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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com June 2016: Issue 115

early years nutrition slimming groups dietetics in palliative care fermented foods IMD watch

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FROM THE EDITOR

welcome Emma Coates Editor

So here we are, half way through 2016! Go on, you can say it… where’s the time gone? Before you know it, it’ll be Christmas. Nevertheless, before we reach the warm fuzziness of the winter festive period, we have work to do.

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

With the promise of sun and possibly some sand and sea, the huge drive to lose some of those extra pounds and get ‘beach ready’ grips the nation. Scan the covers of many of the commercial glossy magazines and they all promise the quick-and-easy summer diet plans to ‘drop a dress size’, ‘lose 7lbs in seven days’, or they reveal the diet secrets of those perfect (photo-shopped) celebrities. And it’s not only the magazines spouting this ‘dietary advice’, just using your smart phone, via social media, you can thumb your way through any diet plan you deem worthwhile in order to rock that bikini or slinky dress this summer. Thankfully, we have two articles this month which cut the wheat from the chaff when it comes to commercial slimming programmes and fad diets. In her first article for NHD, Maria Dow, Freelance Dietitian, delves into both NHS and commercial slimming programmes, outlining their characteristics and comparing outcomes. Ali Hutton, Medical Affairs Dietitian, then goes on to take a closer look at a few common fad diets which promise miraculous results in the weight management department. The June issue of NHD also has a distinct gastro feel. Freelance Dietitian Helen West shares her first article for us, which discusses probiotics, in particular, the relevance and possible benefits of fermented foods: can sauerkraut or kombucha tea really influence gut health? The third week of June is ‘Love Your Liver’ week, which is the British Liver Trust’s (BLT) national awareness campaign to highlight three simple

steps to maintain a healthy liver and reduce the risks of developing liver problems. Vanessa Hebditch from the BLT, updates us with the current liver disease facts and offers us an insight in the work of the BLT. Now, NHD is no two-horse mag, we’ve got more than just weight management and gastro to offer you. Dr Emma Derbyshire asks the question, ‘Should we make foods for little ones less sweet?’ Humans have an innate affinity to sweeter tasting food, but that shouldn’t mean that commercial food aimed at infants and young children should be sweetened, promoting the development of a sweet tooth. In her early year’s nutrition article, Emma discusses the current thinking around the early exposure to sweet tastes. Louise Robertson, Specialist IMD Dietitian, provides this month’s IMD watch article, giving us a comprehensive overview of Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) and talks us through the dietary considerations and follow-up of adults with this condition. Anne Wright RD touches on the challenging area of palliative care, defining the various stages and clarifying the nutritional goals for this patient group. We also have information on legislative changes governing gluten in foodstuffs by Helen Rose, plus our regular PENG column, reporting on their essential Dietetic Outcomes Toolkit ‘DOT’. I hope you enjoy this mid-year issue of NHD. Instead of scrolling through all of those online fad diets, I think I might start my Christmas shopping! - Emma www.NHDmag.com June 2016 - Issue 115

Contents

13 COVER STORY

Early years nutrition: avoiding a sweet tooth 6

News

Latest industry and product updates

36 IMD watch MCADD follow-up in adults

Liver disease awareness

The British Liver Trust campaign

40 Gluten in foodstuffs EU legislative changes

20 Slimming groups

45 On behalf of PENG The key to better outcomes

Pros and cons

24 Fad diets The latest trends examined 28 Palliative care A challenging role for dietitians

48 Web watch Online resources

and updates

50 Dates for your diary Upcoming events and course

33 probiotics

51 The final helping The last word from Neil Donnelly

Fermented foods

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.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

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Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com June 2016 - Issue 115

ISSN 1756-9567 (Print)

Verbatim patient quote, Fresenius Kabi data on ﬁle – Thick & Easy™ Clear Acceptability Study Report Sept 2014

Simply restoring confidence Thick & Easy™ Clear is a gum-based drinks thickener that retains the natural appearance, taste and texture of fluids,1 and also ensures a consistent thickness over time. What’s more, Thick & Easy™ Clear: • Encourages fluid intake, meaning that patients can hydrate effectively while consuming drinks in their own time • Facilitates confidence to drink by reducing the fear of swallowing Contact us today on 01928 533516 or visit www.fresenius-kabi.co.uk and find out how we can help your patients rediscover a sense of normality. References: 1. Fresenius Kabi data on file – Thick & Easy™ Clear – Acceptability Study Report Sept 2014. ® Thick & Easy is a registered trademark of Hormel Health Labs. Fresenius Kabi Ltd is an authorised user. © Fresenius Kabi Ltd. October 2015 Date of preparation: October 2015 Job code: EN01141

NEWS

food for thought Fresh FV intakes still disappointing A new report published by the NFU Horticulture and Potatoes Board has Dr Emma found that, since 2007, purchases of Derbyshire fruit have fallen by 14%, vegetables by 5% and PhD RNutr potatoes by a whopping 20%. As this is purchase data, taking in-home food waste (Public Health) Nutritional Insight into consideration, actual average intakes are only around three portions of fruit Ltd and vegetables per day. So, it can be seen that public health initiatives, such as the UK 5-A-Day campaign, originally launched in 2003, are not being sustained. Emma is a It is thought that the shift away from eating fresh fruit and vegetables could freelance nutritionist and former senior be down to the growing consumer trend of ‘food grazing’: eating food that academic. Her is ‘ready to go’ rather than the traditional three meals a day. This is thought interests include to impact on vegetable intakes, in particular, which are typically eaten with pregnancy and public health. an evening meal. Alongside this, only 18% of UK households now plan their www.nutritionalmeals for the week ahead, with most people doing more frequent, smaller insight.co.uk shops it seems. hello@nutritionalinsight.co.uk Unfortunately, the fruit and vegetable sector needs to keep up with this shift in consumer behaviour it seems, providing more convenient offerings. Retailers also have their role to play, with the need to offer ‘snack-ready’ fruit and veg products. These should also If you have important news or be developed with the intention of being appealing to research updates to share with children. For example, it has been proposed that children NHD, or would like to send a letter are 85% more likely to eat more fruit and vegetables when they have fun names or shapes and I have to agree. to the Editor, please email us at So, on the whole it seems that there is work to be done in info@networkhealthgroup.co.uk the fruit and vegetable sector to help it stay on trend. A degree We would love to hear from you. of innovation is needed in the way fruit and vegetables are presented, not only to make them more accessible to the generation of food grazers, cutting out peeling and slicing ideally, but also to the younger generation of children and teens.

For more information, see: NFU Horticulture and Potatoes Board (2016). Fit for the Future. Helping Consumers Eat more Fruit and Vegetables. Available at: www.nfuonline.com/nfu-online/news/nfu-reports/fit-for-the-future-april-2016/

Nutrient intakes in the ‘very’ old We are an ageing study median intakes of energy and nonpopulation, so it starch polysaccharide (NSP) were lower is great that some than requirements. In particular, NSP new studies are intakes were just 10.2 g/day, although also collecting nut- these was found to be higher in more ritional data for educated and active 85-year olds. those in the third These are important findings age. Here we have highlighting the need to collect more findings from the nutritional data for the very old. It Newcastle 85+ Study. will be interesting to see results on This publication which focuses on micronutrient intakes which will macronutrient intakes, shows that in the hopefully be published next. For more information, see: Mendonca N et al (2016). British Journal of Nutrition [Epub ahead of print].

www.NHDmag.com June 2016 - Issue 115

B12 deficiency concerns Vitamin B12, alongside folate, is essential for growth and development during the early stages of pregnancy. Now, a new meta-analysis has looked at whether this could also affect birth weight. A total of 80 articles were studied to determine worldwide prevalence of vitamin B12 deficiency and associations with birth weight. Prevalence of vitamin B12 deficiency was: • 21% - First trimester • 19% - Second trimester • 29% - Third trimester Although maternal vitamin B12 status was found to be lower amongst women with low birth weight deliveries, this was not statistically significant, though data from Indian studies mainly contributed towards this trend. Overall, these are interesting and important findings highlighting that vitamin B12 deficiency is common, even amongst non-vegetarian women. This could have broader implications for maternal and foetal health. N et al (2016). American Journal of

Confectionery (under-)reporting It makes senses that calories densely packed into children’s confectionery treats should be linked to overweight and obesity. A new meta-analysis paper has now looked into this. Data was pooled from 19 studies looking at intakes of chocolate and nonchocolate confectionery. All studies also collected data about children’s body weight, size or composition. Surprisingly, no links were found between confectionery eating and children’s body weight, size or composition. Furthermore, eating confectionery once a week was actually associated with a 13% reduced chance of children being overweight or obese. These are interesting findings indicating that, in moderation, the odd confectionery treat may not pose a threat to a child’s weight. That said, it is also possible that this is a ‘true inverse’ association where very heavy under-reporting has contributed to these findings.

print].

of Clinical Nutrition [Epub ahead of print].

For more information, see: Sukumar

Clinical Nutrition [Epub ahead of

For more information, see: Gasser CE et al (2016). American Journal

Nutrient intakes in the young Scientists from the Irish National Pre-School Nutrition Survey have analysed how fruit and vegetable intakes contribute to nutrient intakes in the very young. Data was analysed from 500 Irish children aged one to four years who completed four days of weighed food records. Overall, it was found that fruit and vegetables contributed 50% of vitamin C, 53% of carotene, 34% of dietary fibre and 42% of non-milk sugar intakes from the total diet. Intakes of fruit juice increased with age. Other recent work from the UK Gemini twin cohort study has analysed the diets of 2,336 young children aged 21 months. Parents of the children completed three-day diet diaries. It was found that energy intake, protein and most micronutrients exceeded Dietary Reference Values. However, vitamin D and iron intakes were lower, with 70 and 6% of children not achieving even the Lower Reference nutrient intakes for these, respectively. These are valuable studies highlighting what young children are eating. Clearly, there seems to be a role for vitamin D supplementation in the UK in the early years. For more information, see: O’Connor L et al (2016). British Journal of Nutrition [Epub ahead of print] and Syrad H et al (2016). British Journal of Nutrition [Epub ahead of print].

www.NHDmag.com June 2016 - Issue 115

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CONDITIONS & DISORDERS

THE SILENT KILLER: LIVER DISEASE AWARE Vanessa Hebditch Director of Communications & Policy, The British Liver Trust Before joining The British Liver Trust, Vanessa worked as a freelance communications professional for a variety of clients across the public, private and voluntary sectors. She spent 10 years at the British Diabetic Association, where she repositioned diabetes as a serious health condition. Her work culminated in managing the communications function and leading the rebrand and name change to Diabetes UK.

Liver disease is a major healthcare crisis that we must all do something about. Mortality rates have increased 400% since 1970, and it is now the third leading cause of premature death in the UK. With Love Your Liver Week taking place this month (13th to 17th June), Vanessa form the British Liver Trust gives an overview of the facts and nutritional management of the ‘Silent Killer’. Liver disease is often called the ‘Silent Killer’ as most signs and symptoms show only when damage is advanced and often irreversible. However, with earlier diagnosis and awareness of the main causes - alcohol, obesity and viral hepatitis - lives can be saved. The British Liver Trust exists to support patients and families living with liver disease and provides awardwinning information and leaflets. Crucially, we also work to improve awareness, prevention and early detection. This year, we have been successful in our application to work in partnership with the Royal College of General Practitioners (RCGP) in making liver disease a clinical priority for the next three years for the UK’s primary health care professionals and practice staff. We will be producing a range of materials to help those working in primary care to increase the number of patients who are detected with liver disease at an early stage and receive appropriate treatment. LIVER DISEASE: THE FACTS

Your liver performs over 500 vital functions, including breaking food down and turning it into energy, helping the body get rid of waste, removing harmful substances and fighting infection. Here are some of the key facts: • At least one in five of the UK population is at risk of developing

• • • •

liver disease - that’s more than 12 million of us (CMO 2013). Deaths from liver disease increased by 40% from 2001 to 2012. Liver disease will potentially be Britain’s biggest killer within a generation. Liver disease is currently the UK’s third largest cause of premature death. 25% of the population is now categorised as obese; most will have fatty liver disease and many will have inflammation and scarring that can lead to cirrhosis and liver cancer.

These shocking statistics are something we all must take heed of because liver disease will affect all of us, whether that is ourselves or someone close living with or dying from a liver condition. Some liver conditions are genetic or caused by autoimmune malfunctions, but 90% of liver disease is preventable and it is vital that we are all aware of the risk factors and main causes. These are: • drinking too much alcohol, too often • being overweight • being infected with viral hepatitis These are all things we can do something about to reduce our risk of developing liver disease. The earliest possible diagnosis and best possible care is vital for everyone affected. Andrew Langford, Chief Executive of the British Liver Trust explains: “Although the liver is remarkably resilient and can regenerate if given time to recover, by the time most people have signs and symptoms of liver damage, it is often irreversible. Three quarters of www.NHDmag.com June 2016 - Issue 115

速

CONDITIONS & disorders people already have end stage liver disease when they are first diagnosed - by this time for many it is too late.” Good nutrition supports the liver to function and helps to keep us all healthy. Eating a good, balanced diet to maintain strength and a healthy weight is essential for people with liver problems. Some liver diseases are linked to being overweight; 90% of morbidly obese individuals are thought to have fatty livers. Obesity can also speed the damage associated with other conditions such as alcohol-related liver disease and can decrease the effectiveness of treatments for hepatitis C. It is, therefore, important to maintain a healthy weight, but it is also important for those working in the diet and nutrition industries to be aware of the fact that patients who are overweight are more at risk and may need to be tested to see if they have a problems with their liver. For people who are diagnosed with advanced liver disease and are experiencing symptoms such as fluid retention in the abdomen, their weight may be affected and BMI results can be misleading. In this instance, their diet will need to be managed very carefully by a dietitian with experience of managing liver disease, as it is possible to be overweight as a result of the fluid retention, whilst also to be malnourished. The damage caused by liver disease can also affect the liver’s ability to store and release glycogen, causing fatigue. If you go for long periods of time between meals, the body will start to use its own muscle tissue, or fat, to provide energy, which can lead to malnutrition, muscle wasting and weakness. Patients with liver disease may experience symptoms such as nausea, low energy levels, fluid retention in the legs, or accumulation of fluid in the abdomen (ascites). In these cases, patients will need to follow a more specialised diet. They may also become ill, lose a lot of weight and may not feel like eating. Eating and keeping to a well-balanced diet may be difficult in these circumstances and the patient may need specific advice on how to increase calories and protein intake. These, and other problems associated with liver disease, require specialist dietary advice tailored to the individual from a registered dietitian.

IS COFFEE BENEFICIAL?

There is a growing body of evidence that suggests drinking moderate amounts of coffee can reduce your chance of developing liver disease and can also limit the rate at which liver disease progresses. The British Liver Trust is calling for more clinical research in this area. Although it appears that drinking coffee is beneficial, it is far more important to keep to a healthy weight and not drink too much alcohol. WHAT DOES IT MEAN TO LIVE WITH LIVER DISEASE?

The British Liver Trust is contacted every day by people affected by liver disease. Real people and their stories bring to life the reality of living with the condition and the devastating effect it can have on their everyday lives and their families. A wife whose husband passed away with Non-Alcoholic Steatohepatitis (NASH) told the Trust: “In late 2013, my husband was given the terrible news that he had cirrhosis of the liver. He was not a drinker and as a Greek Cypriot he ate a well-balanced good Mediterranean diet. He was given no treatment and our GP did not really understand the situation. He had not been able to eat for months, lost a lot of weight. Eventually, on Boxing Day 2013, I got him into A&E and within four hours he saw a Liver Specialist and was admitted to hospital. “Unfortunately, he did not respond to the treatments available and after suffering, but still wanting to live and managing to ‘cope’, he eventually died on 5th August 2014 from NASH. This disease needs more done to expose it. Liver disease is always associated with drinkers and, therefore, gets neglected; more should be done to tell people that children and non-drinkers also can suffer from it.” A young woman with Autoimmune hepatitis (AIH) said: “I am not going to lie, it’s not easy being giving this diagnosis and it’s not easy to tell people how you feel, as AIH is not visible. A disease that isn’t visible to people usually means it’s not that bad (in people’s heads). I have bad days, where I just want to sleep, my whole body aches and I don’t want to see anyone, but my loud and happy personality usually takes over and I quickly snap out of it and just carry on. I am slowly learning to live with AIH (and all that www.NHDmag.com June 2016 - Issue 115

CONDITIONS & disorders comes with it) and I found some great advice from the British Liver Trust.” You can read more stories from people affected on the British Liver Trust’s website: www.britishlivertrust.org.uk THE BRITISH LIVER TRUST

The British Liver Trust is a charity that strives to: • raise public liver health awareness through our Love Your Liver campaign and promote lifestyle choices that could prevent liver disease developing; • campaign on behalf of people affected by liver disease, to push for early diagnosis, better treatment, more research and to get improved liver health services recognised as a top priority; • be the first port of call for anyone seeking information about liver disease, whether this be patients and their families, GPs and healthcare professionals, politicians or the media; • provide support services for patients and families through our patient support groups, website, social media services, online support forum ‘HealthUnlocked’ and our helpline; • improve awareness, prevention and early detection. WHAT CAN YOU DO AND WHAT ADVICE CAN YOU GIVE OTHERS?

Firstly, be aware of your own liver health complete our Love Your Liver health screener (www.loveyourliver.org.uk) and read the analysis of your health risks and what to do if you are at risk of liver disease. And then share the screener with your colleagues, friends and family so that they can do the same. For those wanting to decrease their alcohol intake and take the two-three days off alcohol that we recommend, our app www.spruceapp. co.uk provides daily support and encouragement to minimise the damage that alcohol does to our health. The British Liver Trust has a range of publications covering specific areas of liver disease which are helpful. Use the Trust’s website (www.britishlivertrust.org.uk) to find out more about the liver, what liver diseases there are, the research that’s being done and what the British Liver Trust is doing to fight the ever- increasing 12

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epidemic of liver disease in the UK. Please consider how you can support the work we do by fundraising events, regular contributions etc, and by encouraging your employer to choose the British Liver Trust as its nominated charity. The third week in June is Love Your Liver week. More information on how you can support the Trust can be found at www.britishlivertrust. org.uk/support-us/.

THE LOVE YOUR LIVER CAMPAIGN ‘Love Your Liver’ is a British Liver Trust national awareness campaign that aims to raise awareness of three simple steps to maintain good liver health and reduce your risks of developing liver problems: Step 1: Keep to a healthy weight Love Your Liver by making sure you have a healthy diet, plenty of water to drink and regular exercise. Step 2: Reduce the amount of alcohol you drink As a nation, we are drinking far more than our parents did. Too much alcohol can cause serious and lasting damage. The British Liver Trust recommends having two to three days each week without drinking. It’s an easy message, but a very effective way of reducing the amount you drink, giving your liver a rest and making it easier to stick within the Government guidelines of 14 units a week. Step 3: Know and avoid the risks for viral hepatitis Blood-borne viruses such as hepatitis A, B and C can cause permanent liver damage and increase the risk of liver cancer. Avoid these viruses by never sharing personal items like toothbrushes, razors, nail scissors or tweezers, drug equipment and by practising safer sex. If you get a tattoo, make sure it is in a licensed parlour. If you think you may have been at risk in the past - even if it was a long time ago - ask your doctor for a test.

Visit our online screener to see if you are at risk: http://loveyourliver.org.uk/ love-your-liver-health-screener/