment that allows clear categorisation of products (see Table 1). Dr Meier calculated health and eco points from different menu items, and used traffic light banding to illustrate results in a scattergram (see Figure 1). The red zones were dominated by beef dishes on the eco points axis and by a few pork and vegan dishes on the health points axis. This data could be used to cut red menu items from the catering roster, or to present data to consumers to allow their ‘informed choice’ on these issues. It could also be used to schedule red meal items into smaller portion size or less frequent offerings on the menu cycle. Obvious and pragmatic conclusions could be drawn, that computer algorithms can only endlessly fine-tune what are long-established conclusions, that beef consumption has the greatest adverse environmental impacts, and vegan diets have certain nutrient deficits that benefit from the use of fortified foods or supplementation. Some further analysis of menu data shows that, where recipe adjustments are made to improve scoring for eco points or greenhouse points, there is usually also an added benefit to the caterer of a reduction of the cost of ingredi54

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ents. Obviously, this relates to reduced portion sizes of what is usually the most expensive ingredient (meat). In contrast, adjustments to improve the health point scores of vegan recipes may result in increased costs, due to the use of specialist or more expensive ingredients. Another assessment of nutrition and environmental impacts has been carried out by the Swiss canteen company SV Group and the World Wide Fund for Nature (WWF) group in Switzerland. Life Cycle Analysis (LCA) of all food purchases made by the catering group was calculated and a 20% reduction in greenhouse gas emissions was identified by the introduction of three measures: 1. Reduction of food waste by changes to specifications, and changes in kitchen practice. 2. Reduction in the use of vegetables grown in heated greenhouses, and increased use of foods that are seasonal and not transported by air. 3. Reduction in the amounts of meat per meal and greater availability and frequency of vegetarian meal choices. The catering initiative, launched in more than 70 Swiss staff canteens, was branded ‘One Two We’ (meaning One – you the customer, together with SV catering making Two partners, and together We aim to reduce greenhouse gas emissions). The programme was awarded the 2013 Zürich Climate Prize. Nutrient analysis of menus is long established and assessment of sustainability criteria in catering decisions is also very familiar, if still rather variable and inconsistent in the criteria and weightings used. The ability to integrate such data is an appealing concept for those involved in catering (especially for those involved in the marketing of catering services), and dietitians should seize the opportunities offered by the demand for nutrition-plus information.

CEREALS

NUTRITIONAL ASPECTS OF HIGH FIBRE CEREAL INGREDIENTS Cereals and cereal products are a major part of Western diets, providing in the UK with more than one third of daily energy intakes, around a quarter of protein intakes, 40% of fibre intakes and significant amounts of vitamins and minerals.1 Carrie Ruxton PhD, Freelance Dietitian

For article references please email info@ networkhealth group.co.uk

According to the Eatwell plate, cereals form part of the starchy food category that should comprise 33% of the diet by volume. Commonly-consumed cereal foods include breakfast cereals, pasta, rice and bread, as well as the more discretionary options of biscuits, cakes and buns. Breakfast cereals contain an array of cereal ingredients, many of which offer nutritional benefits, or which could be classed as ‘wholegrain’. This article will consider some of these ingredients, particularly in the light of EU authorised health claims. HEALTH CLAIMS

Since 2012, all health claims made on food and drink products must be authorised based on the available scientific evidence. Table 1 presents the health claims that can be made for cereal ingredients. While it is accepted that manufacturers will present health claims on pack in language more appropriate for consumers, it is nevertheless recommended that the wording remains as close as possible to the original statement in order to avoid misleading consumers. Examples of wording on pack include: ‘to give digestion a helping hand’, or ‘to help actively reduce cholesterol’. WHEAT

Wheat is the second most important crop worldwide after rice and is a major staple in several regions.3 The wheat grain consists of a germ, endosperm (which is the starchy element) and bran

fractions which are high in fibre and make up 14-16% of the grain.4 Wheat contains vitamins: thiamin, riboflavin, vitamin B6, folate and vitamin E, as well as sulphur-containing amino acids and phenolic compounds which express antioxidant characteristics. As reviewed by Stevenson et al4, several observational studies have associated wheat fibre with a reduced risk of cardiovascular disease and Type 2 diabetes. In addition, a recent metaanalysis5 confirmed that higher intakes of wheat bran were linked with reduced risk of Type 2 diabetes. However, the few randomised controlled trials (RCT) are contradictory. The discrepancy may be because viscosity of fibre is the key factor in delivering metabolic effects.6 Observational evidence also exists for an inverse association between wheat fibre intake and cancer risk4 This is backed by two large clinical trials (n=3209 combined) which found that men, but not women, with higher intakes of wheat bran had a 19% lower risk of colorectal adenoma recurrence.7 OATS

Oats are consumed mainly in Europe and are a source of thiamin, niacin, folate, vitamin E, phosphorus, iron, magnesium and zinc. They are also rich in the soluble fibre, beta-glucan, which has been proven to lower LDL cholesterol. Beta-glucan works by boosting the transport of bile acids through the gastrointestinal tract which enhances their excretion via faeces. This, in turn, NHDmag.com October 2015 - Issue 108

NHD Extra - cereals Table 1: Authorised health claims for cereal ingredients2 Ingredient

Claim

Amount needed

Contributes to an acceleration of intestinal transit

10g wheat bran fibre daily. Food must also qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

Contributes to an increase in faecal bulk

Food must qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

Contributes to an increase in faecal bulk

As above

Contributes to the maintenance of normal blood cholesterol levels

Food must contain at least 1.0g beta-glucan per portion and must state that beneficial effects occur at daily intakes of 3.0g

Contributes to the reduction of the blood glucose rise after a meal

Food must contain at least 4.0g of beta-glucan for each 30g of available carbohydrates per portion and should be eaten as part of a meal

Lowers blood cholesterol

Food must contain at least 1.0g beta-glucan per portion and must state that beneficial effects occur at daily intakes of 3.0g

Contributes to the maintenance of normal blood cholesterol levels

As above

Contributes to the reduction of the blood glucose rise after a meal

Food must contain at least 4.0g of beta-glucan for each 30g of available carbohydrates per portion and should be eaten as part of a meal

Barley grain fibre

Contributes to an increase in faecal bulk

Food must qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

Rye fibre

Contributes to normal bowel function

As above

Wheat bran fibre

Oat grain fibre

Oat beta-glucan

Barley beta-glucan

stimulates the synthesis of new bile acids from endogenous and dietary cholesterol which lowers blood cholesterol levels.8 There is consistent evidence to link consumption of oats with cardiovascular health via a direct impact on total and LDL cholesterol and, possibly, via changes to post-prandial glycaemia and blood pressure.9 A systematic review evaluated the published literature on oats and lipid management finding that oats significantly lowered total or LDL cholesterol in most of the 21 RCT included.10 A more up-to-date systematic review confirmed these findings for cholesterol, but disputed whether oats had any impact on blood pressure or glycaemia due to under-powered RCT.11 Oats have been identified as having a role in weight management, but the evidence can be inconsistent. A 12-week RCT in 144 participants found a reduced waist circumference in those given an oat cereal versus a low fibre control cereal.12 However, in two other trials, there was no spe56

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cific weight loss attributed to the high oats diet, although metabolic benefits were apparent.13, 14 RYE

The rye grain is related to wheat and barley and is commonly used in Europe for bread flour and muesli. Health aspects of rye include blood lipid reduction, glycaemic control and weight management. An acute trial in 12 healthy subjects found that rye products produced a significantly lower insulin response compared with a control wheat bread, which was not related to the glycaemic index (GI) of the products, suggesting that other bioactive properties were at work.15 In addition, rye had a greater impact on satiety compared with the control food. A four-week trial in 21 participants confirmed these findings and reported that wholegrain rye was associated with a significant reduction in post-prandial glucose and insulin, as well as an increase in short-chain fatty

NHD Extra - cereals

Barley is a fibre-rich grain that contains significant levels of beta-glucan and insoluble fibre, and has been classified as low GI. acids, suggesting colonic fermentation of rye constituents.16 However, a crossover trial in women with impaired glucose tolerance found no effect of rye on insulin sensitivity, although acute postprandial insulin excretion was higher.17 Turning to lipid reduction, a crossover trial in 40 adults with hypercholesterolaemia found significant reductions in total and LDL cholesterol when rye was consumed, but only in men.18 A dose response was also noted. These effects were confirmed by a later trial in 63 healthy adults which noted that LDL cholesterol became more resistant to oxidation with each rise in the consumption of rye.19 The addition of plant sterols had no observed impact on LDL cholesterol oxidation. BARLEY

Barley is a fibre-rich grain that contains significant levels of beta-glucan and insoluble fibre, and has been classified as low GI.20 Originally used by animal feed and brewing sectors, barley is now being incorporated into a greater variety of food products due to its health benefits. In a five-week RCT, involving 18 men with hypercholesterolaemia, partially replacing usual carbohydrates with barley-rich products, total cholesterol, LDL cholesterol and triglycerides were significantly lowered without reducing HDL cholesterol.21 The positive impact was most likely mediated via changes in soluble fibre. Similar findings were reported when an experimental diet containing barley and legumes was compared with a healthy control diet matched for fibre content.22 In the 46 female participants, significant reductions were seen over four weeks in total cholesterol, LDL cholesterol and diastolic blood pressure. Unlike the previous study, HDL cholesterol levels did reduce. Further research20 suggests that the beta-glucan content of barley can lower blood glucose and insulin responses, while the overall soluble fibre content appears to stimulate production of GLP-1, a satiety hormone.

DISCUSSION AND CONCLUSIONS

This brief review highlights the benefits associated with increased consumption of fibres from wheat, oats, barley and rye. Studies consistently report associations with lipid management and, in some cases, glycaemic control. Studies on weight loss and blood pressure control are less consistent. The benefits appear to be mediated via fibre, often soluble fibre such as betaglucan and other bioactive compounds. Given the habitual low fibre intakes in the UK at 14g in adults and 12g in children compared with the Dietary Reference Value of 18g, it is well accepted that choosing wholegrain options is a positive step. No specific wholegrain targets exist in the UK, but in the US and Canada, it is recommended that adults and older children consume three to five 16g wholegrain portions daily. An analysis of the National Diet and Nutrition Survey found that median wholegrain intakes were 20g in adults and 16g in children, i.e. just over one portion daily.23 Only 17% of adults and 6.0% of children met the US/Canadian recommendation. A systematic review24 confirmed associations between wholegrain foods and reduced risk of chronic conditions. In conclusion, the promotion of wholegrain or high fibre cereals, such as oats, barley, wheat and rye, could significantly benefit health as supported by European health claims. Manufacturers should be encouraged to include more of these ingredients in products. Acknowledgement This work was supported by the Breakfast Cereal Information Service, an independent information body set up to provide balanced information on breakfast cereals. It is supported by a restricted educational grant from the Association of Cereal Food Manufacturers. See www.breakfastcereal.org for more information. NHDmag.com October 2015 - Issue 108 57

NHD Extra - a day in the life of . . .

a Renal Dietitian I have worked in a combination of acute and community sectors within the NHS, including Renal, where I have worked for the past two years. My areas of interest also include sports nutrition and gastro.

Heather Alford Registered Dietitian, East and North Hertfordshire NHS Trust

If you had asked me when I was graduating university whether I would be a Renal Dietitian in the next few years, I doubt I would have said yes. Although I enjoyed the biochemistry and medical complexities of the kidney in my studies, I was still a little bit scared of them before I accepted the job at the Lister Hospital in Stevenage. I didn’t have any renal experience when I first started in my job, but the benefit of working in a multiprofessional environment is that you are always learning from someone.

My workload largely involves the main haemodialysis unit based within the hospital. I also see low clearance and post-transplant patients in clinic and cover the renal ward when needed My workload largely involves the main haemodialysis unit based within the hospital. I also see low clearance and post-transplant patients in clinic and cover the renal ward when needed. The dialysis unit has approximately 115 patients, including those who have recently started dialysing and those who have more complex conditions or who are unwell on dialysis needing more nursing care and are unable to dialyse at the satellite units. I normally start my day at 8.30am, unless I am doing a twilight shift to see the patients who dialyse in the evenings. 58

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I prep the dialysis patients to see that day. We tend to see our patients on dialysis, as they are generally here for four hours, three times a week and are understandably reluctant to have any more time taken out of their day. When I enter the unit, I am asked to review a patient who has come in 7.0kg over their dry weight and has a high potassium level. She is almost blind, has recently had a below knee amputation due to diabetes and is relying on her partner to shop and prepare food for them both (her partner’s cooking skills are limited to reheating ready meals). She is permanently hungry and immobile and has gained a lot of weight recently. She had no problems with kidney disease until a few months ago and ‘crashlanded’ onto dialysis. This is going to be a challenge and in particular reminds me that, ever increasingly, patients have so many medical and social factors other than the one we have been asked to see them about. While on the unit, another nurse asks me to review a patient who they spotted eating an orange who has a potassium level of 6.2mmol/l. I report back following the consultation that the small orange (4mmol K+ and part of her fruit and vegetable allowance) probably didn’t have much to do with her potassium level; she had a latte (20mmol K+) as a one off and has been having a few more packets of potato crisps (10mmol K+) recently. We came up with a plan to find some suitable substitutes for her snacks and drinks which would still allow her to get the vitamins and minerals from a certain amount of fruit and vegetables.

NHD Extra - a day in the life of . . .

Once a week, after lunch, I meet with the consultant nephrologist, the renal pharmacist and one of the dialysis nurses for our quality assurance (QA) meeting. We discuss a selection of the dialysis patients to determine whether they are well dialysed, meeting their biochemistry targets, whether they have any outstanding medical issues, whether they could be referred for an arteriovenous fistula or for transplant and their nutritional status. I make a list of those that would benefit from a review - one who is struggling with their phosphate binder, one who wants to lose weight to be eligible for transplantation and one who’s intra-dialytic weight gains have increased and will put more strain on their heart and lungs. I spend some of the remainder of the afternoon preparing for the low clearance clinic, a manic multi-professional clinic with those who have progressive kidney disease and who are being worked up for haemodialysis, home-based therapies (peritoneal dialysis or home haemodialysis), conservative management or transplant. I have to spend a bit of time preparing this clinic because, although I really want to see everyone on the list, there isn’t enough time. So, I check everyone’s biochemistry and weight history and decide who might be more of a priority. There is generally a

nice range of renal dietetics for every clinic - a couple with small appetites and prescribed nutritional supplements, some with high potassium levels, some with high phosphate levels and some with diabetes and/or trying to lose weight. I will generally plan to see a couple of new patients as well, just to introduce myself and explain our role, since many of them won’t have seen a dietitian before. It is always good to explain what we are here for, so that we are more approachable. Here again, I plan to see a few more patients than I really have time for, as there are always a few that don’t want to see the dreaded dietitian! Towards the end of the day, I try to write up my records, I am hot desking in the renal reception office this afternoon and since I am the only one in the office at the time, a couple of patients come up to ask where their appointments are, or try to give me bottles of urine or blood that I really don’t want, for transplant tests and research projects. I smile and pray that the things they are about to hand over aren’t still warm. Even though fistulas and circulating haemodialysis machines don’t bother me anymore, this is one step too far for me! Undoubtedly, my write ups get carried over until later in the week, as I run out of time and head home having washed my hands thoroughly! NHDmag.com October 2015 - Issue 108

NHD October 2015 issue 108

Articles inside

The final helping

Events and courses

Growth faltering

Omega oils

dieteticJOBS

Iron for sport

Web watch

Probiotics

Malabsorption

Crohn’s disease