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NETWORK HEALTH DIGEST NHDmag.com
The Magazine for Dietitians, Nutritionists and Healthcare Professionals November 2017: Issue 129
KETOGENIC DIET THERAPY
ONS AND DEMENTIA PREMATURE INFANT FEEDING ‘TEATOXING’ IBS & LOW FODMAPS
Coeliac disease & the GF diet pages 25-28
FROM JANUARY 2018, APTAMIL PEPTI-JUNIOR WILL BE THE NEW NAME IN THE DIETARY MANAGEMENT OF MALABSORPTION RELATED CONDITIONS
Cow & Gate Pepti-Junior Product Code: 56560 PIP Code: 049-0714 Bar Code: 8712400590167
Aptamil Pepti-Junior Product Code: 124560 PIP Code: 049-0714 Bar Code: 8718117606917
SAME FORMULATION, NEW BRAND
WHAT DO I NEED TO KNOW?
SPECIALLY FORMULATED TO:
– Aptamil Pepti-Junior will be available in 450g tins, exactly the same as Cow & Gate Pepti-Junior
Enhance digestion and absorption1,2 Promote palatability3-5 Reduce osmotic load6
– From JANUARY 2018, Cow & Gate Pepti-Junior will be called Aptamil Pepti-Junior – Only the brand name, packaging and codes will change, the formulation will remain the same
WHAT DO I NEED TO DO? – Continue to prescribe Cow & Gate Pepti-Junior until Aptamil Pepti-Junior becomes available, then simply switch over – the formulation is unchanged
For more information, call our Healthcare Professional Helpline on 0800 996 1234, or visit www.eln.nutricia.co.uk References: 1. Keohane PP et al. Gut 1985;26(9):907-13. 2. Bach AC, Babayan VK. Am J Clin Nutr 1982;36(5):950-62. 3. Mabin DC et al. Arch Dis Child 1995;73(3):208-10. 4. Pedrosa M et al. J Investig Allergol Clin Immunol 2006;16(6):351-6. 5. Miraglia Del Giudice M et al. Ital J Pediatr 2015;41:42. 6. Shaw V, Lawson M (eds). Clinical Paediatric Dietetics. 4th ed. Oxford: Blackwell Publishing, 2015.
IMPORTANT NOTICE: Aptamil Pepti-Junior is a food for special medical purposes for the dietary management of malabsorption related conditions. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6 months. FOR HEALTHCARE PROFESSIONAL USE ONLY. 17-075/September 2017
FROM THE EDITOR
WELCOME Emma Coates Editor
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.
So, I flip over into another month on my ‘inspirational quotes’ calendar to read:‘. . . the tools that allow for optimum health are diet and exercise…’ Thanks Bill Toomey for that. I’m not going to lie; I had to Google who he was! All became clear - good old Bill is a world record holding American track and field athlete, who competed in the 1968 Olympics and won gold in the decathlon. Now, as a profession, we certainly advocate both diet and exercise as tools for achieving the best health outcomes for our patients; however, we need additional tools to support us in this Olympic feat. I’m not necessarily talking about the skills we equip ourselves with, but the actual tools that help us to implement our advice. Yes, that’s right; I’m talking about nutritional products, guidelines and other great stuff known as evidence. Here at NHD this month, we have built you a formidable toolbox, with an excellent collection of articles focusing on the aforementioned tools. We are pleased to welcome back Jacqui Lowden RD who leads us through an update of current recommendations, guidelines and products on Premature infant feeding. It is also a great pleasure to bring you our Cover Story that focuses on Ketogenic diet therapy from Sue Wood RD, who explains how the diet can benefit a wide range of patients. However, it is yet to be utilised by many dietitians and healthcare professionals. In a duo of articles which provide much debate and careful consideration, Lee Martin RD shares the current evidence around the efficacy of prescribed ONS in dementia patients and dietitian, Rebecca Gasche, with her debut article for NHD, discusses the hot potato that is gluten-free prescribing in the NHS. Both are poised to give you
and your colleagues something to talk about during coffee break. In a side step into the not so evidence-based world of Teatoxing’ for weight loss, Alice Fletcher RD joins us for the first time with her article which sheds light on the social media driven phenomenon of using specialist ‘tea’ products on a daily basis to promote rapid slimming effects. We also bring you two case studies focusing on very different patient types: Suzanne Ford RD shares her complex management of a patient with ornithine transcarbamylase (OTC) deficiency, while Claire Chaudhry RD gives a detailed plan for a martial arts client who improved his performance following her advice. Coming back to my opening quote regarding diet and exercise being perfect tools for optimum health, there are no truer words when it comes to weight management. Turn to the back of this digital issue and you will find NHD Extra our monthly supplement which this month features low carbohydrate diets. Maeve Hanan discuses their uses including weight management amongst other things and Alice Fletcher takes us through their use in Type 2 diabetes and asks the question: “Is it time that we changed our practice?” There’s so much more to discover in this issue too: articles, research, regular columns and tools galore. You’re going to need a bigger box! Emma www.NHDmag.com November 2017 - Issue 129
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CONTENTS
6
News
8
Face to face
11 COVER STORY Ketogenic diet therapy 43 SPORTS NUTRITION
Latest industry and product updates
Improving performance through diet
With Kate Halliwell
19 ONS and dementia Effective nutiriton support?
25 COELIAC DISEASE Prescription GF foods: the debate
47 IBS: beyond low FODMAP Navigating the world of nutritional advice
50 Book review The Angry Chef
29 Premature infant feeding Current guidelines and products 35 IMD watch: case study Ornithine transcarbamylase deficiency
38 'TEATOXING' Overview of a growing diet trend
by Anthony Warner
52 Health claims Regulations update 55 Events, courses & dieteticJOBS Dates for your diary &
career updates
56 A dietitian's life The last word
by Sarah Howe
Copyright 2017. All rights reserved. NH Publishing Ltd. 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
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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 Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES
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@NHDmagazine ISSN 2398-8754
This material is for healthcare professionals only. *
So, how do you actively manage cow’s milk allergy?
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†Versus an eHCF without LGG® or formulas based on rice hydrolysate, soy or amino acids. ’Return to milk’ means the normal physiological process in which the daily diet plays a role. When achieved it allows milk and dairy foods to be fully introduced without experiencing an allergic reaction.
References: 1. Baldassarre ME et al. J Pediatr 2010;156:397–401. 2. Nermes M et al. Clin Exp Allergy 2010;41:370–377. 3. Canani RB et al. J Pediatr 2013;163:771–777. 4. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding provides the best nutrition for babies. *Trademark of Mead Johnson & Company, LLC. © 2017 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. UK/NUT/17/0024 October 2017
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NEWS
FOOD FOR THOUGHT
Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire
If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk
NEW GUIDELINES FOR THE MANAGEMENT OF NUT ALLERGIES We have seen a continued increase in the number of people with nut allergies and rise in deaths, especially amongst younger children since the 1990s. Presently, nut allergies affect around 2% of children and one in 200 adults. So clearly, improved diagnostics are needed. In October, new guidelines were published by the Standards of Care Committee of the British Society for Allergy & Clinical Immunology (BSACI). Improved diagnostics, including skin-prick and IgE testing, are recommended to avoid incorrect self-diagnosis of allergies. The new guidelines aimed at GPs are rigorous and cover how to identify high risk groups, diagnose and manage all types of allergy, right from food challenges to emergency treatment. Given that nut allergies can reduce the quality of life even more than illnesses such as diabetes these new guidelines are very timely. Let’s hope that they are well utilised and put into good practice… Figure 1: Suggested algorithm for the diagnosis of peanut allergy
For more information, visit: The British Society for Allergy & Clinical Immunology (BSACI). www.bsaci.org/Guidelines/peanut-and-tree-nut-allergy
SCOTLAND'S NEW DIET AND OBESITY STRATEGY The Scottish Government has launched its unhealthy weight are sown at an early age and we consultation document A Healthier Future - Actions also know what drives it. With almost one in three and Ambitions on Diet, Activity and Healthy Weight. of our children overweight or obese, we must act The document lays three key areas for action, now. The proposed action on price promotions including transforming the food environment, and junk food advertising aimed at children, living healthier and more active lives and therefore, are key and it’s good to see them leadership and exemplary practice. included. However, the proposals lack weight Professor Steve Turner, the Royal College reduction targets and this would significantly of Paediatrics and Child Health’s Officer for strengthen the final measures. We look forward to Scotland, commented on the document: working with the Scottish Government to ensure “This comprehensive set of proposals would this ambitious obesity strategy is delivered.” go a long way towards tackling Scotland’s obesity For more information visit https://news.gov.scot/news/time-for-boldepidemic. We know that the seeds for a lifetime of action-on-obesity 6
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NEWS NUTRIENTS IN BREAST MILK REFLECTIVE OF MUM’S DIET We often hear that "breast is best" and indeed this is certainly the case immunologically. However, if new breastfeeding mums are not eating well, or not topping up with a supplement, this can have ramifications for the nutritional density of breast milk? A new systematic review has collated evidence in this area. The authors from Shahroud University collated evidence from 59 observation and 43 intervention studies which all looked at the effects of mums’ diets in relation to the composition of their breast milk. Authors found that the mums' dietary intake was related to the nutritional composition of their breast milk. In particular,
fatty acids, fat soluble vitamins, vitamin B1 (thiamin) and C correlated most strongly. So, it seems that breast may not be best if mum is not getting the levels of nutrients that are needed when feeding. For more information, see: Keikha M et al (2017). Breastfeed Med doi: 10.1089/bfm.2017.0048.
To book your company's product news LOW RED MEAT INTAKES: A CONCERN FOR WOMEN? Blanket health messages to lower red meat intakes could have adverse implications on the micronutrient quality of women’s diets, particularly intakes of iron and zinc, according to a new study published in the journal Nutrients. The data set comprised dietary and blood analyte data for 2,021 women aged 11 to 64 years from years 2008/2009 to 2011/2012. The secondary analysis of the UK National Diet and Nutrition Survey (NDNS) data revealed that women consuming less than 40g total red meat were more likely to have micronutrient intakes below the Lower Reference Nutrient Intake (LRNI) for zinc, iron, vitamin B12 and potassium and have lower habitual vitamin D intakes than women consuming between 40g and 69g daily. It is apparent that encouraging all population groups to eat less red meat it not the way forward as this may exacerbate nutrient shortfalls in some at-risk groups. Continued research is worthy of further exploration in this important area of work. For more information, see: Derbyshire, EJ (2017) Nutrients Vol 9, 768.
for the next issue of NHD call 01342 824073
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F2F
FACE TO FACE Ursula meets: Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
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Ursula meets amazing people who influence nutrition policies and practices in the UK. KATE HALLIWELL Nutrition and Health Manager: Food and Drink Federation Registered Nutritionist
The Food and Drink Federation (FDF) offices used to be a dark underground labyrinth, near the tourist and theatre zone of Covent Garden in London. Kate Halliwell invited me to meet her in the shiny new offices that FDF moved into last November. Being a few yards from the most visited museum in Britain, the British Museum, means that Kate can enjoy high culture in her lunch break. But being the pivot of nutrition policy for food and drink manufacturers in the UK means that she rarely gets time to admire stones (Rosetta) or marbles (Elgin). Kate’s first qualification was an MSc in biochemistry at the University of Oxford. I quizzed her as to why she had chosen such a difficult course. “It wasn’t difficult for me; it was easy,” she replied. Perhaps doing biochemistry at Oxford is really very simple, or perhaps Kate is very clever: I suspect the latter. Her first job was within the science team of the exam awarding body Edexel. She helped plan the science content of school lessons with teachers and education advisers, and from this, curriculum schedules and publications were produced. She then took two years out to travel, exploring South America, Australia and many South East Asian countries. She came back refreshed and inspired to develop her career in health rather than education. Edexel were happy to take her back as a project manager and she completed a diploma in Nutritional
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Medicine at the University of Surrey in the evenings and at weekends. Her next job was with the Food Standards Agency (FSA). Front-of-Pack traffic light labelling (my pet hate) had just become the agreed policy of UK government. It was a voluntary scheme, but there was much pressure for the uniform adherence of this additional nutrition information scheme by UK food producers and manufacturers. Kate was there to encourage and support the implementation of traffic light labelling by as many packaged food providers as possible: cheering or chiding, or just generally being very helpful to those who were wavering about the decision. During this time, Kate managed an arrangement with her employer, then the FSA, to fund her to complete her Masters in Nutritional Medicine at the University of Surrey. After two years with traffic lights, Kate was promoted to a newly formed ‘catering’ team which initially focused on developing a nutrition labelling approach in out-of-home (OOH) settings. Detailed consumer focus work and business recruitment followed to enable a pilot of calorie labelling at point of choice - menus and menu boards. There was, and still is, a huge range of calories (and other nutrients) in products which can look similar. A lack of labelling makes it very hard for consumers to know what they’re choosing. Kate was there to support energy labelling (or more, if possible) in pilot companies. “Muffins, for example,
could look similar but vary by 500 calories in terms of energy content,” said Kate. “Information about energy content could encourage people to make different choices and producers to reformulate.” When I asked whether this was theory or evidenced, she said, “Yes/no…sometimes. Consumers make different choices when energy information is provided, but occasionally, results contradict expectations and some studies hint that such information leads to mostenergy-for-money choices, depending on the food and the consumer group.” In addition, Kate spent lots of time talking to owners of cafes and takeaways and small restaurants to develop general healthier catering guidance that they could relate to. Initially, much of her work was with the National Federation of Fish Fryers, advising on chip sizing, frying oil specifications and ways to reduce salt content and portion sizing; perhaps her friends and colleagues did note the slight waft of fish-and-chips whenever Kate entered the room. In 2011, she became nutrition manager for the trade association, the Food and Drink Federation, which has a membership of over 300 food and drink businesses. She was there to deliver sciencebased information to member companies and to then support the development of cross-industry positions promoting consumer health. The by-stealth salt reduction strategies were being agreed and implemented by many food companies in the UK and Kate was there to understand technical issues and support clarity and uniformity of implementation attempts. One issue of debate was whether salt targets should be different, i.e. lower for new-launch products compared to long-established brands. For lots of reasons, it was decided that a split-target was not a good idea, and that all foods in a sector should be monitored by the same figure. Current priorities are sugar reductions: “Although this is more difficult than salt reductions. Sugar adds to bulk and colour and texture to foods,” said Kate. The UK food industry supports government and health professional attempts to
tackle population obesity, but is anxious about the many confusing and mixed messages in media, and supports consistency of communications being about energy balance and calorie reduction. There are two committees on FDF that keep Kate, now promoted to nutrition and health manager, busy. The nutrition committee monitors technical details of legislation and recommendations in the formulation of food products. The diet and health committee considers wider policy implications, as well as considering those that affect consumer understanding and choices around foods. Both committees require keeping up to date with science and legislation and policies and the opinions of government and healthcare professionals and consumer groups, as well as critical lobbying groups pushing for greater and faster changes in product reformulation and marketing. Kate says that, “such groups keep us on our toes and that is a good thing. We should be open to the thoughts and critiques of those who support public health.” Some healthcare professionals are critical that someone like Kate spends so much time working with food companies that make less healthy foods. But Kate feels strongly that she is able to support many small improvements to products made by the UK food industry. “I ask them,” she says, “whether they would prefer that nutritionists or dietitians had no contact at all with food producers?” Because Kate is the middle link between government and scientific experts, and the technical staff across the wide range of UK food industries, she is the ideal person to pass on messages and ideas between these groups. She is the science-to-producer translator. And she can clearly communicate food sector issues to government and health lobby activists. “My job is really enjoyable and exciting. And the best thing is that I am always talking to very interesting and intelligent people.” For Kate, intelligence was not just about strings of qualifications; rather it was about being pragmatic about constant improvements that could and should be made to national diets.
If you would like to suggest a F2F date
(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact:
info@networkhealthgroup.co.uk www.NHDmag.com November 2017 - Issue 129
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COVER STORY
KETOGENIC DIET THERAPY: WHAT’S ALL THE FUSS ABOUT? Susan Wood Specialist Dietitian; Ketogenic Therapies, Matthew's Friends Clinics and Charity
The referral of a young adult for ketogenic dietary therapy (KDT) certainly sent shivers of uncertainty down my spine in 2008 and nine years on, I still get a sense that many dietetic colleagues, particularly those in adult practice, are ill at ease when ketogenic diets (KD) are mentioned. However, the basic biochemical premise of a KD is simple . . .
Susan works full time for Matthew's Friends Clinics and Charity as a specialist Ketogenic Dietitian, treating children and adults with drug resistant epilepsy and adults with brain tumours.
When the body goes from the fed to the fasted state, the liver switches from an organ of carbohydrate utilisation and fatty acid synthesis to one of fatty acid oxidation and ketone body production.1 Ketones are circulated as an alternative energy source to glucose, ensuring uninterrupted fuelling of essential tissues with high energy demand (e.g. brain and heart muscle). A low carbohydrate KD mimics this fasting state and shifts us into fat burning mode, using fats consumed in the diet, supplemented with fats taken from body stores if the dietary fat intake is insufficient. It results in a sustained presence of ketones and a flattening of post-meal glucose and insulin peaks, with levels tending toward the mid to lower end of the normal ranges. The benign ketosis associated with a low carbohydrate KD must not be confused with ketoacidosis (Table 1).2 Beyond the changes in circulating ketones, glucose and insulin, a myriad of biochemical pathways and the gut
microbiota are altered, leading to many possible mechanisms of action by which the KD exerts a range of therapeutic effects. Almost a century on from its creation as a treatment for epilepsy, scientists still struggle to pin down ‘the ketogenic effect’. Nevertheless, its utility continues to deliver profound changes in around half the children and adults undergoing supervised KDT for drug resistant epilepsy and it remains the only treatment for Glucose transporter type-1 deficiency and Pyruvate Dehydrogenase Deficiency (PDHD). The potential for KD metabolism to influence the aberrant cellular function underpinning a broad range of medical conditions is creating significant research interest too, meaning that KDT is not going away anytime soon (Table 2 overleaf).3-6 KETOGENIC DIET BASICS
The most powerful, over simplified and misguided nutrition message to reach the UK population over the last few decades has been that; ‘fat is
Table 1: Ketosis is NOT Ketoacidosis The difference between the two conditions is a matter of volume and flow rate: Ketosis: benign nutritional ketosis is a controlled, insulin regulated process that results in a mild release of fatty acids and ketone body production in response to either a fast from food, or a reduction in carbohydrate intake. Ketoacidosis is driven by a lack of insulin in the body. Without insulin, blood glucose rises to high levels and stored fat streams from fat cells. This excess amount of fat metabolism results in the production of abnormal quantities of ketones. The combination of high blood glucose and high ketone levels can upset the normal acid/base balance in the blood and become dangerous. In order to reach a state of ketoacidosis, insulin levels must be so low that the regulation of blood sugar and fatty acid flow is impaired.
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KETOGENIC DIET THERAPY Table 2: Ketogenic therapy; emerging clinical applications and future potential • Brain tumours • Cancer (various sites other than brain) • Alzheimer’s disease • Parkinson’s disease • Amyotrophic Lateral Sclerosis (ALS) • Multiple sclerosis • Mitochondrial disorders • Traumatic brain injury • Post stroke care • Autism • Migraine and cluster headaches • Depression • Aging • Cardiovascular health, obesity, Type 2 diabetes and metabolic syndrome Table 3: KD Protocols used in the clinical management of epilepsy Classical KD All foods are measured and combinations are selected to maintain a similar ratio of carbohydrate, protein and fats at meals and snacks. This is referred to as the ketogenic ratio (e.g. 2:1, 3:1, 4:1) and is calculated by dividing the total grams of fat by the total grams of carbohydrate and protein combined. While the higher classical ketogenic ratios (if required) may be easily achieved in the diets of younger children, ketogenic ratios beyond 3:1 are not so feasible for adults and older teenagers due to their higher daily protein requirement. Medium chain triglyceride (MCT) KD All foods are measured and combined to deliver a steady percentage of energy from carbohydrate, protein, long chain triglycerides (LCT fat from foods) and medium chain triglycerides (MCT from prescribed oil/emulsions, etc) in all meals and snacks. The MCTs provide 30-60% of total energy and are more ketogenic than LCTs; enabling a lower total fat intake and a slightly more liberal intake of carbohydrate and protein. Note: MCT oil or emulsion may be used as a fine-tuning option alongside any form of ketogenic therapy if enhanced ketone production is desired. Modified Atkins Diet (MAD) USA Protocol Only carbohydrate is carefully controlled (10-20g per day depending on age) and always combined with a generous source of fats. Protein foods are eaten liberally alongside, to appetite. In the UK, many centres use a slightly more controlled version of the MAD; providing some portion guidance to ensure an adequate fat intake and counselling towards a moderate intake of protein foods, to aid ketosis. We refer to this as a Modified KD (MKD). Low Glycaemic Index Treatment This is similar to a MAD, the essential difference being that the carbohydrate allowance is approximately 10% of energy requirement (25g CHO per 1,000kcals), but restricted to sources of carbohydrate with a Glycaemic Index of 50 or below. This approach may be an option for seizure management as its goal is glucose control rather than ketosis. However, this approach would not be favoured as adjuvant therapy in brain tumour management, or for conditions where ketone levels are perceived to play a more directly relevant role.
bad and carbohydrate is good’. KDT turns this perceived macronutrient hierarchy on its head and, therefore, requires a considerable mindshift for most. Understandably, concerns about the effect of a KD on blood lipids and weight feature highly. Both are monitored throughout as standard practice, with adjustments made to the KD prescription as required. Published data indicates that although total cholesterol levels may rise significantly in the first three months or so, they readily normalise by 12 months and it is 12
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possible that changes in circulating lipids have some part to play in the therapeutic outcome.7,8 Typically, we find that HDL levels increase and triglyceride levels remain normal, but responses are individual, hence the recommendation to monitor from baseline and throughout KDT, appraising this alongside the many variables contributing to the clinical condition and overall wellbeing of each individual. There are four basic approaches used in clinical KDT; however, the crossover between
them is significant (see Table 3). They all share the following: • A very low carbohydrate intake. • An increased fat intake to provide adequate calories, replacing those lost through carbohydrate restriction. • An adequate protein intake. • Overall energy control to match individual requirements, delivering growth, weight loss or weight stability as required. • Vitamin, mineral and trace element supplementation as required. • Medical assessment and biochemical screening pre-therapy with reviews throughout treatment at three, six and 12 monthly intervals depending on the age/wellbeing of the patient and stage of therapy.9 • Ongoing home-monitoring of symptoms, weight, growth, blood or urine checks. Regular discussions with the managing dietitian (by telephone, email or face to face) to review this data and agree on ‘finetuning’ of the diet prescription to optimise symptom management.9
FOOD, FEED OR BOTH?
A KD can be administered as a regular oral diet, a bottle feed, an enteral feed, or in a feed/food combination to match the individual requirements. KD meals can be created to suit any age and textural feeding requirement. Oral meals and snacks are generally based on regular fresh food ingredients; meat, fish, eggs, nuts, seeds, cheese, butter, cream, vegetable oils, vegetables and fruits. Food allergies and food preferences can generally be accommodated too. Specially formulated prescribed food products may be essential, optional, or not required, depending on the clinical and social presentation of the individual requiring KDT (Table 4 overleaf). ENTERAL OR BOTTLE FED KD
For infants and those requiring enteral feeding at any age, the KD can be provided entirely or partly in a liquid form. Ketocal (Nutricia) is currently the only ketogenic feed range available in the UK and based on the ratio system used in the classical ketogenic diet (e.g. 4:1 or 3:1 ratio). Although designed for children up to 10 years,
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KETOGENIC DIET THERAPY Table 4: Prescription products available to support ketogenic therapy
Enteral feeding products
• Ketocal (Nutricia) • Ketocal 4:1 LQ. Ready to feed in 200ml carton • Ketocal 4:1 powder. Suitable as a sole source of nutrition from 1-10 years or as a supplementary feed beyond 10 years • Ketocal 3:1 powder. Suitable as a sole source of nutrition from birth to 6 years of age or as a supplementary feed beyond 6 years All variants available in unflavoured or vanilla flavour
Oral feeding
• Ketocal (Nutricia) Range as for enteral feeding (above) • Keyo (Vitaflo) Ready to eat semi-solid 3:1 ratio food. Chocolate flavour. Suitable from 3 years of age onwards. Suitable as a sole source of nutrition up to 10 years of age
Supplementary fats
• Long chain triglycerides (LCT) fats: Calogen (Nutricia), Carbzero (Vitaflo) • Medium chain triglycerides (MCT) fats: MCT oil (Nutricia), Liquigen (Nutricia), Betaquik (Vitaflo), MCT Procal (Vitaflo) • LCT and MCT combined: Fresubin 5 kcal shot (Fresenius Kabi)
Supplementary proteins
• ProSource TF (Nutrinovo), Protifar (Nutricia)
Special foods
• New range from Ketocare • Ketoclassic savoury 3:1(bread roll) • Ketoclassic bar 3:1 (snack bar) • Ketoclassic chicken meal 3:1 (ready-meal in a pouch)
Vitamins and minerals (complete)
• Phlexy-Vits (Nutricia). Tablets or powder sachets. Suitable from 11 years to adult. • FruitiVits (Vitaflo). Powder sachets. Suitable from 3-10 years
Therapy monitoring equipment
• Blood ketone monitoring strips (measure β-hydroxybutyrate only) and blood glucose monitoring strips to match available metre, e.g. - Freestyle Optium Neo - GlucoRX HCT - GlucoMen LX 2 • Urine ketone monitoring strips (measure Acetoacetate only): - Ketostix (Bayer) and others
Ketocal formulations can easily be adjusted to match the KD prescription requirements of the majority of older children and adults by adding protein, carbohydrate and fat modules as required. New enteral feeds aimed at meeting the KD prescription needs of older children and adults are currently in development and eagerly awaited by the clinical ketogenic world. For those with milk protein allergy, it is also possible to devise ketogenic enteral feeds using individual protein, fat and carbohydrate sources, with the addition of appropriate electrolyte, vitamin mineral and trace elements. Transition from a normal enteral feed to a ketogenic feeding regime is generally achieved using a step-wise approach over a few days as tolerated. This can be implemented by either introducing the ketogenic feed as a percentage 14
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of the existing enteral feed, or introducing full ketogenic feeds at a reduced ketogenic ratio. THINKING ABOUT KETOGENIC MEALS
As already mentioned, the shift from prioritising carbohydrate to prioritising fats, takes quite a bit of getting used to, for most. To ease patients and families into this, it is helpful to consider some initial first-steps during the four to six weeks running up to KD initiation. In this way, they have a chance to try out new ideas and become familiar with the types of food to focus on. This can make the ketogenic changeover much easier to cope with. First steps • Swapping high sugar snacks such as cakes, biscuits, sweets and chocolates for alternatives such as cubes of cheese, slices of
• •
•
• •
ham, chunks of chicken, berries with cream, vegetable sticks with full fat dips, etc. Swapping full sugar drinks for sugar-free versions. Introducing lower carbohydrate vegetables such as broccoli, cauliflower, celeriac, celery, courgette, kale, mushrooms, salad leaves and spinach; adding butter, oils or creamy sauces to them. Experimenting with different breakfast choices such as egg-based cooked breakfasts or exploring adapted recipes for KD porridge, KD muffins or perhaps KD pancakes. Experimenting with KD bread and cracker recipes and shop bought lower carbohydrate alternatives. Trying out alternatives to milk (e.g. unsweetened almond or soya milks) and any prescribed products, such as the Ketocal range, Carbzero, Calogen, Betaquik, or Liquigen, if any are to be incorporated into the diet plan.
Meals generally need to be made from fresh, basic ingredients, so a willingness to plan a menu and prepare meals from first principles is essential. Lots of practical help with identification of macronutrient sources, lower carbohydrate replacements and meal planning is required in the early days (Table 5). However, in time, most families and adults can be supported to become knowledgeable and confident in this respect. Lots of practise and a bit of positive encouragement certainly does make ketogenic meal creation easier. The increased popularity
of low carbohydrate diets in the public domain has led to some very inspirational websites and books with recipes ideas that can readily be tweaked to match individual meal prescriptions. TRANSLATING PRESCRIPTION NUMBERS INTO MEALS
This is the aspect of KDT that seems to create the most anxiety in new starters and it is the responsibility of the managing team to ensure that patients and families are provided with appropriate tools and are enabled to learn the basics, so that they can build on this knowledge and gain confidence over time. There are two main counting methods: Food choice lists (e.g. 1g CHO choices, 10g fat choices, 6g protein choices) and meal planning sheets are the simplest way to start out. By focusing on building meals around the three essential macronutrients, a portion of protein (measured or portion guided), a source of carbohydrate (always measured) and a generous supply of fats (measured or portion guided), families quickly get an eye for their frequently used food sources and soon learn to spot when the balance of foods in the meal doesn’t look quite right. It’s a good idea to encourage starting out with a few simple meals and lots of repeats of the favourites in the first few months. It’s the effect of the macronutrient shift on symptoms that is under scrutiny, rather than the fanciness of the recipes. As a boost to ease menu planning for adults and older children starting out on MKDs, we have produced a guide and recipe booklet www.NHDmag.com November 2017 - Issue 129
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KETOGENIC DIET THERAPY Table 5: Useful foods for ketogenic diets Ketogenic diet alternatives to high carbohydrate staples
Bread
• KD recipes based on ingredients such as nuts, seeds and their flours, eggs, cream cheese, baking powder (low carbohydrate versions), psyllium husk and xanthan gum • Commercial low carbohydrate breads: Livlife bread loaf, Atkins (bread mix), Sukrin (bread mix), Jo-Lo (bread mix) • PRESCRIPTION ONLY: 3:1 Ketoclassic Savoury (Ketocare Foods); similar to a bread roll
Pizza bases
• KD recipes based on cauliflower, or ketogenic bread ideas as above • Commercial pizza base options, e.g. Lo-dough flatbread/pizza base
Crackers and crispbread
• KD recipes based on nuts, seeds and their flours • Commercial alternatives such as Atkins Fibre Crackers
Pasta
• KD pasta recipes using eggs, psyllium husk, cream cheese, etc • Spiralised vegetables; courgette, butternut squash, etc, can be used in place of spaghetti • Cabbage leaves and lettuce leaves can be used in place of lasagne sheets • Egg omelette can be cut into narrow strips and used in place of spaghetti • Commercial pasta alternatives; Shirataki noodles based on Konjac root; e.g. Miracle Noodle, Zero Noodles, Slim Pasta, Bare Naked Noodles
Potato
• Celeriac can be used to make crisps, chips, wedges and mash • Cauliflower can be roasted or mashed • Swede can be roasted, mashed or made into chips
Rice
• Cauliflower can be grated and stir fried • Commercial rice alternatives: Konjac root ‘pasta’ in a rice grain shape
Flour
• Nuts and seeds (ground or as ‘flours’) such as almond, coconut, flax and sesame can be used in KD recipes for pastry, muffins, cakes and biscuits • Psyllium Husk, xanthan gum, flour-free baking powders and eggs are readily used in low carbohydrate baking to help with the structure of baked goods • PRESCRIPTION ONLY: Ketocal 4:1 and 3:1 powder (Nutricia) and MCT Procal (Vitaflo) as high fat low carbohydrate ‘powders’ may be used in meal recipes See www.matthewsfriends.org/keto-kitchen/keto-recipes/cooking-with-prescription-products/ Other ketogenic essentials and helpful additions
A mix of versatile and palatable fat sources
• Double cream, crème fraiche, butter, cream cheese, lard, vegetable oils; eg olive oil, coconut oil, other vegetable oils, mayonnaise, hollandaise sauce, avocados, etc • New high fat, low carb products such as Coyo coconut yoghurt
Low carbohydrate milk substitutes for general use
• Unsweetened almond and soya milks provide a fraction of the carbohydrate found in cows’ or goat milk
Sweeteners
• Some choose to avoid artificial sweeteners and any products containing them. Others use products such as sugar-free drinks, sugar-free jellies and Da Vinci flavoured syrups (contain sucralose) finding these useful. For baking, we may recommend carbohydrate and calorie free options such as Hermesetas liquid (liquid saccharin), or Stevia powder products without maltodextrin. Low carb products with sugar alcohols (e.g. sorbitol, xylitol, erythritol) are best avoided in the early months of ketogenic therapy, but may be incorporated once a more stable ketogenic state has been reached and tolerance can be observed
Other flavour enhancing ingredients
• Dried herbs and spices; checking labels of ‘mixes’ for added sugars or flour. Commercial stocks; looking for lowest carbohydrate versions. Savoury spreads and flavours; Bovril, Marmite, Worcestershire sauce, mustard, vinegar, a dash of soya sauce • Essences, e.g. vanilla essence may be used in drinks and for cooking
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entitled Colour & Shine. (Ketogenic meals should always be shiny and ideally colourful too!) Each breakfast, lunch and dinner recipe provides approximately 5g carbohydrate, 40g fat, 18g protein and 450kcal. Each snack recipe provides approximately 1g-2g carbohydrate, 15g fat, 2-4g protein and 150kcal. For those requiring more than 5g carbohydrate or 40g fat as their guideline meal prescription, additional 1g carbohydrate and 10g fat choices can simply be added from the lists provided. It can really help new starters in the early days when they are learning about making KD meals and exploring the impact of the KDT therapy on symptoms too. Computer based ketogenic meal planners can be used from the outset by computer/app confident families or introduced part way through the ketogenic treatment when they are becoming more confident and wish to expand their meal horizons. Programs such as the Electronic Ketogenic Manager (EKM) are an invaluable help for more complex multi-ingredient recipes, particularly for Classical and MCT KDs where protein carbohydrate and fat are all measured.
Note: prescription adjustment may be required when moving from a slightly looser choice lists generated menu to a tighter electronic program generated menu. KDT remains under-utilised within the world of complex epilepsy, and is only just being explored as a potential therapy or supplementary therapy for other conditions for which modern medicine has no cure.10 With its potential to alter cellular fuelling, downregulate inflammatory pathways, control glucose levels and deliver effective weight control, it is a wonder that broader exploration of its potential is taking so long. Could the ‘fat is bad and carbohydrate is good’ message be clouding our willingness to explore KDT and lower carbohydrate diets, to evaluate the metabolic potential beyond? As interest in low carbohydrate/ketogenic nutrition is increasing outside clinical dietetics, I sense a readiness to dismiss this as a fad and passing phase from within. Eight years ago, I would have dismissed the apparent hype too, but now that I have seen the clinical impact that ‘more fat, less carbohydrate’ can deliver, I have been forced to re-examine and ‘shift’ my own long-held preKDT beliefs.
References 1 Ward, Colin. Ketone body metabolism [internet]. 2015 Nov 18; Diapedia 51040851169 rev. no. 29. https://doi.org/10.14496/dia.51040851169.29 2 www.ketogenic-diet-resource.com/ketoacidosis.html. Accessed 28.9.17 3 Paoli A, Rubini A, Volek JS, Grimaldi KA. Beyond weight loss: a review of the therapeutic uses of very-low carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013; 67(8): 789-796 4 Paoli A, Bianco A, Damiani E, Bosco G. Ketogenic Diet in Neuromuscular and Neurodegenerative Diseases. Biomed Res Int. 2014; 2014: 474296 5 Feinman RD, Pogozelski WK, Astrup A, Bernstein RK et al. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition. 2015; 31(1): 1-13 6 Klement R. Beneficial effects of ketogenic diets for cancer patients: a realist review with focus on evidence and confirmation. Med Oncol. 2017; 34:132 7 Liu YM, Lowe H, Zak MM, Kobayashi J et al. Can children with hyperlipidaemia receive ketogenic diet for medication-resistant epilepsy? J Child Neurol. 2013 Apr; 28(4): 479-83 8 Cervenka MC, Patton K, Eloyan A, Henry B et al. The impact of the modified Atkins diet on lipid profiles in adults with epilepsy. Nutr Neurosci. 2016; 19(3): 131-7 9 Kossoff EH, Zupec-Kania BA, Amark PE, Ballaban-Gil KR et al. Optimal clinical management of children receiving the ketogenic diet: Recommendations of the International Ketogenic Diet Study Group. Epilepsia Volume 50, Issue 2 2009, p 304-317 10 Masino SA (Editor). Ketogenic Diet and Metabolic Therapies: Expanded roles in health and disease. Oxford University Press. 2017.
WHO ARE MATTHEW'S FRIENDS? Matthew’s Friends is a charity that specialises in medical ketogenic dietary therapies and has been working alongside NHS ketogenic therapy teams, offering information and support for those on a medically supervised therapy since 2004. In September 2011, we opened the first Matthew's Friends Clinic at Young Epilepsy as a means of providing a tertiary level clinical service to increase the availability of ketogenic dietary therapy to children and adults with drug resistant epilepsy in the UK where NO local provision is currently available. The small experienced team of ketogenic dietitians, ketogenic diet assistants and a neurologist is led by neurologist Professor J Helen Cross OBE. In 2016, we launched Matthew’s Friends KetoCollege, which is an annual training meeting for medical professionals wanting to work in the field of medical ketogenic dietary therapies.
www.matthewsfriends.org
www.mfclinics.com
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FROM HOLDING BACK.. . .TO HOLDING JACK
. .In a shot SOMETIMES PATIENTS CAN’T MEET THE ENERGY REQUIREMENTS THEY NEED THROUGH NORMAL DIET AND ONS ALONE.1
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Little wonder it helps so much
55% 92% 67%
Increase calorie intake by 55% IN ADDITION TO NORMAL diet 2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4
Pro-Cal shot is a food for special medical purposes and should be used under strict medical supervision. ® Reg. Trademarks of Société des Produits Nestlé S.A.
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References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.
All information correct at the time of print. December 2016
NUTRITION SUPPORT
Lee Martin Specialist Gastroenterology Dietitian, University College London Hospitals NHS Foundation Trust
Lee works in Gastroenterology and Neurogastro enterology. He also has a special interest in supporting the mealtime experience of people living with dementia. For correspondence please email: lee@thedmat.com
ORAL NUTRITIONAL SUPPLEMENTS: ARE THEY AN EFFECTIVE INTERVENTION IN PEOPLE LIVING WITH DEMENTIA? Oral nutritional supplements (ONS) are still being touted as the saviour of malnutrition by leading UK charities who consistently publish positive research findings when pooling data for all patient groups. But what about sub groups of the population including those living with dementia? What does the evidence suggest about the use of ONS and can ONS improve outcomes such as increased weight and body mass index (BMI) and, therefore, prevent malnutrition? Like most things, the answer is not as simple as yes or no and for people with dementia, there are some important considerations to take into account which this article will attempt to emphasise. EFFECTIVENESS
Systematic reviews suggest that weight gain is variable when using ONS,1 while meta-analyses suggest a statistically significant improvement in weight and BMI.2 To be effective, prescribed ONS must be consumed. Compliance of ONS in all populations suggests 78% compliance (range 37-100%), but is negatively associated with age.4 A Cochrane review of ONS compliance in those >65 years of age found mean compliance of 66% (range 50-85%).5 While specifically in dementia, compliance rates range from 8.5% to 90% with that 8.5% coming from a one-year long-term follow-up study, indicating long-term ONS use is unlikely to be effective due to compliance. Finally, when looking at compliance, one cannot overlook the reporting or lack of reporting of dropouts. For example, one study
including mainly people with mild dementia had a dropout rate of 54% (65 participants) for a 24-week ONS intervention with ‘distaste’ sighted as the main reason for drop out.6 Potential reporting bias in ONS research trails has been questioned3 and considering positive research is more likely to be published and the effectiveness of ONS in dementia is still open for debate, there are many factors to consider when deciding on ONS as a treatment option. PROBLEMS WITH SCREENING AND ASSESSING THE USE OF ONS
Often, the main indicator for offering or prescribing ONS is poor oral intake and weight loss.1 Although poor oral intake can be assessed from food record charts and weight loss, or risk of malnutrition can be assessed using the malnutrition universal screening tool (MUST), or similar screening tools, the actual reasons why weight is lost or food is not consumed is not fully evaluated. Rarely is an assessment made on the individual’s mealtime abilities or what level of assistance they require to eat their food,7 even though www.NHDmag.com November 2017 - Issue 129
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HELPING YOU TO UNWRAP THEIR POSSIBILITIES You can support your patients’ recovery by choosing the Fortisip range of oral nutritional supplements and help them get back in the game
Date of preparation: October 2017
Nutritional Support - integral to the continuum of care
NUTRITION SUPPORT
“Screening for malnutrition is important, but if it is at the detriment of further and more person-centred assessments then its value is lost.” mealtime abilities will affect oral intake and the effectiveness of nutrition interventions.2 If the reason for the individual’s weight loss is related to their ability to feed themselves, then providing additional ONS without supporting their eating and drinking abilities is unlikely to lead to an increased intake. The MUST and all literature associated with its use strongly advocate the use of ONS based on BMI and weight loss; however, an assessment of the individual’s eating abilities and a clear idea of what assistance the individual requires would surely help target assistance and screen those individuals who would gain most from ONS as an effective intervention. For further information on assessing mealtime abilities in people with dementia, please refer to my previous NHD article published in June 2016 for additional information.8 A further drawback with using weight loss and BMI as the main indicator for prescribing ONS is evidence suggesting people with dementia and with a low BMI (<20kg/m2) are found to decrease their oral intake when prescribed ONS. Additionally, these individuals continue to have decreased habitual intake even when ONS are ceased.7,9 Furthermore, weight loss in these individuals with a low BMI and later stage dementia can be seen despite consuming all prescribed ONS.13 Disappointingly, this can be commonly seen in dementia care9 and was something I witnessed many times in nursing home residents whose needs were not fully supported at mealtimes. Careful prescription of ONS in people with dementia and a low BMI (<20kg/ m2) is warranted. If ONS affects oral intake at subsequent meals then this may indicate that the individual is less likely to return to pre-ONS oral intake levels once ONS is removed and, therefore, overall intake will decrease. Recent guidelines published by ESPEN recommend the
use of the Mini Nutritional Assessment (MNA) either in its full or short form (MNA-SF) to assess malnutrition in older people,10 while a previous ESPEN consensus statement recommends BMI <20 kg/m2 for subjects <70 years of age and BMI <22 kg/m2 for subjects 70 years and older.11 When working with the older people with dementia population, one should strongly consider the most appropriate assessment methods used. It is worth noting that people with dementia who have a low BMI are more likely to have later stage dementia and are also more likely to have reduced mealtime abilities.12 “Screening for malnutrition is important, but if it is at the detriment of further and more person-centred assessments then its value is lost.” INCREASING THE CONSUMPTION AND EFFECTIVENESS OF ONS IN DEMENTIA
Some potential ways to increase the efficacy of ONS is provided in Table 1, although, as with all general advice, there are some important points to consider for individuals. In general, people with dementia are less likely to suffer a decrease in appetite if ONS are provided in small regular intervals.1 However, a reduction in intake may still be observed. Offering ONS between meals is often used and recommended, but it is debatable as to what the most desirable and effective between-mealtimes is. If lunch is the main meal of the day, as it often is in care settings, close monitoring of lunch intake is required to ensure that oral food intake is not decreased from ONS use prior to this.9 Importantly, when comparing meal intakes for both ONS and oral snacks as between-meal interventions (twice daily), a decrease in intake at meals was seen. However, this was only significant in those receiving ONS.7 Similarly, the percentage of a meal eaten decreased when both a 200ml ONS was provided between meals www.NHDmag.com November 2017 - Issue 129
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NUTRITION SUPPORT Table 1: Increasing the consumption and effectiveness of ONS in dementia Distribution
In care settings, often ONS is not provided when advised/ordered and this may lead to significant amounts not being consumed.
Frequency
Specify set times between meals for providing ONS.
Frequency
Distributing ONS in small regular amounts at same time as medication rather than with/ after food. This may also decrease waste of ONS.
Assistance
Assistance provided when ONS is administered increases consumption, especially in those â&#x20AC;&#x2DC;physicallyâ&#x20AC;&#x2122; impaired.
Presentation
Decanting ONS into a glass or mug improves acceptability.
Volume
Large volumes of ONS (200mls plus) between meals may affect intake at the next meal. Especially relevant to ONS provided mid-morning or too close to lunch as a decrease in lunch intake has been seen in some individuals.
Monitoring
A two-day trial of ONS can be an effective measure for determining a short-term intervention of ONS. This is to see if oral intake is maintained (robust monitoring of food charts required) and to assess if ONS does actually provide increased intake.
Monitoring
Rotating ONS on a three-week on and three-week off schedule in those most likely to respond to ONS, i.e. those who maintain oral intake and increase intake from ONS and/ or those who once ONS is removed increase oral intake again, may not only increase effectiveness, but reduce staff burden administering and monitoring ONS.
Outcomes
Regular monitoring and recording of ONS consumption, oral food intake and weight changes while prescribed ONS are essential for assessing effectiveness.
Outcomes
The effect size for ONS has been estimated at 0.5kg to 2kg weight gain over one to six months. If after one month no weight gain is seen, then both the way ONS is provided and the actual ONS provided should be reconsidered.
Compiled from references 1, 7. 9, 2. See text for specific issues with these approaches.
Table 2: Potential ways to increase the compliance and effectiveness of ONS in dementia and non-dementia Volume
Providing ONS with increased calories (>2kcal/ml) and decreased volume.
Choice
Increased variety of flavours may be better than providing variety of types of ONS.
Monitoring
Increased regular monitoring as used in research studies does seem to increase compliance, therefore monitoring techniques used in research should be applied to clinical settings.
Compiled from reference 4.
and when a 60ml ONS was provided four times per day. Nevertheless, the decreased intake was significantly more when the 200ml volume was provided.2 Providing assistance with eating and drinking is seen as a labour intensive caring task and in instances of inadequate staffing levels, ONS can become a meal replacement rather than a supplement to the diet.1 Be wary of settings where staff time and staffing levels are reduced as people with dementia need increased assistance at mealtimes due to reduced mealtime abilities.7 Table 1 highlights two potential monitoring techniques to determine in whom the ONS intervention will be most effective with regards
to ONS impacting on oral food intake. One monitoring intervention involves a two-day trail of ONS and detailed recording of oral food intake.7 Secondly, in those who require ongoing use of ONS, then a three-week on and three-week off rotation system can be employed to effect.9 NON-DEMENTIA SPECIFIC ONS PRACTICAL TIPS
Considering the effectiveness and compliance of ONS in all patient groups rather than in only dementia groups, we can see some similar themes emerging as highlighted in Table 2. Interestingly, the review from which Table 2 was compiled found no significant differences in set time delivery, medication rounds or providing www.NHDmag.com November 2017 - Issue 129
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NUTRITION SUPPORT ONS ad-libitum on consumption of ONS, or mean energy intake when looking at all patient groups.4 Looking at mean results obtained from groups are not always generalisable to subgroups or individuals. Some research that focuses on dementia does highlight the impact of timing on compliance and effect on oral nutrition intake,7,9,13 although conflicted results are still seen.2 Many of these tips for increasing effectiveness rely on the staff providing additional assistance in some form and probably the benefits from this type of administration of ONS in the research is due to increased staff assistance at this time. CONCLUSION
The research discussed indicates more staff availability to provide assistance and monitoring of ONS can increase the effectiveness of ONS consumption and weight gain. In the cash strapped world of older peopleâ&#x20AC;&#x2122;s care, however, more staff availability is often not a viable choice. Certainly, if the correct level of assistance is provided, then providing snacks or oral food may be just as or more effective and cost less than ONS.7 So are ONS an effective intervention in people living with dementia? Temporary use of ONS can be both beneficial and detrimental to short-term nutritional intake and body weight, but is unlikely to improve longterm weight or functional outcomes.14 There are several practical ways to increase compliance and consumption of ONS (Tables 1 and 2), but they all
require additional staff resources. Additionally, current screening tools (e.g. MUST) used in the assessment for administration or prescription of ONS may not be specific enough to assess the nutritional complexities in people with dementia. Those identified as at risk of malnutrition by low BMI (<20kg/m2) and/or with later stage dementia may not respond to ONS as an effective intervention.3 ONS may cause a decrease in oral intake which is not recovered when ONS is stopped, but why ONS creates such dependence is unknown. For someone living with dementia where mealtimes will be one of their few opportunities for social interactions, a decrease in meal intake is unwanted from both a nutritional and quality-of-life aspect. Certainly, research suggests the psychosocial impact of mealtimes is a key factor in improving nutritional intake in people with dementia.15 Finally, there is a need to assess the precursors to decreased nutritional intake and weight loss, such as reduced mealtime abilities and then intervene at this stage.2 Nutrition and dietetic interventions for people with dementia have been suggested to focus on strategies to improve mealtime abilities and eating environments to promote oral intake.14 The family members of people with dementia prefer oral food being offered1 and although research has failed to ask people living with dementia what they think, one would imagine they would agree.
References 1 Hines S, Wilson J, McCrow J, Abbey J and Sacre S. Oral liquid nutritional supplements for people with dementia in residential aged care facilities. Int J Evid Based Healthc. 8, 248-251 (2010) 2 Allen VJ, Methven L and Gosney MA. Use of nutritional complete supplements in older adults with dementia: Systematic review and meta-analysis of clinical outcomes. Clin Nutr 32, 950-957 (2013) 3 Hanson LC, Ersek M, Gilliam R and Carey TS. Oral feeding options for people with dementia: A systematic review. J Am Geriatr Soc. 59, 463-472 (2011) 4 Hubbard GP, Elia M, Holdoway A and Stratton RJ. A systematic review of compliance to oral nutritional supplements. Clin Nutr 31, 293-312 (2012) 5 Milne A et al. Protein and energy supplementation in elderly people at risk from malnutrition ( Review ). Cochrane Libr 2-4 (2009) 6 Manders M et al. The effect of a nutrient dense drink on mental and physical function in institutionalised elderly people. J Nutr Heal Aging 13, 760-767 (2009) 7 Simmons S, Zhuo X and Keeler E. Cost-effectiveness of nutrition interventions in nursing home residents: A pilot intervention. J Nutr Health Aging 14, 367-372 (2010) 8 Martin L. Innovation in the nutritional care of dementia. NHD Extra 115, 53-57 (2016). https://sites.create-cdn.net/sitefiles/27/1/5/271513/ISSUE_115_ innovation_in_the_nutritional_care_of_dementia.pdf 9 Parrott MD, Young KWH and Greenwood CE. Energy-containing nutritional supplements can affect usual energy intake postsupplementation in institutionalised seniors with probable Alzheimerâ&#x20AC;&#x2122;s disease. J Am Geriatr Soc. 54, 1382-1387 (2006) 10 Cederholm T et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 36, 49-64 (2017) 11 Cederholm T et al. Diagnostic criteria for malnutrition - An ESPEN Consensus Statement. Clin Nutr 34, 335-340 (2015) 12 Lin L-C, Watson R and Wu S-C. What is associated with low food intake in older people with dementia? J Clin Nurs 19, 53-59 (2010) 13 Faxen-Irving G et al. The effect of nutritional intervention in elderly subjects residing in group-living for the demented. Eur J Clin Nutr. 56, 221-227 (2002). 14 Jansen S et al. Nutrition and dementia care: Informing dietetic practice. Nutr Diet 72, 36-46 (2015) 15 Keller HH. Improving food intake in persons living with dementia. Ann N Y Acad Sci 1367, 3-11 (2016)
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CONDITIONS & DISORDERS
Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.
COELIAC DISEASE: GLUTEN-FREE FOODS ON PRESCRIPTION THE DEBATE Coeliac disease (CD) is a lifelong autoimmune disease which affects one in 100 people in the UK.1 It is caused when the body has an abnormal response to gluten a protein found in wheat, barley and rye. This abnormal response causes damage to the microvilli found within the small intestine, which can lead to gastrointestinal symptoms and the malabsorption of nutrients. The only treatment - which reverses the damage done to the microvilli is to follow a strict gluten-free (GF) diet. For decades patients with CD have been entitled to GF food on prescription. However, in more recent years, some clinical commissioning groups (CCGs) are now restricting or completely stopping this. Currently around 40% of CCGs in England have taken this decision.2 Since becoming available on prescription in the late 1960s, many patients with CD have utilised the option to receive GF foods to help manage diet and in turn their health. A prescribing guide - Gluten Free Foods: a revised prescribing guide 20113
- was developed to assist GPs and healthcare professionals with the availability of foods on prescription. It states that bread/rolls, breakfast cereals, crackers/crispbreads, flour/ flour-type mixes, oats, pasta and pizza bases are all available on prescription and approved by the Advisory Committee on Borderline Substances (ACBS).3 So, why stop it? And what impact may it have on this patient group? THE DEBATE AGAINST
It’s hard to go a day without reading headlines around the NHS and its financial debts. Recent statistics state that the NHS net deficit for the 2015/16
Table 1: The availability of gluten-free foods on prescription in primary care.6 Product White bread
NHS Indicative Price (Price per 100g)
GF product price per packet (price per 100g)
Branded non-GF equivalent price per packet (price per 100g)
£3.69 (92p)
£1.94 (43p)
£1 (12.5p)
£6.73 (£1.34)
£1.57 (45p)
£1.22 (22.9p)
Cornflakes
£3.48 (93p)
£1.72 (48p)
£1.75 (35p)
Plain flour
£3.10 (62p)
£1.62 (17p)
£1.44 (14.4p)
Oats
£2.78 (56p)
£2.30 (49p)
£1.04 (20.9p)
£3.46 (£1.73)
£2.08 (£1.37)
£1.36 (45.3p)
£23.24
£10.47
£7.81
Pasta
Biscuits Total price (one of each item)
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CONDITIONS & DISORDERS
Those who argue that GF food on prescription should be stopped feel that this decision plays an important role in managing the NHS finances, allowing room for more funding for other treatments. financial year was £1.851 billion4 and the provider deficit for the 2016/17 financial year has been confirmed at £791m.5 Those who argue that GF food on prescription should be stopped feel that this decision plays an important role in managing the NHS finances, allowing room for more funding for other treatments. James Cave, a general practitioner, argues that, “It’s ludicrous for the NHS to be treating a food product as a drug and to require GPs and pharmacists to behave as grocers.” He goes on to explain how the “complex rules” on what can be prescribed can often cause stress, confusion and be a timeconsuming process for both patients and GPs. What may be his strongest argument, is pointing out that GF food on prescription is far more expensive than the supermarket price. “The NHS pays up to £6.73 for 500g of pasta, yet 500g of GF pasta will cost £1.20 at a supermarket”.2 These figures do not include the dispensing fee which is charged on top of all prescriptions. Table 16 on the previous page demonstrates the differences in prescribed, non-prescribed and non-GF products. Simon Stevens, the chief executive of NHS England, also feels that GF foods on prescription should end. He argued in an interview with The Daily Mail that the NHS is spending over £22 million on GF products that you can also now buy at Morrison’s, Lidl or Tesco.7 Staple GF foods were first available to patients in the 1960s, when the availability of GF foods was limited. They are now readily available in supermarkets, as well as a wider range of naturally GF food types being available,8 meaning that the ability to obtain these foods without a prescription has become much easier. Simon Stevens leads on to make a point that the stopping of GF foods on prescription is to ensure that the NHS makes enough headroom to spend money on innovative new drugs.7 A 26
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further argument from health minister, Lord O’Shaughnessy, to support this said: “The NHS is one of the most efficient health services in the world, but we need to do more to ensure that we get the best possible value for taxpayers’ money. Changing the way we prescribe GF food could make an important contribution to saving the NHS millions of pounds a year.”8 GF foods are within the category of ‘Other Food for Special Diets’, which had the greatest net ingredient cost (NIC) in 2015, as published in the Prescriptions Dispensed in the Community: England 2005-2015 report. The amount totalled £99.7m, of which GF foods accounted for £26.8m.6 So, how is this working out so far? Many CCGs have already stopped providing GF foods on prescription. Norwich and North Norfolk CCGs decided to end prescribing of GF foods, except in exceptional circumstance. This resulted in the spend of £400,000 on GF prescribing in 2015, falling to just £21,000 in 2016. Norfolk CCG report that this has allowed them to have more money available for other treatments, and that they have received mostly positive feedback from both members of the public and GPs on this decision.8 Further to these points, the availability of GF foods on prescription may result in patients becoming accustomed to receiving them to supplement their food shopping. Some patients may put pressure on their GPs to prescribe nonstaple products, or larger quantities, especially if they are exempt from prescription charges, to feed other family members and to avoid separate meal preparation. We must also take into account that research has suggested that some (albeit a minority of) GPs will prescribe GF products if a patient requests it, without confirming a diagnosis of CD.6 This could be an increasing problem as the ‘trend’ of following a GF diet (GFD) grows.
On the other side of the debate, we see experts argue that removing prescriptions for GF products unfairly discriminates against people with CD, may lead to severe health concerns for patients and long-term costs to the NHS. A final argument is that although the only treatment for CD is to follow a GFD, this does not mean that patients need alternative breads/pastas/cereals to manage their disease. There are many naturally GF grains, such as rice, potatoes, oats and quinoa to name a few, that patients can base their meals around. GF products are, therefore, not a necessity and some feel are incomparable to medications that treat other autoimmune diseases. To further argue against the fact that GF foods on prescription help with adherence to a GFD, there have been systematic reviews which demonstrate that the existing evidence for factors associated with adherence to a GFD is of variable quality9 and that options for the standardised evaluation of adherence remain unsatisfactory.10 THE DEBATE FOR
On the other side of the debate, we see experts argue that removing prescriptions for GF products unfairly discriminates against people with CD, may lead to severe health concerns for patients and long-term costs to the NHS. With a GFD being the only treatment for CD, is it fair to discontinue this? The National Institute for Health and Care Excellence’s quality standards for coeliac disease11 highlights the role of prescriptions to ensure that the diet is affordable and accessible for all patients. The experts say that there is no other example in the NHS of a disease having its treatment costs cut by 50-100%, and ask if CCGs would consider this if the treatment for CD were an immunosuppressive drug and not food? Gastroenterology experts David Sanders and Matthew Kurien, along with Sarah Sleet, Chief Executive of Coeliac UK, argue that understandably the NHS needs to find ways to cost save and that GF food prescriptions might seem like an easy target for CCGs trying
to make savings. However, when compared to the overall spending of the NHS prescribing budget, annual prescription costs for GF foods were £25.7m in England last year - just 0.3% of the total budget.2 On another financial aspect of the argument, the fact that GF foods are markedly more expensive (see Table 1) and limited, patients should be entitled to have them on prescription. When looking at the short-term cost of GF prescribing for long-term savings, a good example is the increased risk of osteoporosis in coeliac patients who do not follow a strict GFD. NICE estimated that the cost of GF food on prescription was £194.24 per patient per year based on NIC.12 A hip fracture caused by osteoporosis, the most common complication of untreated CD, costs on average £27,000 per fracture,13 the equivalent to 138 years of prescribing GF staples for an individual. This demonstrates that, in fact, GF food on prescription is a low cost treatment for a lifelong autoimmune disease and by contrast, treatment of long-term complications such as osteoporosis or intestinal lymphoma risks a concerning financial impact on the NHS, not to mention the significant burden for patients. In addition to this, in the argument that prescription products should be replaced with naturally GF grains, Coeliac UK amongst others, has raised valid points with regards to nutritional composition of these foods. CD patients have higher calcium requirements - 1000mg/day14 as opposed to 700mg/day - and may be more at risk of suffering from iron deficiency anaemia due to gut damage. Therefore, obtaining the correct amount of nutrients from their diet is essential for health and to prevent long-term complications. Cereals and cereal products contribute significant amounts of iron and calcium to the diet. Data from the National Diet and www.NHDmag.com November 2017 - Issue 129
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CONDITIONS & DISORDERS Nutrition Survey shows that cereals and cereal products contribute 44% of total iron intake and 30% total calcium intake to the diet.15 As suggested in the against argument, replacing 72g GF bread with a portion of rice containing the same amount of calories would reduce the iron content by 96% and the calcium content by 90%.16 Similarly, replacing GF bread with a portion of peeled, boiled potatoes containing the same amount of calories would reduce the iron content by 71% and the calcium content by 93%. The government’s own Eatwell Guide suggests that our diet should consist of one third wholegrains. Many people with CD rely on prescription foods to meet this, and those who will be most affected by the withdrawal of prescriptions are likely to be the least able to manage the complexity of the dietary changes required to maintain this recommended nutritional balance.17 Finally, a number of studies are cited in support of the use of GF foods on prescription. For example, research from King’s College London concluded that due to the limited availability of GF foods in different stores and increased cost, having access to a range of GF food on prescription is important to
support people with CD and help them meet their nutritional needs.18 When looking at the availability of GF staple foods, research has also suggested that it is not consistent in retail outlets. There is poor availability in budget supermarkets, corner shops and smaller stores.18,19 Further research undertaken by Coeliac UK suggests that access to GF food on prescription is viewed as the most important factor for people with CD in terms of adherence to a GFD, with 86.6% citing it as an important factor in maintaining the GFD and 47% citing this as the single most important factor.20 CONCLUSION
Unfortunately the current situation for GF prescribing appears unfair, with different areas in the UK offering varying options for patients. No one can say what the impact on discontinuing GF foods on prescriptions will have - it may seem like a short-term gain financially, but is the NHS overlooking the serious long-term complications that may happen as a result? Or is the NHS prescribing an irrational product, should the money saved be put towards treatments which have no other option in treating the disease? Lots to think about…I’ll let you make up your own mind.
References 1 Coeliac UK. www.coeliac.org.uk/coeliac-disease/about-coeliac-disease-and-dermatitis-herpetiformis/ 2 BMJ Press Release. Should gluten-free foods be available on prescription? 2017. www.bmj.com/company/wp-content/uploads/2017/01/gluten-freefoods.pdf 3 Gluten Free Foods: A Revised Prescribing Guideline 2011. (2011). www.coeliac.org.uk/gluten-free-diet-and-lifestyle/prescriptions/ national-prescribing-guidelines/ 4 NHS England, Annual Report 2015/16 5 NHS Improvement, Quarterly performance of the NHS provider sector: quarter 4 2016/17 6 The Availability of Gluten Free Foods on Prescription in Primary Care. Department of Health. 2017. www.gov.uk/government/uploads/system/uploads/ attachment_data/file/604842/Gluten_free_foods_cons.pdf 7 www.theguardian.com/society/2017/mar/28/nhs-draws-up-list-of-items-to-be-banned-from-prescriptions 8 www.gov.uk/government/news/consultation-launched-on-prescribing-of-gluten-free-foods 9 Haines ML, Anderson RP, Gibson PR. Systematic review: The evidence base for long-term management of coeliac disease. Aliment Pharmacol Ther 2008; 28(9): 1042-66. www.ncbi.nlm.nih.gov/pubmed/18671779 10 Leffler DA, Edwards George JB, Dennis M et al. A prospective comparative study of five measures of gluten-free diet adherence in adults with coeliac disease. Aliment Pharmacol Ther 2007; 26: 1227-35. www.ncbi.nlm.nih.gov/pubmed/17944737 11 NICE Coeliac Disease Quality Standard QS134, 2016. www.nice.org.uk/guidance/qs134 12 NICE NG20: Coeliac disease; recognition, assessment and management Appendix G HE Report. 2015 13 NICE Clinical Guideline CG124: The management of hip fractures in adults. 2011. www.nice.org.uk/guidance/cg124 14 NICE NG20: Coeliac disease; recognition, assessment and management. 2015. www.nice.org.uk/guidance/ng20 15 Henderson L, Irving K, Gregory J, Bates CJ, Prentice A, Perks J, Swan G, Farron M. National Diet and Nutrition Survey: adults aged 19-64 years vitamin and mineral intake and urinary analytes. 2003 16 O'Connor A. An overview of the role of bread in the UK diet. Nutrition Bulletin, 2012. 37(3): p. 193-212 17 Document: Department of Health consultation response. Coeliac UK. 2017. www.coeliac.org.uk/ document-library/4509-department-of-health-consultation-response/ 18 Singh J and Whelan K. Limited availability and higher cost of gluten-free. Journal of Human Nutrition and Dietetics, 2011 19 Burden M et al. Cost and availability of gluten-free food in the UK: in store and online. Postgraduate Medical Journal, 2015: p. postgradmedj-2015-133395. 20 Food Information Research, Coeliac UK, 2006 Unpublished
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PAEDIATRIC
PREMATURE INFANT FEEDING Jacqui Lowdon Paediatric Dietitian, Leeds Childrenâ&#x20AC;&#x2122;s Hospital
Jacqui is a Clinical Specialist in Paediatric Cystic Fibrosis at Leeds Children's Hospital. She previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.
Preterm infants are those born before 37 weeks completed gestation. Preterm birth is the primary cause of neonatal death worldwide and carries lifelong risks to health.1,2 Immaturity-related conditions, such as respiratory and cardiovascular disorders, remain the most common cause of infant deaths in the UK.3 However, a recent publication4 has demonstrated that there has been an increase in survival of very preterm infants in England over 2008-2014 (2008: 88.0%; 2014: 91.3%), with the greatest improvement at 22+0- 23+6 weeks. The more preterm and smaller an infant is at birth, the more vulnerable they are nutritionally. The primary aim of nutrition support in preterm infants is to achieve growth similar to that of normally growing foetuses of the same gestational age, but there is also strong evidence that early nutrition affects neuro-cognitive outcomes5,6 and motor outcomes, such as the presence or severity of cerebral palsy.7,8 Therefore, everyone involved in providing care for preterm infants, needs to be aware
of the critical importance of good nutrition in both the short and long term. NUTRITIONAL CONSEQUENCES OF BEING BORN TOO EARLY
Table 1 summarises the nutritional differences between a full term infant and one born at 24 weeks gestation. Over the first few months, the adequacy of the nutrition provided on the neonatal unit will influence whether the infant will continue to develop.
Table 1: Nutritional differences - full term versus preterm Term infant
Preterm infant
37-40 weeks gestation, where intrauterine environment has been appropriate
24 weeks gestation
Body weight of >2.5kg, doubling within the first year of life
Body weight of around 600g
Skeleton to protect from the physical environment, and by one year of age, supporting the infant
Skeleton inadequately calcified and at high risk of fracture
Musculature sufficiently developed to allow inflation of the lungs, breastfeed and move
Musculature insufficiently developed to inflate lungs
Insulating layer of fat around organs and under skin, also providing protection and an energy reserve
No adipose stores to provide protection, insulation or energy reserves
Sufficient iron stores for first three to four months
No iron stores
Structurally and physiologically mature digestive system to process nutrition
A digestive system whose structure cannot support the transit of food and has not developed adequate enzyme support to digest adequate nutrition
A brain that will co-ordinate processes and communicate its needs
Primitive and underdeveloped brain
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Table 2: Summary of main ESPGHAN recommendations10,15 Nutrient
Recommended intake
Fluid ml/kg/day
135-200
Energy kcal/kg/day
110-135
Protein g/kg/day (depends on infant’s body weight)
Body weight <1kg: 4.0-4.5 Body weight 1-1.8kg: 3.5-4g
Sodium mg/kg/day
69-115
Potassium mg/kg/day
66-132
Calcium mg/kg/day
120-140
Phosphate mg/kg/day
60-90
Vitamin A µg RE/kg/day
400-1,000
Vitamin D*µg/day (not per kg/day)
20-25
Folic acid µg/kg/day
35-100
Iron mg/kg/day
2-3 from 2-6 weeks of age (from 2-4 weeks of age in ELBW infants)
Table 3: Recommended protein to energy ratios as per ESPGHAN guidelines10 Weight
Protein g/100kcal
Protein:energy ratio
1-1.8kg
3.2-3.6g/100kcal
12.8-14.4%
<1kg
3.6-4.1g/100kcal
14.4-16.4%
NUTRITIONAL GUIDELINES
No UK guidelines exist for enteral feeding of preterm infants and so international guidelines are used.9,10,11,15 Table 2 summarises the main ESPGHAN recommendations.10,15 ENERGY REQUIREMENTS
Energy requirements are higher for preterm infants, estimated to be 110-135kcal/kg/day10 as opposed to 96-120kcal/kg/day for term infants.12,15 In cases of intrauterine growth restriction (IUGR), higher requirements are not always necessary, as it will depend on the cause of the IUGR. PROTEIN REQUIREMENTS
Recommended protein for preterm infants:10,15 • Infant body weight 1-1.8kg 3.5-4g/kg/day • Infant body weight <1kg 4-4.5g/kg/day No benefit has been reported for feeding >4.5g/kg/day. As well as the level of protein required, attention also needs to be made to the protein to
energy ratio: ‘Synthesis of new tissue is energy intensive and strongly affected by the intake of protein and other nutrients; thus, achieving an adequate energy to protein ratio is as important as providing adequate energy intake.’10,15 This is particularly important if supplements such as a glucose polymer or fat emulsion are added to the feed (Table 3). AGE-DRIVEN VERSUS INFANT-DRIVEN NUTRITION RECOMMENDATIONS
Despite the availability of these international nutrition recommendations, preterm infants remain vulnerable to suboptimal nutrition. This standard approach of assessing nutrient intakes based on chronological age may make it difficult to identify the origin of nutrient deficits and/or excesses. A recent publication13 compared the nutrient intakes of preterm infants during the period of weaning from parenteral nutrition (PN) to enteral nutrition (EN), called the transition (TN) phase, and compared the data with those analysed using the standard ‘chronological age’ approach, www.NHDmag.com November 2017 - Issue 129
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THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all. • Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.
REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Date of preparation: July 2015 RXANI150143
Table 4: High risk infants <27 weeks or <1,000g birthweight Haemodynamically unstable on inotropes Previous NEC or high risk for NEC Recent abdominal surgery Growth restricted infants with absent or reversed end diastolic flow
assessing whether the identification of nutrient deficits and/or excesses can be improved. The nutrition phase analysis approach revealed substantial macronutrient and energy deficits during the TN phase. In particular, deficits were identified as maximal during the EN-dominant TN phase (enteral feeds ≥80ml/kg/d). In contrast, the chronological age analysis approach did not reveal a corresponding pattern of deficit occurrence, but rather intakes that approximated or exceeded recommendations. The authors concluded that actual intakes of nutrients, analysed using a nutrition phase approach to evaluating nutrition support, allowed a more infant-driven rather than age-driven application of nutrition recommendations. This approach highlighted nutrient deficits occurring during the transition phase. Overcoming nutrient deficits in this nutrition phase should be prioritised to improve the nutrition management of preterm infants. EXPECTED WEIGHT GAIN
Intrauterine growth rate of approximately 15g/ kg/day is the most commonly used and accepted rate of weight gain for preterm infants, although this can be difficult to achieve.9 However, an accelerated weight gain in preterm infants should be avoided, as this has demonstrated detrimental consequences on longterm health, such as cardiovascular disease.14 When monitoring growth, the UK-WHO Growth Charts should be used. When correcting for gestation, the following guidance is accepted: • Gestation ≥37 weeks - no correction • Gestation 32 to 36+6 correct until age 1 year • Gestation 23 to 31+6 correct until age 2 years When calculating requirements, the actual weight should be used. In cases where the actual weight is lower than the birthweight or their highest dry weight, use the birthweight or highest dry weight.
CHOICE OF FEED
Breast milk Breast milk is the feed of choice for preterm infants, with all of its benefits being well documented. Where fortification is required, expressed breast milk (EBM) should be fortified with a commercial multicomponent breast milk fortifier (BMF) suitable for the preterm infant. As unfortified BMF cannot meet the needs of preterm infants <1.5kg, it can be commenced in stable preterm infants, usually once 150ml/kg/ day EBM is tolerated. Fortification should then continue until the infant is thriving. In cases where a supplementary preterm formula is given in addition to EBM and BMF, then the BMF should be stopped once 50% of requirements are given as formula, to prevent an excess of protein. It is important to carefully consider when to use a BMF in high risk preterm infants. Table 4 lists high risk infants. PRETERM FORMULA
Preterm infants who are not able to receive breast milk and are <2kg and <35 weeks, should be placed onto a preterm formula. There are three preterm formula milks available in the UK: • SMA PRO Gold Prem 1 (partially hydrolysed formula) • Nutriprem 1 low birth weight (whole protein formula) • Hydrolysed Nutriprem (extensively hydrolysed formula) Additional vitamin and mineral supplements are not required if the infant is on 150ml/kg/day of a preterm formula. These formulas should be continued until the infant is thriving, reaching 2.0-2.5kg and/ or discharged. Depending on growth achieved, www.NHDmag.com November 2017 - Issue 129
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PAEDIATRIC a post discharge or term formula can be used on discharge. Supplements Various supplements of vitamins and minerals will need to be added in depending on the feed used. If a preterm formula is being given at 150mls/ kg/day, then phosphate, sodium and calcium supplements will only need to be prescribed based on individual assessment. If a term infant formula is used, then 0.6mls multivitamin drops, an iron supplement and folic acid (only until term) will need to be prescribed, with phosphate, sodium and calcium supplements based on individual assessment. Infants fed on unfortified EBM will require 0.6mls multivitamin drops, an iron supplement and folic acid (only until term), with phosphate, sodium and calcium supplements based on individual assessment. For those infants fed on EBM with a suitable BMF, depending on which BMF is used, they will require an iron supplement with phosphate, sodium and calcium supplements based on individual assessment.
POST-DISCHARGE NUTRITION
If breastfed on discharge, then this should be encouraged post-discharge, with added supplements. Multivitamin drops (0.6ml) will always be required until first birthday. Most also require iron (1ml) until six months of age. If formula-fed and poor growth, a nutrientenriched post-discharge formula (NEPDF) such as Nutriprem 2 or SMA PRO Gold Prem 2 is recommended. Each infant will need to be individually assessed, as some may require this until six months corrected age. Once the NEPDF has been stopped, a term formula should be used until 12 to 18 months corrected age, depending on the nutritional adequacy of the complementary diet. CONCLUSION
Unlike respiratory, cardiac or neurological disease, nutritional morbidity can often be hidden. Today, many preterm infants have minimal respiratory or neurological morbidity, but good nutritional status is essential for every baby, and the longterm adverse effects that poor nutritional care might cause needs to be highlighted. Nutritional management should start as soon as the infant is born, continuing during the post-discharge period to help achieve optimal outcomes.
References 1 Lawn JE, Cousens S, Zupan J for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005; 365: 891-900 2 Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008; 371: 261-9.doi:10.1016/ S0140-6736(08)60136-1 3 Childhood mortality in England and Wales: 2015. Office for National Statistics. www.ons.gov.uk/peoplepopulationandcommunity/ birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2015. Accessed 7th October 2017 4 Shalini Santhakumaran, Yevgeniy Statnikov, Daniel Gray, Cheryl Battersby, Deborah Ashby, Neena Modi, on behalf of the Medicines for Neonates Investigator Group. Survival of very preterm infants admitted to neonatal care in England 2008-2014: time trends and regional variation. BMJ June 2017. Downloaded from http://fn.bmj.com/7th October 2017 5 Cooke RWI. Are there critical periods for brain growth in children born preterm? Arch Dis Child: Fetal Neonatal Ed 2006; 91 (1): 17-20 6 Isaacs EB, Gadian DG, Sabatini S et al. The effect of early human diet on caudate volumes and IQ. Pediatr Res 2008; 63 (3): 308-14 7 Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ 1998; 317 (7171): 1481-87 8 Dabydeen L, Thomas JE, Aston TJ, Hartley H, Sinha SK, Eyre JA. High-energy and -protein diet increases brain and corticospinal tract growth in term and preterm infants after perinatal brain injury. Pediatrics 2008; 121 (1): 148-56 9 Tsang RC, Lucas A, Uauy R, Zlotkin S. Nutritional needs of the preterm infant: scientific basis and practical guidelines. Baltimore: 2006, Williams & Wilkins 10 Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Decsi T, Domellรถf M, Embleton ND, Fusch C, Genzel-Boroviczeny O, Goulet O, Kalhan SC, Kolacek S, Koletzko B, Lapillonne A, Mihatsch W, Moreno L, Neu J, Poindexter B, Puntis J, Putet G, Rigo J, Riskin A, Salle B, Sauer P, Shamir R, Szajewska H, Thureen P, Turck D, van Goudoever JB, Ziegler EE. Enteral Nutrition Supply for Preterm Infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee. (ESPGHAN). JPGN 2010; 50: 1-9 11 Koletzko B, Poindexter B, Uauy R. Nutritional Care of Preterm Infants. Scientific Basis and Practical Guidelines. Karger 2014. 12 Scientific Advisory Committee on Nutrition. Dietary Reference Values for Energy. SACN, London, 2011. 13 Brennan A, Fenton S, Murphy B, Kiely M. A Missing Link in the Nutrition Management of Preterm Infants. Journal of Parenteral and Enteral Nutrition. March 21, 2017. https://doi.org/10.1177/0148607116686289 Accessed 7th October 2017. 14 Singhal A, Cole TJ, Fewtrell M, Lucas A. Breast milk feeding and lipoprotein profile in adolescents born preterm follow-up of a prospective randomised study. Lancet 2004; 363: 1571-1578 Transition Phase Nutrition Recommendations 15 GOSH guideline: Nutrition: enteral nutrition for the preterm infant at www.gosh.nhs.uk/health-professionals/clinical-guidelines/ nutrition-enteral-nutrition-preterm-infant
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IN ASSOCIATION WITH THE NSPKU
Suzanne Ford NSPKU Dietitian for Adults Suzanne Ford is a Metabolic Dietitian working with Adults at North Bristol NHS Trust and also for the National Society of Phenylketonuria).
IMD WATCH
CASE STUDY: DIETETIC MANAGEMENT IN ORNITHINE TRANSCARBAMYLASE DEFICIENCY A 34-year-old female with an ornithine transcarbamylase deficiency planned to conceive. This article is an account of dietetic management before and during pregnancy and delivery. BACKGROUND This female patient is a carrier manifest of an X linked urea cycle disorder, ornithine transcarbamylase (OTC) deficiency. She is known to have c.217-1G>A mutation, which is a mutation associated with relatively little enzyme activity. The deficient enzyme places the individual at risk of hyperammonaemia which can lead to encephalopathy and death. Treatment of OTC deficiency is a safe protein diet (i.e. moderately low, with or without essential amino acids and micronutrient supplements), daily ammonia scavengers, an arginine supplement and, finally, glucose polymer emergency regimen to reduce the effects of catabolism.
For further reading and more information please email info@ networkhealth group.co.uk
This patient has a history of decompensations - critical care and heroic measures were needed; the last hospital admission was at age 33 years old and she is under sixmonthly follow-up with her metabolic team. The patient’s medications were: • Sodium benzoate 16g in divided doses orally; • L-Arginine 6g daily orally; • B12 3 monthly intramuscular injection; • Calcichew D3 forte orally; • Forceval once daily orally. Dietary management centred on a moderate protein restriction; it is possible that the patient was not consistently compliant; she had hospital admissions for management of hyperammonaemia at age 15, 26, and 33. Her use of emergency regime was approximately once per year due to intercurrent illnesses. In inborn errors of metabolism the best outcomes are with planned pregnancy, so, in 2010, the patient and her husband had genetic counselling. They went on to have pre-implantation genetic diagnosis (funding was obtained from clinical commissioners). The patient underwent an obstetric and gynaecological assessment including cyst removal, super-ovulation and egg harvest, then in vitro fertilisation followed by genetic diagnosis of foetus and implantation. This was done twice to no avail. Following this, there was a natural conception of an affected male and termination in April 2015. After the termination, another natural pregnancy occurred, this time found to be female. DIETARY MANAGEMENT PRECONCEPTION AND FIRST TRIMESTER 1. The patient changed from taking a standard multivitamin to pregnancy multivitamin/ mineral, including 400ug folic acid and also an omega-3 supplement (containing 200mg preformed docosohexanoic acid). 2. Frequent detailed dietary assessment based on a preconception weight of 54kg, with advice for an intake of 45g protein (0.83g/kg) and approximately 1,670kcals daily. 3. There was very strong encouragement to take an emergency regimen (of 25% glucose polymer solution every two hours) if experiencing nausea or vomiting, and to contact the metabolic team/seek admission to A & E if this did not work for more than eight hours.
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IMD WATCH 4. I reiterated standard recommendations for food safety advice in pregnancy. 5. At eight weeks into pregnancy, I asked the patient to: a) start taking daily essential amino acid supplement (providing additional 5g protein); b) eat every three hours whilst awake - gave list of 200kcal snacks; c) increase carbohydrate intake, and ensure she was eating carbohydrate more frequently - this was strongly linked to the snacks, but also to ensure that she d) have 200mls of her emergency regimen drink (25% glucose polymer) every night at bedtime (9pm); e) get a suitable anti-emetic from her GP - she was prescribed cyclizine which is known to be safe in pregnancy; f) use fatigue management strategies as fatigue was a significant feature at this stage. When regular carbohydrate is needed, dietetic assessment should always include sleep patterns and sleep duration. METABOLIC DECOMPENSATION IN THE FIRST TRIMESTER At 9/40 this patient was admitted to ICU with an ammonia of 300, she was encephalopathic and uncooperative so was sedated, intubated and fed via a nasogastric tube, along with having intravenous ammonia scavengers - benzoate with butyrate, plus intravenous dextrose for extra calories. The feed was 12 hours Nutrison only, as after this time the sedation was lifted, the patient vomited out her nasogastric tube and declined a second tube. She had oral nutrition support (Fortisips no more than four daily) for day two to four of her admission and went home on day five. At this stage, the effects of metabolic decompensation on her foetus were unknown. Careful questioning is vital after a decompensation, as part of understanding causative factors and preventing future events. In this case, the aetiology was a reduced intake secondary to nausea and also tiredness, latter exacerbated by having taken cyclizine (antihistamine anti-emetics with potential sedative side effect). Preceding the decompensation, there had been over 14 hours with no carbohydrate intake. DIETARY ADVICE SECOND TRIMESTER Protein intake kept at ~45g/day (0.83g/kg)
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DIETARY ADVICE THIRD TRIMESTER • Increased total protein intake at 28/40 by increasing dietary protein to 50g/day. • 32/40 - further increase to 60g total protein - 0.9g/kg/day. Growth scan at 28/40 - abdominal circumference, head circumference and femur length as well as foetal, weight were all on 50th centile; four-weekly repeat growth scans showed good interval growth and always remained close to the 50th centile. PLAN FOR LABOUR • Induction of labour likely on estimated date of delivery, i.e. at 40/40 if the patient had not delivered naturally by then. • 10% IV dextrose to start on admission with medications, plus oral glucose polymer solution, to provide external calories for the effort of labour. • Regular anti-emetics administered to avoid vomiting and also IV antibiotics and paracetamol given to mother to prevent or damp down any metabolic stress.
PERI-PARTUM DIETARY MANAGEMENT PLAN • 2,500kcal if possible during labour/post labour. • ‘Sliding scale’ SOS25/snacks to meet above. • 25-30g protein daily peri-partum. • Low protein/high carbohydrate snack and meal options previously discussed. • Ensure fully prepared - glucose polymer in her hospital bag; low protein foods on standby. BEFORE DISCHARGE AND POST DISCHARGE • IV dextrose continued until eating and drinking well and was replaced with oral glucose polymer drinks until day five to six. • Ammonia monitoring - this was done daily day one to seven post-delivery. • Six- to 12-hourly ammonia monitoring if any increase occurred (there was one small increase only). • Discharge home on was on day 10 (the discharge was complicated by the daughter’s OTC status looking positive and in fact this was confirmed via genetics subsequently - neonatal ammonia levels are difficult to interpret). • Follow-up was three times per week in first week post discharge, and twice weekly ammonia levels for one month postpartum - the involution of the uterus (a large release of endogenous collagen, i.e. protein into the blood stream) can occur anytime between one and eight weeks post-delivery. I can report that there were no subsequent metabolic decompensations since the one described here. Metabolic stability has been achieved for the time being for this patient
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Alice Fletcher Registered Dietitian, Countess of Chester NHS Foundation Trust Alice has been a Registered Dietitian for almost three years working within NHS Communitybased teams. She is passionate about evidencebased nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time. NutritionIn Wonderland.com
For full article references please email info@ networkhealth group.co.uk
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‘TEATOXING’: AN OVERVIEW OF AN EVER-GROWING DIET TREND Over the past three years, diets that promise to detox the body and promote rapid slimming effects following regular ingestion of specific tea, have become increasingly popular on social media. The regimen usually consists of two cups of tea per day, with a day and night-time blend, to be taken for 28 days. There are over 710,000 posts hash tagged as ‘teatox’ on Instagram. This craze shows no signs of stopping. Teatox products also appear in mainstream healthfood shops and have recently been advertised on television. They commonly have celebrity endorsements, mostly lesser known reality television personalities, with more well-known celebrities increasingly jumping on board, including Hilary Duff, Britney Spears, Demi Lovato and Kylie Jenner (and no, I’m not sure why Kylie Jenner is famous either!). Undoubtedly, these well-known women are being paid large sums of money to promote teatox brands, however, they are under no obligation to disclose this - and don’t. There are around 10 main companies with products available in the UK (click here to see Table 1). The advertising is slick and beautiful, with the majority featuring tall tanned immaculately preened young women holding the products with their heads cocked to one side, smiling at the camera. The marketing is clever and attractive. It makes you want to look like the models. All you need to do is fork out an extortionate sum for two teabags per day. The do-the-bare-minimum-and-berewarded mentality is reminiscent of diet pills or supplements such as raspberry ketones or aloe vera gel, only this time the take-home message is marketed behind
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a seemingly innocuous substance. The majority of people in the UK drink tea, it isn’t something you would instantly associate with the possibility of harm (except perhaps if it burns you!). WHAT ARE THESE PRODUCTS COMMONLY PROMISING?
• • • • •
Improve fat burning Reduce bloating Cleanse and detox the body Make the consumer feel ‘lighter’ All natural ingredients with no hidden chemicals
Weight loss is always alluded to but not always directly stated. Although the brands often include advice to eat healthy wholesome and nutritional food and exercise regularly, some claim to have the desired effects without the user changing their diet and lifestyle. Five of the six main companies I looked at in detail provided dietary information including meal plans to ‘improve results’. However, two of these were at an added cost (click here for Table 1). DETOX
I do not need to explain to anybody reading this article that ingestible products promising to ‘detox’ the consumer are unfounded. As we know, there are currently no foods or fluids
available that can ‘detox’, or, in other words, remove (unidentified) toxins from our bodies. The general public, however, are less aware of this and it is a term we are hearing being used more frequently (particularly in the month of January). WHO ARE TEATOX PRODUCTS AIMED AT?
From the extensive marketing within social media there is no doubt that teatox products are aimed at young women. From looking at the websites and social media platforms of the 10 companies discussed, six appear to be aimed purely towards women, three appear more gender neutral from their marketing style and products, one of the 10 sells a product specifically aimed at men. Skinny Teatoxes’ latest advertising campaign is titled ‘Back to school blowout’. Skinny Teatox also sell a ‘breast enhancing tea’ named ‘Bounce with me’. You read that right the first time. COST
The average cost for a 28-day programme of the companies mentioned in Table 1 is £35 (price range = £14-£41). Teatox products are commonly sold to be cheaper the more of them you purchase. This could be encouraging further usage. WHAT’S ACTUALLY IN THE PRODUCTS?
All the companies I looked into (Table 1) state the ingredients within their daytime and night-time blends on their websites, but some were easier to find than others. The ingredients are listed in order of volume, as with any food product, but the exact quantities of the ingredients are not stated for any products. Some companies provided me with more specific information upon request, others I did not hear back from. In total, three of the seven companies that I contacted for further information (mainly regarding senna content) did not respond (after 10 working days). Laxative ingredients Sennosides within senna leaf and pod extract acts as a stimulant laxative. This type of anthroquinone stimulant laxative acts by irritating the lining of the gastrointestinal tract, resulting in increased peristalsis, therefore, elimination of intestinal contents. The onset of action is between six to 12 hours following ingestion. Senna is effective in
the treatment of diagnosed constipation and for bowel evacuation prior to medical procedures.1-3 The advice within the British National Formulary states that the recommended dosage of senna for adults is 7.5-15mg daily (max per dose 30mg daily); the dose is usually taken at bedtime; the initial dose should be low then gradually increased; higher doses may be prescribed under medical supervision. It should not be taken consecutively for more than a week unless advised so by a doctor.3,4 Commonly, teatox products contain senna in their night-time blends. Of the 10 companies discussed in this article: • six presently sell products containing senna; • two have sold products containing senna in the past, but have now removed it; • two companies sell only products that do not presently and never have contained senna. How much laxative? Unlike liquid or tablet form medications containing senna leaf/pod extract that state the milligrams of senna contained within the product, it is very tricky to work this out for teatox products. When I asked Flat Tummy Tea for the amount of senna in milligrams contained within their tea, they stated that it contains 1g per teabag. I emailed the company for clarification regarding how that compares to over-the-counter senna tablets, but they could not provide any further help. Flat Tummy Tea do state the following on their website regarding their night-time tea: ‘Weaken or strengthen the effects by infusing it for less or more time.’ Could this trend be normalising the repeated regular use of laxatives? Taking stimulant laxatives such as senna for four weeks without a break, without clinical indication (for constipation or to prepare for a colonoscopy) could lead to: • serum electrolyte imbalances (mainly low sodium and potassium); • disruption to flora in the bowel; • long-term senna usage (in this case repeating the teatox regimen several times per year over a number of years) may lead to a lazy bowel and reliance on laxative agents for regular bowel movements; www.NHDmag.com November 2017 - Issue 129
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FOOD & DRINK • reduction in absorption of vitamins and minerals from the large intestine, resulting in nutritional deficiencies (particularly alongside a restrictive diet).5-7 Senna is not appropriate for those with a diagnosis of inflammatory bowel disease, this is not specifically advised on any of the 10 companies’ websites.3 Notably, senna is not recommended in conjunction with liquorice root preparations or diuretics.3 Liquorice root As stated above, liquorice root preparations are not recommended in conjunction with senna.3 Of the 10 companies discussed, two available in the UK contain both senna and liquorice root in one teabag. (Teatu, Flat Tummy Tea). Not all of the ingredients in Skinny Teatox are stated. Bootea used to contain liquorice root and senna prior to February 2017. I was unable to find any studies related to liquorice in tea form aside from one case report from the British Medical Journal where a 45-year-old woman presented to her general practitioner with hypertension and mild hypokalaemia. The patient had been drinking up to six cups of liquorice tea per day as a substitute for caffeinated tea and fruit-based infusions. When she stopped consuming the drink within two weeks her symptoms, hypertension and hypokalaemia had entirely resolved.8 Ingredients with diuretic properties Other herbal ingredients very commonly listed (click here for Table 1) include hawthorn, fennel, dandelion and nettle. These have all been found to act as herbal diuretics (increasing the excretion of urine from the body as well as the amount of sodium in urine) with variable potency. EATING DISORDERS AND LAXATIVE USE
Laxatives can lead to temporary weight loss by causing dehydration, especially if used alongside diuretics. Because of the quick and efficacious activity, stimulant laxatives such as senna, are most frequently abused to promote weight loss by increasing gastrointestinal transit time.5-7 40
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Surveys conducted by Beat (the UK’s leading eating disorders charity) has found that the use of laxatives as a weight loss aid is a significant problem, and that the use of them seems to be growing. Beat are campaigning for laxative products to be regulated and have age restrictions.9 IMPACTS UPON MEDICATIONS
There have been media reports of women not realising that these teatoxes may affect the efficacy of the contraceptive pill, with unplanned pregnancies resulting from this.10 Some companies have improved the visibility of any warnings about effectiveness of the contraceptive pill in response to this media coverage.11,12 From reviewing company websites, I found that of the six products that contain senna mentioned in Table 1, three (Flat Tummy Tea, Skinny Teatox and Skinny Me) state that possible reduced efficiency of the contraceptive pill may occur and recommend using extra protection. In contrast, Lyfe Tea and Teami do not state this; Teatu states, ‘We highly recommend that you consult with your doctor on this matter, as it is on a case-by-case basis’. This company also recommends the use of their product for at least three months. INCH LOSS, NOT WEIGHT LOSS
The companies discussed often appear to avoid stating that customers will ‘lose weight’ by taking their products, focusing more on having a flatter stomach and reduction in bloating when it comes to written communications. The copious before and after photos, however, are clearly insinuating that users are smaller following completion of the teatox programmes. The most alarming thing about the before and after photographs commonly used is that the women pictured are very rarely overweight to begin with. Many testimonials allude to feeling lighter after following the programmes. Any weight loss that is felt is likely to be secondary to fluid losses from a mixture of diuretic and laxative ingredients (if laxatives included). No fat mass will be lost unless there has been a significant calorific deficit.
The teatoxing companies are not marketing their products as a short-term one-off fix. They are encouraging customers to become part of the ‘journey’ or ‘movement’ SHOW ME THE EVIDENCE: CLINICAL TRIALS
I contacted six of the companies listed in detail within Table 1 for any clinical trials related to claims made regarding teatox products that they sell. Unfortunately, none of the companies directed me to a clinical trial of any of their products. RETURN CUSTOM
The teatoxing companies are not marketing their products as a short-term one-off fix. They are encouraging customers to become part of the ‘journey’ or ‘movement’ (no pun intended). For the 10 companies discussed, the advice around frequency and duration of the teatox programmes varies, for example, Teatu (containing senna) recommends use of their product each day for at least three months for best results. Other teatox programmes are recommended to last for generally 14 to 28 days. Consumers may find that they feel increasingly ‘sluggish’ or constipated when not using the products and, therefore, go back for more. STANDING UP AGAINST LAXATIVE MISUSE:
It took almost 29,000 signatures on a petition developed by Dr Lauretta Ihonor to remove senna root and leaf from some teatox products on the UK market.11,12 Bootea, Skinny Mint and Slendertoxtea have produced laxative-free versions for sale in the UK. Holland and Barrett held talks with Bootea and reached a decision to change the labelling on the packaging of original formula Bootea teatoxes to make the risks clearer and also outline that people under the age of 18 should not take it. Slendertoxtea, one of the UK’s popular teatox brands, was inspired by the petition and as a result decided to stop using senna in their teatoxes altogether. FINAL THOUGHTS
• Teatoxing, if laxative agents are not included within the ingredients, is unlikely to be highly
•
• •
•
•
damaging to users, however, the benefits of such a regimen are also not evidenced by any clinical trials, only positive customer testimonials. It may well be that people feel as though they can stick to a healthy balanced diet more easily if they have purchased a ‘teatox plan’, but there is not any clinical evidence to support this for the products discussed. It is difficult to calculate amounts of active ingredients consumed due to the nature of brewing tea. Repeated use of herbal tea containing unclear amounts of senna may cause harm, particularly alongside liquorice root preparations.3 The teatox trend may be normalising the repeated regular use of laxatives as a weight loss aid amongst young women. It must be noted that senna in tablet and liquid form can be purchased over the counter in many high street shops without a prescription, something Beat are campaigning against.9 The marketing of teatox products containing laxatives and diuretics towards young women who are a healthy weight is potentially dangerous.
All of the above information regarding the named teatox companies was accurate at the time of submitting this article (13/9/17) Teatox company websites: Bootea: www.bootea.com Flat Tummy Tea: https://flattummyco.com Lyfe Tea: https://lyfetea.com Skinny Me: www.skinnymetea.com.au Skinnymint: www.skinnymint.com Skinny Tea Co: https://skinnytea.co.uk Skinny Teatox: https://skinny-teatox.com Slendertoxtea: www.slendertoxtea.co.uk Teami: https://www.teamiblends.co.uk Teatu: www.teatuteatox.com
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YOUR ESSENTIAL RESOURCE
NUTRITION MANAGEMENT
SPORTS NUTRITION: CASE STUDY Claire Chaudhry Community NHS Dietitian/ Freelance Dietitian, BCUHB (NHS) and Private
In Claire’s 15 years of experience, she has worked in acute and community NHS settings. Claire has taught nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private. www.dietitian claire.com
For full article references please email info@ networkhealth group.co.uk
Protein requirements for athletes can usually be obtained through diet alone.1 Despite this, the protein supplements market has risen by 27% since 2014 and consumers in the UK spent £66 million on sports nutrition food and drink products in 2015.2 Many athletes believe that taking protein supplements will promote muscle building and enhance performance; however, the research evidence of using amino acid supplements and or protein supplements as an Ergogenic aid finds no clear benefits.3 In a BBC documentary, Journalist Rick Kelsey discusses the use of protein supplements with professors, athletes and suppliers. In the article, Professor Graeme Close from Liverpool John Moore’s University (LJMU), challenged a regular whey protein supplement
user to go without his supplement for six weeks. After the six weeks, the experiment revealed that the user had indeed built up his muscle by diet and activity alone, hence he didn’t require the protein supplements.4 The following dietary case study was a male client in 2016 who was also taking protein supplements: branch chain amino acids (BCAA) consisting of leucine, isoleucine and valine and also whey protein powder containing 21gm of protein per 25gm serving.
1 ASSESSMENT MALE, MARTIAL ARTIST - CLIENT B • Client B, male age 29, weight 91kg, height 186m • Multiple martial artist: - Brown belt Judo working towards black belt (trains once a week) - Brazilian Jujitsu working towards blue belt (trains twice a week) • Other regular activity: a weekly run, one to two hours of squash once a week, strength training at his gym four to five times a week up to an hour a time. Client B is a member of the BASC (British Association Shooting and Conservation),5 he shoots every fortnight and eats what he shoots. • Client B completed a food diary and consecutive physical activity level (PAL) diary for seven days in May 2016. PAL diary revealed that he averages one to three hours of intensive activity per day, divided into two sessions. In those seven days he had one day off training. • Client B was feeling tired after exercise and wanted to have a dietary analysis of his current dietary intake. Dietary aims of sports nutrition6 • Maintain sufficient dietary carbohydrate intake during training and competition: maintain energy balance and maintain muscle glycogen levels. • Maintain sufficient fluid intake, to maintain normal thermoregulatory function during exercise and prevent dehydration, which can reduce physical ability and increase fatigue.
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NUTRITION MANAGEMENT
Client B is a member of the BASC (British Association Shooting and Conservation),5 he shoots every fortnight and eats what he shoots. Photo: with thanks to Tom Sykes photography; wwwtomsykesphotography.co.uk
2 IDENTIFICATION OF NUTRITION AND DIETETIC DIAGNOSIS Client B’s diet summary Over the seven days, Client B’s diet was varied; protein sources were chicken and venison. A variety of dairy sources included cheese, yoghurt, full fat milk and a variety of carbohydrate sources from pasta, potatoes (white and sweet), with different breads and a high fibre breakfast cereal. He consumed no alcohol and no caffeine (apart from the odd chocolate bar). In the seven days no fish or fish products were consumed. His average daily fruit and vegetable portion intake was around three daily, mostly coming from steamed vegetables and salad. He also consumed branch chain amino acids (BCAA) 5gm (three out of seven days) and whey protein powder 25gm (five out of seven days) mixed with either water or milk (the whey protein, milk and water were added to Client B’s dietary intake. BCAA were not added). Using a nutritional analysis programme based on McCance and Widdowson,7 Client B’s average mean daily macronutrients and micronutrients were calculated and compared with his individual requirements. Kilocalories (kcal) - Mean intake of 3,335kcals daily which was within his estimated range of 3,151-4,464kcals.8 Protein - He consumed a mean average of 214gm* of protein daily (averaging 2.3gm per kg). His protein intake daily ranged from the lowest at 92gm (around 1gm per kg) to a maximum intake of 304gm (around 3.3gm per kg). This level was above his estimated calculated requirements of 109gm-154gm (1.2-1.7gm per kg per day).9 His mean average intake of protein provided 26% of his total kcals, when in fact it should be around 15%. As he is a regular shooter of venison and grouse, he is not limited with obtaining animal protein sources. The Manual of Dietetic Practice states that having more than 1.5gm per kg of protein daily may carry health risks, e.g. kidney disease and demineralisation of bone, thus high levels of protein intake should be avoided. *Note that the BCAA were not added. Carbohydrate - He consumed a mean average of 390gm of carbohydrate daily (averaging 4.2gm per kg). His carbohydrate intake ranged from the lowest at 267gm (around 2.9gm per kg) to a higher level of 512gm (around 5.6gm per kg). This level was below the recommendations of sports nutrition: between 50-70% of kcals should come from carbohydrate or 6-8gm per kg per day (546-728gm). His mean average intake of carbohydrates provided 44% of his total kcals. Client B’s diary also showed that there were regularly long gaps between eating, in particular after exercise ranging from three to six hours. Fat - Total mean average fat intake was 112gm which provided 30% of his total kcal intake. Out of the total fat intake, his mean saturated fat intake was 45gm (providing 14% of his total kcals), his trans fat was 2gm (providing 0.6% of total kcals). The average male should aim to have no more than 30g of saturated fat a day and trans fat consumption aiming for less than 2% of total kcal consumption.10 Client B’s diet showed that although his fat % was low at 30%, his saturated fat consumption was higher than the recommended intake for the general population. His trans fat consumption was lower than the recommendations. Fibre - 23gm of non-starch polysaccharide (NSP) and 25gm of Association of Official Analytical Chemists (AOAC) daily fibre consumed from Client B was meeting the daily recommendation from the SACN report 2015, 18gm-30gm daily.11
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Fluid - Client B’s mean fluid intake over seven days was 1,595mls coming from full fat milk and water. His lowest amount of daily fluid intake was 513mls, his highest was 1,857mls. Therefore, some days he was not meeting his fluid requirements, estimated using 8-35mls per kg from A Pocket Guide to Clinical Nutrition, or the recommendation of males, aiming for a minimum of 2,000mls a day.12 Vitamins and minerals - The average mean intake of his vitamins and minerals shown met his required DRVs - RNIs for Client B.13 A dietetic plan was devised to meet the dietetic aims and to suit his lifestyle.
Fig 1: Sports nutrition recommendations = % of 3 macronutrients from total Kcals.
Fig 2: Client Bs average % of macronutrients from total Kcals over 7 days
3 PLAN NUTRITION AND DIETETIC INTERVENTION Client B had an hour-long consultation and the following points were discussed: • Increase carbohydrates and increase the timings of food, in particular carbohydrate foods Client B was often leaving a gap of up to six hours of not eating despite having a high PAL. We discussed the addition of fruit smoothies as an extra snack during the day, which would also increase his fruit intake. Also advised to increase the portions of pasta, potatoes and rice with his meals. Encouraged to monitor weight weekly to ensure weight remains stable. • Fat intake, advised to reduce saturated fat (SFA) Client B’s natural yoghurt was not low fat and a large proportion of his saturated fat came from this, also hard cheese and full fat milk. Advised to change to low fat yoghurt and semi-skimmed milk and add in snacks high in monounsaturated fat, e.g. nuts. Meat choices of grouse and venison contain slightly less saturated fat per 100gm than chicken (SFA gm per 100gm; grouse is 0.8gm, venison is 0gm and chicken is 2.1gm). We also discussed how to look at food labels more clearly in relation to fats. • BCAA and whey protein not required Client B’s average protein intake with the whey protein added was too high, therefore he did not require any BCAA or the whey protein supplements. Portions of protein rich foods reiterated at mealtimes in relation to easing delayed onset muscle soreness (DOMS) around 15-25gm of protein within an hour after exercise can help with muscle recovery.14 The BCAA which he purchased contained various synthetic E numbers, in particular E110 (yellow), E129 (orange) and E133 (bright blue). Although these E numbers have been approved in foods in Europe in small amounts, there continues to be concern that children and adults can suffer from side effects from the stated E numbers, e.g. skin or rhinitis allergies and behaviour changes. However, there is currently not enough strong evidence to show this for everyone, some products do contain a warning on the label. Client B decided to stop the protein supplements. • Increase fluid intake Ideas provided to increase his fluid intake either through a homemade isotonic drink before, during and after intensive activity and or drinking more water/semi-skimmed milk. Fruit smoothies were also encouraged to increase fluid and carbohydrate intake. • Oral health As he was given dietary advice to increase his amount and frequency of carbohydrates and also the usage of isotonic drinks before during and after training, good oral health was actively encouraged.
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NUTRITION MANAGEMENT 4 IMPLEMENT NUTRITION AND DIETETIC INTERVENTION Discussed in the consultation: • Comparisons of dietary intake with recommendations. • Examples of Client B’s newly adapted meal plans. Extra literature was supplied, e.g. portion sizes, snack ideas, labelling information, isotonic recipe and BDA food facts – Fluids.15 5 MONITOR AND REVIEW Client B’s testimony: “After completing the seven-day diet diary, I underwent a consultation session with Claire to discuss the findings, confirm the good points of my diet and highlight areas for improvement. Although I had a reasonable understanding of the importance of protein in sport, carbohydrates and fuelling the body was something I was confused with. Claire was able to talk me through the process using simple scientific explanations and bringing them into context in terms of diet. Claire explained that although I had been consuming sufficient protein, I had been taking insufficient levels of carbohydrates on board, as well as leaving too much time between exercise and eating. “In the following two weeks after the consultation, I have been consuming slow releasing carbohydrates immediately after training or consuming one of my main meals. I have noticed a drop in post-workout fatigue and no longer feel the ‘lull’ in my activity levels which I once had and considered to be normal. Fat intake was also an issue with my diet. I was consuming too much fat from saturated sources and insufficient levels of good fats. Claire listed the many sources of mono-unsaturated fats and what amounts I should try to be consuming on a daily basis (which I now acquire mainly with nuts, seeds and olive oils). This awareness now allows me to analyse food labels more accurately and has allowed for a much healthier balanced diet. “Although I generally consumed sufficient amounts of vegetables, my diet did tend to lack fruit, mainly due to a dislike of texture with some fruits. Claire directed me to some ideas for fruit smoothies incorporating yoghurt and honey. Being full of taste and easier to consume in bottles, I am now consistently reaching my target of five items of fruit and vegetables each day. “Some diet changes can be difficult, others are incredibly easy. One easy example in my case was switching from full fat milk to semi-skimmed milk which allowed me to still obtain the benefits of this protein and calcium source with lower levels of fat than before. As the milk is consumed with breakfast cereal, I haven’t noticed a change in taste at all. “Finally, as well as changes in health, I have noticed small financial advantages to having my diet assessed. I previously purchased Branch Chain Amino Acid supplements to ensure that I was obtaining a sufficient amount of protein each day. Claire calculated that I was already obtaining enough in my diet and with the changes I was to incorporate with her guidance, I would not need any further supplements as the correct levels would come from my diet alone. Another handy financial saving was making my own isotonic drinks at home. Simple, cheap and easy to do, which I otherwise would never have known. “The changes I have made under this professional guidance are not only sensible and achievable, but since I now understand more of the science behind healthy diet plans, I feel more knowledgeable and in control than I have in the past.” 6 EVALUATION Email received June 2017 from Client B: “A year on, I’m feeling far better, as I’ve carried on and kept things consistent. The plan was easy to stick to. I feel I have more energy than I used to before; taking the appropriate carbs on at the right time and being more hydrated has definitely helped. In March, I competed for my Judo black belt and I passed, I had five fights and won all five. The final three fights were all in a row, one straight after the other with no break; this shows how things have improved.”
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CONDITIONS & DISORDERS
DIETS FOR IBS: BEYOND LOW FODMAP Alex Gazzola Freelance writer, Editor and Author Alex is a UKbased freelance writer specialising in food allergy and intolerance, coeliac disease, gut health, freefrom food, IBS and digestive disorders. He also writes on skin/cosmetic allergies. www. alexgazzola.co.uk
IBS: Dietary advice to calm your gut by Alex Gazzola and Julie Thompson RD, is out this month. The book highlights that, with a good understanding of IBS and careful management, much can be done to bring the condition under control. In his article for NHD, Alex offers advice on low FODMAPs. Like anyone else, IBS patients to some degree must navigate a swirling world of nutritional advice coming at them from assorted, often suspect sources, and characterised by dubious terminology: ‘superfood’, ‘clean eating’, ‘detox’, and the rest. No matter how much dietitians emphasise the importance of following the evidence base, many people remain vulnerable to the alluring promise of glowing health and wellbeing - and often a so-called ‘clean’ bowel - typically associated with faddish and purifying regimens. Specialist gastro dietitian Julie Thompson and I wrote our new book, IBS: Dietary advice to calm your gut (Sheldon Press, £9.99), as a realistic, achievable and supportive guide to eating well and reducing symptoms. Neither of us wanted to come across as the diet police, but we felt it essential to warn readers that so-called clean eating and detox diets aren’t friends to anyone, let alone those with IBS. Although the backlash against them is now in full flow, spearheaded by ‘Angry Chef’ Anthony Warner and a social media-savvy squad of dietitians and anti-faddists, we’re likely to be dealing with the after-effects of the phenomenon for some years. Some of the typical foods given evangelical prominence in these regimens - avocados and coconut water, for instance - are high-FODMAP and may well trigger symptoms; as is date
syrup, touted as a ‘sugar free’ alternative, when it is anything but. Purportedly ‘cleansing’ aloe vera, discouraged in NICE guidelines for IBS, can trigger the abdominal cramps and diarrhoea from which patients are often looking to escape. And any plan which stipulates the unnecessary adherence to only raw or home-prepared food may result in the omission of ‘processed’ foods that are nutritious, tasty and gut-kind too. This is particularly true for those already following other dietary restrictions - be they due to palatability, for moral, ethical or religious reasons, or because of food hypersensitivities such as coeliac disease or food allergy - which aren’t widely addressed in the context of FODMAP-restricted plans. Finding FODMAP friendly products isn’t always easy, but there are promising signs to suggest this situation may improve. New certification programs - namely the FODMAP Friendly program, and Monash University’s Low FODMAP Certified™ program - offer distinctive logos which, if they become popular, will assist the identification of suitable foods. The launches of a few dedicated low FODMAP brands and start-ups are also www.NHDmag.com November 2017 - Issue 129
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CONDITIONS & DISORDERS
14 Allergens The way allergens are labelled on prepacked foods has changed. The Food Information Regulation, which came into force in December 2014, introduced a requirement that food businesses must provide information about the allergenic ingredients used in any food they sell or provide. There are 14 major allergens which need to be mentioned (either on a label or through provided information such as menus) when they are used as ingredients in a food. Here are the allergens, and some examples of where they can be found:
1
Celery This includes celery stalks, leaves, seeds and the root called celeriac. You can find celery in celery salt, salads, some meat products, soups and stock cubes.
2
Cereals containing gluten Wheat (such as spelt and Khorasan wheat/Kamut), rye, barley and oats is often found in foods containing flour, such as some types of baking powder, batter, breadcrumbs, bread, cakes, couscous, meat products, pasta, pastry, sauces, soups and fried foods which are dusted with flour.
3
EU labelling regulations names 14 food allergens, which account for 90%+ of food allergies in Europe . . . .
Crustaceans Crabs, lobster, prawns and scampi are crustaceans. Shrimp paste, often used in Thai and south-east Asian curries or salads, is an ingredient to look out for.
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Eggs Eggs are often found in cakes, some meat products, mayonnaise, mousses, pasta, quiche, sauces and pastries or foods brushed or glazed with egg.
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Fish You will find this in some fish sauces, pizzas, relishes, salad dressings, stock cubes and Worcestershire sauce.
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Lupin Yes, lupin is a flower, but it’s also found in flour! Lupin flour and seeds can be used in some types of bread, pastries and even in pasta.
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Milk Milk is a common ingredient in butter, cheese, cream, milk powders and yoghurt. It can also be found in foods brushed or glazed with milk, and in powdered soups and sauces.
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Molluscs These include mussels, land snails, squid and whelks, but can also be commonly found in oyster sauce or as an ingredient in fish stews
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MUSTARD
Mustard Liquid mustard, mustard powder and mustard seeds fall into this category. This ingredient can also be found in breads, curries, marinades, meat products, salad dressings, sauces and soups.
Nuts Not to be mistaken with peanuts (which are actually a legume and grow underground), this ingredient refers to nuts which grow on trees, like cashew nuts, almonds and hazelnuts. You can find nuts in breads, biscuits, crackers, desserts, nut powders (often used in Asian curries), stir-fried dishes, ice cream, marzipan (almond paste), nut oils and sauces.
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Many products are naturally free of the 14, but carry ‘may contain traces’ warnings – the bane of food allergy sufferers.
Peanuts Peanuts are actually a legume and grow underground, which is why it’s sometimes called a groundnut. Peanuts are often used as an ingredient in biscuits, cakes, curries, desserts, sauces (such as satay sauce), as well as in groundnut oil and peanut flour.
to be welcomed, although many remain small enterprises: Foddies, SOME 14 Foods and Fodmapped in Australia, Trueself and Fody Foods in the US, and Lauren Loves, Slightly Different Foods and Fodify Foods in the UK - the last of which being the brainchild of two dietitians, Janet Hopkins and Hannah Hunter. But for now, until all these become more mainstream, those with multiple restrictions can still find it a challenge to find suitable, palatable and nutritionally adequate foods. Although our book considers many diets, here are some pointers for just a few.
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Sesame seeds
These seeds can often be found in bread (sprinkled on hamburger buns for example), breadsticks, houmous, sesame oil and tahini. They are sometimes toasted and used in salads.
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Soya
Often found in bean curd, edamame beans, miso paste, textured soya protein, soya flour or tofu, soya is a staple ingredient in oriental food. It can also be found in desserts, ice cream, meat products, sauces and vegetarian products.
Sulphur dioxide (sometimes known as sulphites)
This is an ingredient often used in dried fruit such as raisins, dried apricots and prunes. You might also find it in meat products, soft drinks, vegetables as well as in wine and beer. If you have asthma, you have a higher risk of developing a reaction to sulphur dioxide.
Beer
For more information, visit: food.gov.uk/allergy or nhs.uk/conditions/allergies
Sign up to our allergy alerts on food.gov.uk/allergy-alerts, or follow #AllergyAlert on Twitter and Facebook Let’s keep connected at food.gov.uk/facebook Join our conversation @foodgov
The same goes for vegan yoghurt alternatives, but a small pot of plain soya yoghurt (or flavoured with low FODMAP fruits) is usually fine.
Watch us on food.gov.uk/youtube
DAIRY-FREE/VEGAN
Lactose-reduced animal milks are off the menu for those following milk-free diets, be it for ethical reasons or food allergy. Although there are lots of plant-based milk alternatives, not all are suitable for all diets. Check ingredients for high FODMAP apple juice and recommend a calcium-fortified option if applicable. Be aware that Provamel Soya Natural calcium-fortified contains apple juice, though. Alpro Almond Unsweetened Fresh, Hazelnut Original and Coconut Original are three that we recommend in the book. Oatly Oat Drink (fortified) and Provitamil Oat Milk are safe options but neither is gluten free; Rude Health Oat Milk, which is gluten free, is not calcium fortified. Vegan cheese alternatives are not always low FODMAP. Check for onion and garlic flavourings and all sources of added vegetable fibres. Bute Island’s Sheese products are typically a safe bet. 48
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LOW-ALLERGEN/‘14 FREE’
Those with IgE-mediated allergies to a number of foods have an unenviable task in trying to source safe FODMAP friendly products. EU labelling regulations names 14 food allergens, which account for 90%+ of food allergies in Europe, and which must always be emphasised on food ingredient labels. Many products are naturally free of the 14, but carry ‘may contain traces’ warnings – the bane of food allergy sufferers. Increasingly, brands are making a virtue of any ‘14 allergens free’ status, and the following should be safe for low FODMAP diets: • Rizopia organic brown rice pasta • Bfree gluten-free breads, wraps and rolls (oats used in some products) • Dove’s Farm Gluten Free flours, pastas and biscuits • Venice Bakery UK’s plain free-from and vegan pizza bases (the seasoned varieties contain garlic powder) • Just Gluten Free Bakery – rolls and sliced breads • Good Hemp Milk Unsweetened • Functional Food Company’s IBsnacks A regularly updated list of ‘14 free’ brands can be found on my site, Allergy Insight, here: www.allergy-insight.com/free-from-food/14allergens-free. Do bear in mind that not all products from all brands will be suited to a FODMAP-restricted plan.
The Low FODMAP Diet App from Food Maestro . . . gives details of suitable and unsuitable foods. Their general Food App is free and is useful for those on restricted diets (allergies, intolerances) to help them validate safe products. JEWISH KOSHER
Following religious restrictions and specific diets for food intolerances can be a challenge. Kosher rules are complex and are not just a matter of eating foods approved via the Beth Din. The status of products can change depending on manufacturers’ use of ingredients, so advice is to check regularly. Email, text alerts and telephone information is available from the Kashrut London Beth Din (KLBD). Their site states the pareve status of foods: www.kosher.org.uk/koshersearch. The Manchester Beth Din site is also useful: www. mbd.org.uk/site/kosher-products. The website www.isitkosher.uk may also be helpful. Suitable low FODMAP products which are Kosher certified include the following: • Barkat gluten/wheat-free matzo crackers; some supermarkets stock a brand called Yehuda, imported from Israel, and made with potato and tapioca. • Yarden Aubergine and Mayonnaise • Mr Freed’s Tuna Salad and Coleslaw are gluten free and dairy free • Eskal brand is kosher certified - they have gluten-free pretzels and other baked goods • Schwartz Cheddar, Sol Edam slices, The Milk Company Original Mozzarella Rolled
(these are Chalav Yisreal supervised milk products) • Kellogg’s Cornflakes and Rice Krispies (neither is gluten free) and Kallo Puffed Rice The KLBD’s Really Jewish Food Guide has a good selection of free-from products suitable for the low FODMAP diet. Note that supervised kosher milk is not likely to be lactose free. Lactose drops are a possibility, however, note that the drops are not explicitly approved. The local Beth Din or Rabbi can offer advice. ONLINE /PHONE SEARCHES
The Low FODMAP Diet App from Food Maestro (www.foodmaestro.me) costs £3.99 and gives details of suitable and unsuitable foods. Their general Food App is free and is useful for those on restricted diets (allergies, intolerances) to help them validate safe products. One way of finding products online is to use search functions and filters, eg, gluten free and Kosher can be selected on Ocado, but there are filters for Halal, vegan and other all allergens too. Sadly, low FODMAP filtering options don’t seem to be available yet for supermarkets, but surely it’s only a matter of time . . .
WE HAVE FIVE COPIES OF IBS: Dietary Advice to Calm Your Gut by Alex Gazzola and Julie Thompson to give away in an NHD FREE prize draw. The book, published by Sheldon Press, examines diets for IBS, such as gluten free, dairy free and carbohydrate-aware (low FODMAP). It also explains why some popular diets and detox regimes may not be helpful, and looks at how lifestyle factors can affect IBS. For your chance to win a copy, please email us at info@networkhealthgroup.co.uk stating that you want to be included in the IBS Dietary Advice NHD book giveaway. Closing date for entries is Monday 4th December 2017.
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FOOD & DRINK
THE ANGRY CHEF: BAD SCIENCE AND THE TRUTH ABOUT HEALTHY EATING Review by Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
AUTHOR: ANTHONY WARNER PUBLISHER: ONE WORLD BOOKS; 2017 ISBN: 978-1786072160 (PAPERBACK) PRICE: £12.99
Mr Warner, aka Angry Chef, is a blogger. Like, it seems, most chefs, he enjoys sweary words; words which in print have a first and last letter and lots of ***s in the middle. Unlike, probably, most chefs, he studied biochemistry at university and really loves the language and methods of science. His occasional exposure to the fluffy thoughts of beautiful young things on social media platforms make him very angry, and his blogs are full of volcanic outrage at the muddled lifestyle claims advocating dietary purity with coconuts or avocados. He has lots of dietitian ‘likes’ on his posts, and obviously the time came when a publisher spotted the opportunity to elevate the impermanent blur of blogs, into the solid materialism of a book. Mr Warner gallops through a few of the dietary claims that have excited public attention in the past few years: detoxing, alkaline ashing, or going paleo, to more threatening and earnest dietary deviances such as GAPS or cancer ‘curing’ diets. There is method in the madness, in that all of these diets have small chunks of valid science within their claims. However, advocates massively distort and misunderstand details and come to silly or dangerous conclusions. It is the task of dietitians to provide constant, consistent, clear clarification and correction (the 5Cs of dietetics?). But for Mr Warner, this is not enough: he shrieks explosive and expletive filled fury, and perhaps this is also a correct response?
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There are many excellent chapters. But first some gentle critique. The blogs are tight and punchy; the book contains much verbal padding; perhaps the attempts to achieve certain word counts to fill pages? Also, there is attempted humour in the form of imaginary backand-forth dialogue with the pseudonym friend, Mr Science Columbo. I was not amused. A red editorial pen should have been used with more vigour. Chapter 14 on Relative Risk is excellent. The vital difference in absolute and relative risks must be familiar to all dietitians and yet it is the basis for alarming daily headlines on food and health risk. Large jumps from a small baseline attract public concern, whereas small increases from higher base figures pass unnoticed, although the latter result in larger absolute numbers affected by a condition. We all know this and yet we are always caught out. Mr Warner discusses a study reporting associations between greater intakes of bacon and the 18% greater chance of developing bowel cancer (compared to non-eaters of bacon). He slices and presents the data in different ways and in one chart, the chance of avoiding bowel cancer comparing eating lots of delicious bacon every day with a bleak-life-without,
Chapter 14 on Relative Risk is excellent. The vital difference in absolute and relative risks must be familiar to all dietitians and yet it is the basis for alarming daily headlines on food and health risk. appears nearly identical. Mr Warner does a grand defence of the odd bacon sandwich on a Sunday morning, and the consensus view is that risks from nitrates are smaller than risks from Clostridium botulinum. But his finding weakness in the bowel cancer-bacon data opens doors to general critiques of all cancer-food associations and may lead to unhelpful conclusions that diet-does-not-matter. Probably not what Mr Warner intended. Chapter 18 on Cancer is also excellent. He explains origins of dubious Gerson and Kelley therapies and describes the currently popular low carbohydrate diets for cancer, such as those promoted by Xandria Williams. Shifts in cancer cell metabolism from oxidative phosphorylation to glycolysis were first described by Otto Warburg in 1924. But these changes may be metabolic adaptions caused by rapid cell growth, and the faster uptake of glucose by cancer cells does not allow conclusions that limiting dietary carbohydrates inhibits their growth. Mr Warner describes some ‘false hope’ cases and concludes that carrot juice and enemas have yet to prove themselves as better than doing nothing. The final three chapters of the book consider countering the constant stream of misinformation about diet and health. But if you are an academic nutritionist, put on some body armour now: ‘Your reductionist experiments do little to shape the narrative when it comes to making decision about food: your arrogance and susceptibility to bias;
your inability to provide a consistent voice, confusing the public by creating needlessly sensationalist headlines that overstate the importance of your work.’ Ouch! In conclusion, the Angry Chef hopes that the reader is now immune to the charms of easy narrative and false hopes, and is left full of uncertainty and doubt (over diet and health claims). His guide to eating well is familiar and Pollan-esque, but just the kind of vague blitheness that many people find frustrating: “Eat different stuff, not too much, not too little, balance it and enjoy it. And eat some fish.” Is this really all there is to say about diet and health? And in future, people will still be asking dietitians and anyone else with a view, “What is healthier? Pumpkinseed oil or linseed oil?” Where experts hesitate, beautiful young bloggers will continue to give loud and certain answers to these questions (and sell the book). Appendix two of the book has the title The Angry Chef’s simple guide to whom we should believe in the world of food. Top of the list are dietitians; they are all dedicated, professional and intelligent and give the best evidence-based information available (but there are not enough of them.). Registered nutritionists are also praised. In contrast, there are Warner-warnings about nutritionists and therapists. This book is intended for the diet-interested general reader. But, of course, dietitians will enjoy the barbs lanced at self-proclaimed nutrition gurus.
We have five copies of The Angry Chef by Anthony Warner to give away in our FREE NHD prize Draw. For your chance to win a copy, email us at info@networkhealthgroup.co.uk stating that you want to be included in the Angry Chef NHD book giveaway. Closing date for entries is Monday 4th December 2017. www.NHDmag.com November 2017 - Issue 129
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PUBLIC HEALTH
UPDATE ON HEALTH CLAIMS Michèle Sadler RNutr Rank Nutrition Ltd 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.
Under the Nutrition and Health Claims Regulation,1 266 health claims have been approved to date for use in the EU. These include 12 claims for children’s development and health, 14 reduction of disease risk claims, five claims based on proprietary data and 235 general function claims of which six are based on newly developed scientific evidence. However, since the early days of the Regulation, the number of applications has fallen considerably, reflecting the high costs of undertaking new studies and uncertainty of the outcome of health claim applications. Negative EFSA opinions far outweigh positive opinions and, in extreme cases, it has taken four to five years to authorise claims, highlighting the unpredictability of the process.2 REFIT
In view of the high level of criticism levelled at the Regulation,1 certain aspects are currently subject to a REFIT (regulatory fitness and performance) evaluation in the EU, which began in October 2015. REFIT is a rolling programme in which EU Regulations are reviewed to ensure they are ‘fit for purpose’. The particular aspects under review are botanical claims and nutrient profiles. Botanical claims The assessment of over 2,000 general function claims for botanical substances remains on hold in order to decide what approach to take. The REFIT evaluation will examine whether the current rules are adequate and how the assessment of botanical claims interacts with the regulatory framework on plants and their preparations. There are currently conflicting approaches whereby clinical studies are required in the Nutrition and Health Claims Regulation, which assesses foods, and the legal acceptance in other Regulations of ‘traditional’ use 52
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evidence for therapeutic indications in medicinal products. This inconsistency needs to be addressed in order to resolve the current situation. The evaluation may extend to further regulatory issues, such as safety requirements. Nutrient profiles As provided for in the Regulation,1 nutrient profiles were due to be set by January 2009. In general terms, these would restrict claims on foods that are not in line with dietary recommendations. If a food fails on one of the criteria, a nutrition claim can still be made provided it is accompanied by a statement ‘High [xx nutrient] content’. However, there is no such derogation for health claims and a food failing on any of the criteria cannot bear a health claim. EFSA published guidance on how setting the profiles might be approached.3 However, because of the complexities involved, no agreement was reached and over eight years since they were due, nutrient profiles have still not been set. The European Parliament has even voted for their elimination. However, consumer organisations, a number of multinational companies and various health bodies remain in favour of setting profiles. The aims of the REFIT evaluation are to consider whether or not nutrient profiles are justified and whether the provisions in the Nutrition and Health Claims Regulation1 are sufficient. The results of the evaluation exercise are due in early 2018 and the action plan and final report are expected in 2019.
CONTROVERSIAL CLAIMS
Despite the lack of nutrient profiles, a number of claims have recently not been authorised because they could be misleading to consumers regarding advice to reduce sugar intakes. These include five claims for glucose and energyyielding metabolism that were given a positive opinion by EFSA but were refused authorisation. Additionally, four claims for caffeine were vetoed by the European Parliament because of concerns about the high sugar content of energy drinks that would be likely to carry such claims. These claims now remain on hold. Hence, despite the absence of nutrient profiles, it seems that other means are being used to restrict claims on foods that are not in line with dietary recommendations. CHILDREN’S CLAIMS
In addition to the 12 children’s development and health claims that have been authorised to date, positive EFSA opinions have been issued for 25 or so proposed claims for micronutrients and omega-3 fatty acids targeted at infants and children up to three years of age. Authorisation for these claims is complicated by EFSA’s proposed conditions of use which refer in part to the compositional criteria for regulated food categories that now fall within the Foods for Specific Groups Regulation.4 Hence, authorisation of claims for mandatory nutrients in regulated products, i.e. infant and followon formulae5 and processed cereal-based food and baby food, is being considered in parallel with implementation of the Foods for Specific Groups Regulation,4 particularly in relation to compositional requirements. For normal foodstuffs intended for infants and young children, EFSA’s proposed conditions of use are at least 15% of the reference values for nutrition labelling. However, the nutrient reference values (NRVs), or reference intakes (RIs) for vitamins and minerals, are based on adult requirements. Whilst the need to set NRVs and RIs for young children has been discussed recently, nothing has yet been proposed. Adding to these dilemmas, from 2020/21 all claims will be prohibited on infant formula products, and hence it has been questioned whether health claims should be allowed
on regulated and non-regulated products (supplements and young child formulae) for infants and young children. The Commission has consulted on these issues and the outcome is awaited. VERY LOW CALORIE DIETS (VLCDS)
Regulation of VLCDs within the Foods for Specific Groups Regulation,4 does not allow for health claims on such products and hence the proposed health claim for ‘reduction in body weight’ which is currently on-hold, is due to be refused authorisation. CLAIMS IN COMMUNICATIONS TO HEALTHCARE PROFESSIONALS
A further development relates to a German court case, requesting clarification about the applicability of the Nutrition and Health Claims Regulation1 to business communications targeted at healthcare professionals. The Advocate General concluded that the Regulation should apply to such communications, the key issue being whether the foods per se are intended for the final consumer, and not the communication. This opinion is not binding on the courts, but is influential in any judgements and is, therefore, of concern since it differs from our interpretation in the UK. SAFETY CONCERNS
A further issue relates to safety concerns that have been raised about particular substances that are the subject of claims or proposed claims. There is provision to assess their safety under the Addition of Vitamins and Minerals and of Certain Other Substances to Foods Regulation.6 Article 8 of this Regulation sets out a process whereby a substance of potential concern can be placed in one of three categories: Part A - prohibited, Part B - with specified conditions, or Part C - under scrutiny for four years. If a substance is listed in Part C there is an 18-month period to submit safety information and a nine-month period for EFSA to give its opinion. A proposed claim for hydroxyanthracene derivatives and improvement of bowel function has been awarded a positive EFSA opinion. However, Member States raised concerns about its safety and under the Article 8 procedure and www.NHDmag.com November 2017 - Issue 129
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PUBLIC HEALTH
. . . the number of applications has fallen with fewer claims being put forward for assessment. In the future, the impact of Brexit could result in divergence of how nutrition and health claims are regulated between the UK and the EU . . . EFSA has been requested to assess available information on its safety. EFSA has also been asked for a scientific opinion on the safety of monacolins in red yeast rice under the same procedure. This substance already has an authorised claim. The safety concern relates to the possible presence of citrinin, a nephrotoxic mycotoxin, in red yeast rice. EFSA’s opinion is due to be published in 2018.
made, to date no terms have yet been approved. One possibility initially considered was the term ‘probiotic’, but the Commission is standing by its initial view that ‘probiotic’ is a health claim. It is, therefore, unlikely that the term will be given generic descriptor status and it will most probably not be able to be used on labels again until the evidence merits an authorised health claim.
GENERIC DESCRIPTORS
CONCLUSIONS
Article 1.4 of the Nutrition and Health Claims Regulation1 makes provision for the use of generic descriptors, (defined as, ‘denominations which have traditionally been used to indicate a particularity of a class of foods or beverages’) that could imply an effect on human health - e.g. tonic water, digestive biscuit, cough drop, etc. Article 1.4 allows a derogation that such terms can be used without having to be accompanied by a related nutrition or health claim. Generic descriptors potentially cover terms perceived as nutrition claims as well as health claims. Application rules for generic-descriptor status were published in September 2013. Though a number of applications have been
Over 10 years since the Nutrition and Health Claims Regulation was published, a number of provisions in the Regulation are still not in place. Parts of the Regulation are currently subject to evaluation, which, in the case of nutrient profiles, will determine whether or not they are implemented at all and in the case of botanical claims, will determine how these are to be assessed. Meanwhile, the number of applications has fallen with fewer claims being put forward for assessment. In the future, the impact of Brexit could result in divergence of how nutrition and health claims are regulated between the UK and the EU and this will be discussed more fully in next month’s issue.
References 1. EU, 2006. Regulation (EC) No 1924/2006 of the European Parliament and of the Council of 20 December 2006 on nutrition and health claims made on foods. Official Journal of the European Union 30.12.2006, L 404 2. Sadler M. European Health Claims: Regulatory Developments. In Foods, Nutrients and Food Ingredients with Authorised EU Health Claims, Volume 3. Ed. MJ Sadler. Woodhead Publishing, 2017, Chapter 1 3. EFSA 2008. Panel on Dietetic Products, Nutrition and Allergies (NDA). The setting of nutrient profiles for foods bearing nutrition and health claims pursuant to Article 4 of the Regulation (EC) No 1924/2006. EFSA Journal 2008; 644:1-44 4. EU, 2013. Regulation (EU) No 609/2013 of the European Parliament and of the Council of 12 June 2013 on food intended for infants and young children, food for special medical purposes, and total diet replacement for weight control and repealing Council Directive 92/52/EEC, Commission Directives 96/8/EC, 1999/21/EC, 2006/125/EC and 2006/141/EC, Directive 2009/39/EC of the European Parliament and of the Council and Commission Regulations (EC) No 41/2009 and (EC) No 953/2009. Official Journal of the European Union 26.6.2013, L181/35 5. EU, 2016. Commission Delegated Regulation (EU) 2016/127 of 25 September 2015 supplementing Regulation (EU) No 609/2013 of the European Parliament and of the Council as regards the specific compositional and information requirements for infant formula and follow-on formula and as regards requirements on information relating to infant and young child feeding. Official Journal of the European Union 2.2.2016, L25/1 6. EU, 2006. Regulation (EC) No 1925/2006 on the addition of vitamins and minerals and of certain other substances to foods. Official Journal of the European Union, 20 December 2006
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DATES FOR YOUR DIARY
dieteticJOBS
Coming up soon . . . THE ROYAL MARSDEN NHS FOUNDATION TRUST - LONDON Nutrition and Cancer: what patients want to know 22 January 2018
A study day for dietitians, nurses, doctors and other healthcare professionals working with cancer patients. The event will aim to look at popular areas of nutrition and cancer and untangle the myths from the evidence. For further details please visit www.royalmarsden.nhs.uk/Nutritionjan or contact the Conference Team on 020 7808 2924, email: conferenceteam@rmh.nhs.uk. Public Health Nutrition Policy University of Nottingham: School of Biosciences 21st November Email: Katherine.lawson@nottingham.ac.uk www.nottingham.ac.uk/biosciences Food Matters Live 21st to 23rd November ExCeL London www.foodmatterslive.com/ Next steps for policy on high fat, sugar and salt foods - regulation, innovation and marketing 12th December www.westminsterforumprojects.co.uk/conference/ HFSS-policy-2018/29228 Gastroenterology (D24GE1) University of Nottingham: School of Biosciences 12th to 13th December Email: Katherine.lawson@nottingham.ac.uk www.nottingham.ac.uk/biosciences
dieteticJOBS.co.uk
FULL TIME DIETITIAN - LOUISE PARKER - LONDON Exciting opportunity for a full-time Dietitian to join London's fastest growing weight loss company. Louise Parker is seeking an outgoing and entrepreneurial Dietitian to join our vibrant team on a full-time basis and continue to provide outstanding service to our clients. The successful candidate will have a passion for health and wellbeing and will enjoy supporting our clients as they transform their lifestyles. You will be service focused and be determined to provide world-class nutrition and lifestyle advice to over 100 clients at any point in time. You will support clients in person consultations, by email and telephone, making outstanding communication and motivational skills essential to the role. Your primary role will be to provide outstanding dietary advice to our client base, support them to achieve extraordinary results and increase client retention. However you will also be expected to further develop the existing advice we give to clients and improving the processes, documents and materials that accompany our programmes. We are offering competitive remuneration commensurate with experience. The role is based from our consultation rooms in Knightsbridge. Please send your CV and covering letter to recruit@louiseparker.uk.com. Closing Date: 1st December 2017
More events on our website here . . .
To place a job ad here and on www.dieteticJOBS.co.uk please call 01342 824073
dieteticJOBS.co.uk • Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements
To place an ad or discuss your requirements please call (local rate)
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NUTRITION AND NUMBERS Sarah Howe Specialist Dietitian Sarah is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults. In her spare time she enjoys helping her work colleague and good friend, Louise Robertson run her blog 'Dietitian's Life'. She also loves fitness and spending time with her two girls. www. dietitianslife.com
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Social media. It really can be a wonderful thing. Since I joined Facebook over 10 years ago, I have watched it evolve, with the introduction of other platforms such as Twitter and Instagram. Like most new concepts, there is that initial fear of getting involved. It can be quite scary to put your life, your thoughts, yourself and even your expertise onto a virtual platform. However, more and more healthcare professionals, including many dietitians are embracing it. Twitter boomed with tweets to support Dietitians Week, which this year, surrounded evidence-based practice. Using social media definitely has its positives for dietitians. It is fabulous for creating a community and raising awareness to the general public about our roles and work ethic. It is also brilliant for sharing information, for following an event when you cannot attend and for general networking. As dietitians, we have a code of conduct to follow, which includes being professional at all times; ensuring anything we are sharing with our professional hat on, is evidence based. However, often what we are sharing isn't trendy and exciting. We talk about sustainable healthy eating and weight loss. Dietitians are very unlikely to post pictures of themselves in bikinis, drooling over a shake that has not only made us lose 10lbs of fat, but also tone and build muscle. It is rare to find a dietitian spouting their experiences on eating a raw food diet or surviving solely on honey, with jaw dropping health results. Why? Because such fads are not evidence based and are potentially dangerous. We are regulated and we want to teach the general population to #trustadietitian and banish the many myths all over social media. Our social media numbers may not be huge. Our followers may not be
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massive and we may not go viral. This isn't necessarily a problem until other ‘nutritional experts’ start to take over social media. These so called experts can post one sensational diet-related story that attracts the masses, which can equate to hundreds of thousands of followers. They are more than often not qualified and tend to go on a sample size of one - themselves and their experience with a certain diet. If someone promises you that cutting out a food group will result in fast weight loss and feeling amazing vs slow and steady loss with the dietitian, who are you going to follow? Who will get your ‘Facebook like’? Not hard to guess really. That diet may result in weight loss, but is it safe, sustainable and does it address any mental health issues going on under the surface for an obese individual? No. But the likes and follows gain in numbers and the ‘diet expert’ gains momentum, may go viral and suddenly has an article in a popular newspaper. For a long time, these ‘false experts’ were the people being quoted in the news. However, it is getting better, with more registered dietitians speaking the truth and educating the general public on evidence-based nutrition. This needs to increase! If something seems too easy in life, it usually is, with weight loss fads included. Most things take hard work and motivation. There is no magic pill. Dietitians need to keep tweeting, keep blogging and keep reaching for that evidence-based viral post to attract the masses. Our voices are the ones that need to be heard and followed. Sarah
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EXTRA
Additional articles for subscribers only
NHDmag.com
November 2017: Issue 129
FOCUS ON FOOD ALLERGY: SMARTPHONE APP SURVEY by Carina Venter
LOW CARB DIETS Articles by Maeve Hanan and Alice Fletcher
NHD-EXTRA: CONDITIONS & DISORDERS
TYPE 2 DIABETES: LOW CARBOHYDRATE DIETS AS TREATMENT Alice Fletcher RD Community Dietitian, Countess of Chester NHS Foundation Trust
Alice has been a Registered Dietitian for almost three years working within NHS community-based teams. She is passionate about evidence-based nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time. NutritionIn Wonderland.com
For full article references For full article please email references info@ please email networkhealth info@ group.co.uk networkhealth group.co.uk
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There is increasing media coverage regarding low carbohydrate diets as a treatment for Type 2 diabetes (T2DM), particularly in place of drug therapies. As a result, more and more people with T2DM are asking if they should “cut out the carbs”. Many dietitians are finding that this style of eating is becoming more difficult to advise against. Is it time that we changed our practice? As a Community Dietitian who delivers diabetes education sessions to those diagnosed with T2DM, I am often asked if service users should “cut out the carbs”. Considering blood sugar levels are directly affected by the carbohydrates (CHOs) that we eat, this does seem like a logical solution and can at times be difficult to advise against. The television coverage of low CHO diets as a treatment for T2DM appears to be increasing over recent years. During an episode of Doctor in the House aired by the BBC in 2015, key sources of CHOs for the person with diabetes were removed, with emphasis placed on removing dairy and wheat containing foods. Time-restricted eating/fasting was recommended, along with suggesting that the 5-a-Day for the individual came from vegetables only, avoiding fruit completely. Shortly after this programme was aired, Dr Duane Mellor gave the following statement on behalf of the British Dietetic Association (BDA): ‘This advice is potentially dangerous with possible adverse side effects. Not only is there limited evidence around CHO elimination and time-restricted eating for those with diabetes, but cutting out food groups and fasting could lead to nutrition problems, including nutrient deficiencies and adversely affect their blood sugar control, particularly in individuals taking certain medications or insulin. ‘Whilst reducing refined CHOs and sugar intake is definitely a positive,
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many of the other recommendations lack evidence from scientific research base. People living with diabetes watching the programme are advised to stick with their current treatment and discuss any changes with their diabetes team, which can include a consultant or GP, dietitian and Diabetes Nurse.’1 The statement was clear: the advice given to hundreds of thousands of people in this programme was not supported by the BDA. The recommendation of low CHO diets for T2DM continues within magazines, newspapers and social media. Often there is emphasis on not needing to count calories and being able to eat as much fat as you would like to, as well as having increased satiety secondary to this. This mantra is particularly backed by Dr Mark Hyman, the American Author of Eat Fat, Get Thin. Dr Hyman is an advocate of a very low CHO diet for T2DM with the majority of calories coming from fat, followed by protein. Dr Hyman is also a fan of ‘bulletproof coffee’ (blending butter into black coffee). Within his latest book he argues that recommendations to cut down on fat and to base meals around starchy CHOs have fuelled the epidemic of obesity and T2DM.2 We know from national databases that across the UK, America and other countries, our intake of starchy CHOs has increased alongside intake of total fat and added sugars. Here in the UK, Dr Michael Moseley has written a book The Blood Sugar Diet
where a low CHO Mediterranean style diet is recommended. The advice within this is similar to that of Dr Hyman, with less sensationalism and dietary restrictions. CHOs such as quinoa, bulgur, whole rye, wholegrain barley, wild rice and buckwheat are recommended in sensible amounts.3 Dr Michael Mosley has T2DM and controls his blood sugar levels into the ‘normal’ range following this style of eating alongside intermittent fasting (the 5:2 diet). When it comes to Registered Dietitians, Dr Trudi Deakin is also an advocate of low CHO diets for the management of T2DM alongside ditching low fat products. Dr Deakin developed the X-PERT education programme for those with T2DM, and it is utilised by many NHS Trusts across the UK. In November 2015, Dr Deakin released a book Eat Fat, Step-by-Step Guide to Low Carb Living alongside the X-PERT programme. She highlights that the programme continues the same, but with less emphasis on low fat, and supports participants with trying different dietary approaches.4 If current trends persist, one in three people will be obese by 2034 and one in 10 will develop T2DM.5 Is it time that we changed our practice? WHAT IS CURRENTLY RECOMMENDED FOR THE DIETARY MANAGEMENT OF T2DM?
Low added (free) sugar diets are recommended for Type 1, 2 and gestational diabetes, as well as generally for a healthy balanced diet. Presently, adults are recommended to consume no more than 30g of added ‘free’ sugars per day (roughly seven sugar cubes), but they are estimated to consume on average two to three times this amount.6 When it comes to T2DM, the advice does
not differ, but added sugars are recommended to be reduced as much as possible.7 When it comes to starchy CHOs, we are recommended to have a large proportion of our diet based on them, as shown in the Eatwell Guide. The advice from Diabetes UK is actually quite vague, stating on their website: ‘Try to include some starchy foods every day.’ The reference intake for CHOs at present as listed on the NHS website, is 260g per day in total. It remains unclear exactly where this reference intake has been devised from. HOW CAN A ‘LOW CHO DIET’ BE DEFINED?
There is presently no specific definition of a low CHO diet, however, studies into low CHO diets usually use a maximum of 20% calories coming from CHOs. Dr Trudi Deakin has suggested the following: • Less than 136g per day = low CHO diet • Less than 50g per day = very low CHO diet4 This article will not specifically discuss levels of CHO intake needed to induce ketosis. WHAT ARE THE COMMONLY DISCUSSED POSSIBLE RISKS OF A LOW CHO DIET FOR THOSE WITH T2DM?
Increased fat intake The general concern from healthcare professionals in the past is that if little or no energy is coming from dietary CHO, then the diet will be higher in total fat as well as saturated fats and, therefore, the risk of cardiovascular disease will rise further (having T2DM already increases this risk). However, as yet, there is not sufficient evidence to prove either way. www.NHDmag.com November 2017 - Issue 129
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NHD-EXTRA: CONDITIONS & DISORDERS Many high-profile advocates of low CHO diets are sceptical, regarding blood cholesterol levels as an indicator of cardiovascular disease risk and saturated fat in excess of current recommended limits having a negative impact upon health. There are several populations around the world that have been reported to eat almost zero CHOs for the majority of their lives (the Masai in Africa, the Inuit people of the Canadian Arctic), yet maintain a healthy body mass index with low incidence of chronic illness. When this is delved into further, however, some studies do show that the Inuit eat a low CHO diet,9 whereas a literature review of the subject found the Inuit diet to generally consist of around 37% CHO, rising up to 53%. This was found to be the case as early as the 1930s. Heart disease and atherosclerosis have also been found to be relatively common.10 Fibre and wholegrains with a low CHO diet There has been further concern from healthcare professionals regarding reduced fibre intake as a result of a low CHO diet. Provided that people eat a diet abundant in vegetables and around two portions of fruit per day, advocates of low CHO diets protest that this should not be an issue. If, however, somebody very adverse to vegetables embarked on a low CHO diet, this could in theory become a problem. Nutritional inadequacy, particularly in regard to micronutrients A presentation on low CHO high fat diets by Dr Trudi Deakin in June 201511 demonstrated through nutritional analysis that a low CHO high fat diet was nutritionally superior to a high CHO low fat diet in regard to vitamin D, calcium, magnesium, zinc and iron, as well as omega-3 to omega-6 ratio. Much like the argument with wholegrains, if vegetables are eaten in very small amounts, it would make a low CHO diet less nutritionally adequate in regard to some important micronutrients. Low CHO diets and medications If people take medications that have a risk of causing hypoglycaemia to control their diabetes, it is likely that low CHO diets without adequate 60
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supervision from healthcare professionals may cause more incidences of hypoglycaemic episodes and this would only be compounded by increasing physical activity. Low CHO diets lead to low levels of glycogen stored in the muscles and liver. Glycogen is important for people with diabetes as a ‘back up’ for the body when blood glucose falls below normal levels, so not having enough of it increases risk of hypos and can make them more difficult to recover from. Low CHO diets should theoretically be safe if a service user does not take any oral hypoglycaemic agents. WHAT DO THE STUDIES SHOW?
A large percentage of those with T2DM are overweight or obese. Low CHO diets have been found to improve overall weight loss in some studies and are generally seen to be the ‘way to lose weight’ by the mainstream media. Notably, in 2014, General Practitioner Dr David Unwin undertook a pilot study with 19 people with borderline and T2DM over an eight-month period where a low CHO diet was advised (under the supervision of Registered Dietitian Heather Crossley). The results of this small study were hugely positive. In summary: • Blood glucose control improved. • By the end of the study period only two patients remained with an abnormal HbA1c (>42mmol/mol); even these two had seen an average drop of 23.9mmol/mol. • Weight fell significantly (an average of 9kg lost). • Waist circumference decreased from 120.2±9.6 to 105.6±11.5cm (p<0.0001). • Blood pressure improved. • Total serum cholesterol decreased. Only one of the 19 people dropped out of the study because the diet didn’t suit them. When it comes to dietary advice provided, participants were given a small diet sheet of just over 500 words. All starchy CHOs were prohibited and fat is said to be ‘fine in moderation’. This is very different to what is recommended in mainstream media or low CHO diets where fat is extensively promoted without the word moderation being used. A control group was not used in this study.12
A different study including 13 people with T2DM and 13 non-diabetic people found weight loss to be significantly greater for those following a low CHO diet compared to standard healthy eating advice. However, HbA1c and lipid levels did not significantly differ between groups. This was, however, a short study of only 12 weeks with a small sample size.13 A recent meta-analysis of 10 randomised trials (1,376 people in total) showed that low to moderate CHO diets have a greater glucoselowering effect compared with high-CHO diets, even without weight loss. Within this review, it was noted that the greater the CHO restriction within studies, the greater the glucose lowering. This metaanalysis did, however, find that apart from improvements in HbA1c over the short term, there is no evidence regarding superiority of low-CHO diets in terms of glycaemic control, weight, or LDL cholesterol in the longer term (after one year).14 A large systematic review and metaanalysis of 20 randomised control trials found a Mediterranean style diet to improve HbA1c levels more than a low CHO diet, although both induced significant weight loss comparatively to a control group. The Mediterranean style diet contained moderate amounts of carbohydrate.15 Snacking In all of the above studies, snacking has been discouraged. The main reason behind this is that insulin (fat storage hormone) levels and incidence of insulin secretion are aimed to be reduced to improve outcomes of weight loss. Low CHO diets may prove more useful in some people than others Studies overall do show a lot of variability. If somebody has insulin resistance, eating a large amount of CHO and then injecting insulin may not result in inadequate blood glucose lowering as it is the resistance that is the main issue, not the lack of circulating insulin. In these cases, lower CHO (and ketogenic diets) may be more useful to reduce insulin levels as well as excess body fat mass.16,17,18
FINAL THOUGHTS
This area of research is mammoth, complex and difficult to sum up in just a few words. As dietitians, we do know that for a lot of people with T2DM, making small realistic changes that can be stuck with forever has lasting effects. However, there are a large number of people who feel that the age old mantra of ‘eat less and move more’ is simply not enough. Not everyone with T2DM will be the same, and some people have a lot more lifestyle changes that they could employ at baseline comparatively to others with the same HbA1c level. For example, one person may consume a lot of added sugars, large starchy CHO portions, be obese and do little physical activity. Another person with a similar HbA1c reading may already consume under the recommended 30g maximum added sugars per day, eat moderate complex CHO portions, be a healthy weight and be regularly active. A diet with extra emphasis on all sources of CHO may be more beneficial for one of these people than the other. Diabetes UK summed it up well in May this year with an update to their position statement on low CHO diets: ‘The current evidence suggests that low carb diets can be safe and effective for people with Type 2 diabetes. They can help with weight loss and glucose management and reduce the risk of cardiovascular disease. So, we can recommend a low carb diet for some people with Type 2 diabetes. But there is no consistent evidence that a low carb diet is any more effective than other approaches in the long term, so it shouldn’t be seen as the diet for everyone.” 19 As Dietitians, it is our job to not just focus on one nutrient, but look at a client’s overall nutrition, lifestyle, likes and dislikes, cooking skills, medications, readiness to change habits, as well as other health conditions and give dietary advice accordingly. Low CHO diets for the management of T2DM may be more appropriate for some people than others and, in my view, should be utilised accordingly. www.NHDmag.com November 2017 - Issue 129
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NHD-EXTRA: WEIGHT MANAGEMENT
CLINICAL USES FOR LOW CARBOHYDRATE DIETS Maeve Hanan Registered Dietitian (full time), City Hospitals Sunderland
Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.
For full article references please email info@ networkhealth group.co.uk
The recommended daily intake of carbohydrates for the general public is around 50% of daily total dietary energy, which is roughly 313g of carbohydrates per day for the average man and 250g for the average woman.1 Low carbohydrate diets (LCDs) involve eating less than 26% of your daily total calorie intake from carbohydrates.1,2 MECHANISM OF LCDs
There are many variations of low carbohydrate diets (see Table 1) which can either be viewed as a fad or a valid clinical diet depending on the context. Limiting carbohydrate intake reduces the rate of insulin released from the pancreas and promotes glucagon secretion which causes the following:3 • Glycogenolysis: the breakdown of carbohydrate stored in liver and muscle tissue so that glucose can be used as an energy source. • Gluconeogenesis: creating new glucose (to be used as an energy source) using non carbohydrate sources such as certain amino acids, pyruvate, lactate and glycerol. • Lipolysis: the breakdown of fat into glycerol and free fatty acids. More extreme LCDs cause a type of fat burning called ketosis which is a compensatory mechanism usually occurring in starvation. When glycogen
stores are depleted, fatty acid oxidation can occur in the liver which produces ketones (or ketone bodies) which can be converted and used as an energy source. However, roughly 10-20% of ketone bodies are thought to be excreted via the skin, urine and breath without being metabolised.3 Although ketosis can result in acidosis in a person who has diabetes, this is not usually seen to occur in starvation or carbohydrate restriction in non-diabetic subjects.3 EPILEPSY AND METABOLIC DISORDERS
The ‘ketogenic diet’ (KD) is a low carbohydrate, high fat diet which was developed in the 1920s to treat epilepsy in children. This can still be used today under medical and dietetic guidance for children who don’t tolerate or don’t respond to epilepsy medication.4-5 Although NICE supports this use of the KD, there is no official recommendation related to the treatment of adult epilepsy due to limited evidence.6
Table 1: Classification of LCDs1-2 Classification
Daily carbohydrate limit*
% of daily calorie intake from carbohydrates
Examples
Moderate carbohydrate diet
130 - 225g
26 - 45%
The Scarsdale Diet The Zone Diet
Low carbohydrate diet
Less than 130g
Less than 26%
The Paleo Diet The Drinking Man’s Diet
Very-low carbohydrate diet
Less than 30g
Less than 6%
The Ketogenic Diet The Atkins Diet
*Based on a 2,000kcal daily intake (the recommended daily calorie intake for a moderate active woman who weighs about 60kg) www.NHDmag.com November 2017 - Issue 129
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NHD-EXTRA: WEIGHT MANAGEMENT Table 2: Variations of ketogenic diets Type of diet
Diet composition
The Classical ketogenic diet (KD)
A ratio of 3-4g of fat is given for every 1g of carbohydrate and protein.7
The Modified Atkins diet (MAD)
Restricts carbohydrates to 15-20g per day but doesnâ&#x20AC;&#x2122;t restrict protein and encourages fat intake.8
The Low Glycaemic Index Treatment (LGIT)
40-60g of carbohydrates are allowed per day (portion sizes are used as a guide), low GI options are encouraged, fats are encouraged and protein is unrestricted.4,9,10
The medium chain triglyceride (MCT) ketogenic diet
60% of energy is derived from MCT fat, or a modified version to improve tolerance which has 30% MCT, plus 30% from long chain fatty acids.7
Table 3: Carbohydrate sources and cardiometabolic health associations (SACN 2015)1 Carbohydrate
Association
High intake of sugars-sweetened beverages
Increased risk of Type 2 diabetes.
Diet high in Glycaemic Index or glycaemic load
Increased risk of Type 2 diabetes.
High glycaemic load
Increased risk of cardiovascular disease.
High intake of white rice
Increased risk of Type 2 diabetes in certain Asian populations.
Consuming brown rice
Reduced risk of Type 2 diabetes.
High intake of potatoes
Increased risk of Type 2 diabetes - but it is not possible to establish a causal link due the confounding factors such as varied cooking methods (e.g. frying potatoes).
High intake of dietary fibre, cereal fibre and wholegrains
Reduced incidence of Type 2 diabetes, cardiovascular disease and coronary events.
High intake of bran and beta-glucan
Lower total cholesterol, LDL cholesterol and blood pressure.
The KD can also be used under medical and dietetic supervision with certain metabolic conditions such as: pyruvate dehydrogenase deficiency (PDH) and glucose transporter type 1 deficiency syndrome (GLUT1).4 The main types of KDs used in clinical practice are outlined in Table 2. WEIGHT MANAGEMENT
Although some meta-analyses identified that LCDs resulted in more weight loss than other dietary methods,11-12 when SACN reviewed the overall evidence base in 2015 they concluded that energy-restricted high carbohydrate low fat diets were more beneficial in reducing BMI as compared to LCDs.1 Some suggested reasons for the weight loss seen on LCDs include a loss of fluid as the process of breaking down glycogen stores can result in about 1kg weight loss as a 63
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result of fluid loss,3,13 and a reduction in calories which may be partially due to the satiating effect of a high protein intake.4,14-15 However, SACN (2015) found no significant difference in energy intake when diets with different proportions of carbohydrates, protein and fat were compared.1 SACN also found that although sugar-sweetened drinks were associated with weight gain and a higher BMI in children and adolescents, when the total amount of carbohydrate in the diet was examined in this group, no association was found between carbohydrate intake and BMI or body fatness.1 Evidence is conflicting in terms of compliance when LCDs are compared with low fat diets.15-16 However, for some individuals, restricting the intake of a specific food group may increase the risk of binge eating and subsequent weight gain.17
In terms of cardiovascular disease, some trials have identified an association between total carbohydrate intake and fasting blood lipids and systolic blood pressure. CARDIOMETABOLIC HEALTH
Some studies have found an association between LCDs and improved glycaemic levels,18-19 but SACN (2015) found that ‘total carbohydrate intake appears to be neither detrimental nor beneficial to cardiometabolic health’, which included glycaemia and incidence of Type 2 diabetes.1 More recently, Diabetes UK released a position statement which concluded that for Type 2 diabetes, LCDs can be safe and effective. However, there is not enough evidence that this approach is better than others in terms of longterm weight management and glycaemic control and that ‘there is no strong evidence to say that [LCDs are] safe or effective for people with Type 1 diabetes’.20 However, there is ongoing research into carbohydrate intake and diabetes. In terms of cardiovascular disease, some trials have identified an association between total carbohydrate intake and fasting blood lipids and systolic blood pressure.1 However, due to confounding factors such as weight loss, it is not possible to establish a causal relationship and SACN (2015) found that total carbohydrate intake had a neutral effect on cardiovascular disease endpoints.1 However, when different sources of carbohydrate are examined, the associated cardiometabolic health outcomes vary (see Table 3).1 CANCER
There is a hypothesis that KDs may be useful in combatting cancer which is based on ‘The Warburg Effect’; an observation that cancer cells prefer producing energy via anaerobic glycolysis rather than oxidative phosphorylation.21 Although there are some animal and in vitro studies which support the use of the KD with specific types of tumour cells,22-24 there is also some contradictory research25 and other studies have identified that ketones may actually fuel certain cancer cells.26-27 Research is ongoing in this area, but currently,
more evidence is needed before the use of the KD can be promoted as a routine treatment option for cancer, especially as this patient group are already at risk of malnutrition and cachexia.21 NUTRITIONAL CONSIDERATIONS
Although most people in the UK would benefit from reducing our intake of ‘free sugars’ (those added to foods by manufacturers, cooks or consumers, and the sugar found naturally in syrups, honey, syrups and unsweetened fruit juices), vilifying total carbohydrates intake can be harmful as it is recommend that 50% of dietary energy should come from carbohydrates.1 Carbohydrates are the main source of fuel used by our body and are also found in many nutritious foods such as wholegrains, fruit, vegetables and dairy products.1,26 There is strong evidence that fibre and wholegrains are associated with a lower risk of cardiovascular disease, diabetes and colorectal cancer.1 Furthermore, an LCD may result in an increased intake of saturated fat and a high intake of saturated fat is associated with an increased risk of cardiovascular disease.29-30 Considering that on average, UK adults already consume less fibre and more saturated fat than the recommended level,31 an LCD could potentially have an adverse nutritional effect. CONCLUSION
There are some well-established clinical uses for LCDs, such as using KDs with certain metabolic disorders, or for seizure control in children with epilepsy which is unresponsive to medication. However, the current evidence is more conflicting in terms of weight management and cardiometabolic health. Although in the UK we should be aiming to reduce our intake free sugars, carbohydrates are also found in many nutritious foods. Therefore, LCDs should only be encouraged in specific situations when there is a clinical indication for their use. www.NHDmag.com November 2017 - Issue 129
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NHD-EXTRA: RESEARCH & RESOURCES
SMARTPHONE APPLICATIONS: ARE THEY A HELP OR A HINDRANCE? Dr Carina Venter PhD, RD Assistant Professor, University of Colorado Denver School of Medicine, USA Carina is currently an Assistant Professor of Paediatrics, Section of Allergy and Immunology at the Children’s Hospital Colorado and University of Colorado Denver School of Medicine, where she is conducting research and working with children and adults with a range of food allergies.
Kate Maslin PhD RD Research Fellow at the University of Southampton, UK
For full article references please email info@ networkhealth group.co.uk
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In this article, Carina and Kate report on a survey that was conducted with users of an electronic smartphone application specifically designed for the management of food allergies in adults. The prevalence of food allergies in children range between 0.1-6.0% in Europe,1 and 1.1-10.4% worldwide.2 Prevalence data on adult food allergies is scarce and no data establishing the true prevalence of food allergies in adults exists.2 Diet plays a crucial role in the management of food allergies. Although the dietary management of food allergy extends beyond individualised allergen avoidance, this aspect will always remain the most important part of patient management.3 Recent studies clearly indicate that food allergies affect quality of life. This is also true for those with self-reported food allergies/ intolerances, who avoid foods due to perceived symptoms.4 Food allergy affects quality of life (QoL) in four domains: food anxiety, emotional impact, social and dietary limitations.5 Venter et al4 found that there was no difference in QoL in those trying to avoid food due to a perceived or proven food allergy (p = 0.062), clearly indicating the burden of food avoidance in both groups. In addition, Greenhawt et al6 showed that anaphylaxis, multiple food allergies and food allergies other than just peanuts or tree nuts were associated with a significantly worse QoL score, most likely due to the vigilance required to avoid the trigger foods. Adhering to a restrictive diet can also affect the time taken to shop and the cost of buying food.7 Wolf et al8 showed that the average weekly price of the six food exclusion diet (SFED) at a standard US supermarket was $92.54
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compared to $79.84 for an unrestricted diet (p = 0.0001). Patients also often had to visit a second specialist grocery store to obtain all the foods needed. Food allergy and nutrition related papers mention that the future of food allergy management should include the use of electronic diaries and software applications to improve patient food intake and nutritional care.9 One of the questions we raised, however, was whether these technologies truly benefit our patients/clients. SPOON GURU
We report below about a brief survey that was conducted with UK users of the electronic smartphone application, Spoon Guru (SG). SG is available in the UK and has just launched in the US (see www.spoon.guru/app for more details). This smartphone application allows the user to find products which match the individual’s dietary requirements, through barcode scanner and search functionality. In order to instil cooking skills and prevent unnecessary reliance on packaged food, the smartphone application also provides recipes matched to the individual’s dietary needs. The smartphone application contains pre-set lifestyle and allergen/intolerance dietary options for the user to select. The list of lifestyle options to choose from include vegan, vegetarian, ovovegetarian, lacto-vegetarian, pescatarian, palm oil free, paleo, organic, low sugar, low salt, low fat and yeast avoidance. The list of allergen options to choose from include the 14 major allergens as identified by the European Union, as
The smartphone application contains pre-set lifestyle and allergen/intolerance dietary options for the user to select. well as other allergens or causes of intolerances as requested by Spoon Guru users. This, for example, includes pulses, beans and peas and SFED. The app allows for extra refinement, for example, you can exclude specific types of nuts, fish, shellfish, beans and gluten containing grains. In addition, if your intolerance is not as severe as a food allergy and you can tolerate trace amounts within your food, you can allow products that have a precautionary ‘may contain’ allergen statement on the label. Current users of the smartphone application (SG app) were asked to complete a very basic 10-question electronic questionnaire between April 2017 and August 2017. SURVEY RESULTS
One hundred and sixty three SG app users completed the survey; 63 (38.7%) with food allergies (FA) or intolerances (FI) or both (FAI) (25 FA, 29 FI and nine FAI) and 100 (61.3%) using the SG app due to personal preferences, lifestyle or other reasons. The survey was completed by 36 males (22.1%) and 127 females (77.9%). The age ranges were: 17 years or younger (6, 3.7%), 18-24 years (12, 7.4%), 25-34 years (32, 19.6%), 35-44 years (39, 23.9%), 45-54 years (45, 27.6%), 55-64 years (16, 9.8%), 65-74 years (11, 6.7%) and 75 years or over (2, 1.2%). For the analysis, we have grouped those with food allergies and/or intolerances (FAI) in one group and compared them against those using the SG due to personal preferences (lifestyle and/or other: LSO). The data is summarised in Table 1. Recoding all the variables in two categories, with the lower three options together (e.g. not at all difficult, a little difficult and somewhat difficult as one variable/option vs quite a bit difficult and very difficult as one variable/option), we found no statistical differences between the answers provided by the FAI group vs the LSO group, the female demographic vs the male, or those 34 years and younger vs those 35 years and older. However, significant differences related to QoL were found. Women indicated that the SG app was more effective in reducing difficulties with shopping
(57% women vs 34% men; Chi square test p-value: 0.037). In addition, women found the recipes more helpful than men (55% females vs 33% men; Chi square test p-value: 0.024) and stated that the SG app was more helpful in improving their QoL than men (74% females vs 42% men; Chi square test p-value < 0.001). Comparing the before and after answers relating to difficulty shopping between the FAI group and the LSO group (question 2 and question 3) showed that the ease of shopping improved significantly for both groups (McNemar’s test: FAFI P<0.001 and LFO p-value <0.001). In the FAI group, 33% (21/63) found shopping difficult before the SG app and only 1.6% (1/63) afterwards. In the LSO group, 23% (23/100) found shopping difficult before using the SG app and 1% (1/100) after using the SG app. IN SUMMARY
Suffering from food allergies, intolerances or even a self-perceived need to avoid certain foods can negatively affect QoL. Two of the main factors include the difficulty as well as the time required to shop for suitable foods. Smartphone applications may assist in making shopping experiences more positive. We set out to determine how the SG app was perceived by its users. Our findings indicate that the SG app significantly reduced difficulties encountered during shopping, but that men may have particular requirements that require further investigation. This survey was conducted in a 10-question simple format with a relatively small sample size. Longer, more in-depth surveys with larger numbers are required to get a better idea of the individual needs of users and how smartphone apps can be improved. www.NHDmag.com November 2017 - Issue 129
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NHD-EXTRA: RESEARCH & RESOURCES Table 1: Comparison of Spoon Guru users with food allergies and/or intolerances vs those using the smartphone application for personal preferences Subset with food allergies and intolerances (n=63) n(%)
Those using the app for lifestyle or other reasons (n=100) n(%)
Before using the smartphone app, how difficult was it to access information on foods that may be unsuitable or problematic? Not at all difficult
2 (3.2)
4 (4.0)
A little bit difficult
21 (33.3)
29 (29)
Somewhat difficult
19 (30.2)
44 (44.0)
Quite a bit difficult
11 (17.5)
19 (19.0)
Very difficult
10 (15.9)
4 (4.0)
How difficult is it for you now to access information on unsuitable or problematic foods now that you are using the smartphone app? Not at all difficult
22 (34.9)
34 (34.0)
A little bit difficult
33 (52.4)
52 (52.0)
Somewhat difficult
7 (11.1)
13 (13.0)
Quite a bit difficult
0 (0)
0 (0)
1 (1.6)
1 (1.0)
Very difficult
How much easier is it to shop since using the smartphone app? Not at all easier
6 (9.5)
4 (4.0)
A little bit easier
16 (25.4)
34 (34.0)
Moderately easier
10 (15.9)
8 (8.0)
Quite a bit easier
24 (38.1)
37 (37.0)
7 (11.1)
17 (17.0)
Very easy
How helpful are the recipes provided by the smartphone app? Not at all helpful
5 (7.9)
6 (6.0)
A little helpful
15 (23.8)
18 (18.0)
Moderately helpful
13 (20.6)
24 (24.0)
Quite a bit helpful
23 (36.5)
34 (34.0)
7 (11.1)
18 (18.0)
Very helpful
What do you like best about the smartphone app? (More than one choice allowed.) Less stress or frustration
22 (34.9)
30 (30.0)
Time or cost saving
17 (27.0)
22 (22.0)
Safety and peace of mind
39 (61.9)
52 (52.0)
More choice
15 (23.8)
16 (16.0)
None/other
3 (4.8)
7 (7.0)
Overall, did the smartphone app improve your quality of life? Not at all
6 (9.5)
11 (11.0)
A little
14 (22.2)
34 (34.0)
Moderately or somewhat
16 (25.4)
24 (24.0)
Quite a bit
21 (33.3)
25 (25.0)
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