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NHDmag.com
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
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NHD Extra - menu scoring Table 1: Sample scores for different menus Menu
n=
Health points>=√
Eco points>= X
Greenhouse points >=X
Mixed menu
155
11.8
104
1.6
Beef dishes
19
12.7
273
4.1
Pork dishes
34
11.5
114
1.7
Poultry dishes
25
12.3
87
1.4
Vegetarian
40
11.7
71
1.1
Vegan
14
10.6
42
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
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.
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
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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
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