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NHDmag.com August / September 2016: Issue 117
SPORTS NUTRITION CASE STUDY
by Helen Phadnis
FUTURE FOODS FROM EDIBLE INSECTS GIVE ME ENERGY... Ursula Arens takes a look at the energy drinks market A DAY IN THE LIFE OF... a Meals on Wheels Nutritionist
NHD EXTRA: PUBLIC HEALTH
GIVE ME ENERGY . . . Review by Ursula Arens Writer; Nutrition & Dietetics
While sweet and sugary drinks face all-round critique from dietitians, it is a mystery that the sector of self-proclaimed ‘energy’ drinks seems to be thriving. Correction: not ‘seems to be’ - ‘is’…
Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula guides the NHD features agenda as well as contributing features and reviews
The link to virile masculinity and gungho disruptiveness seems to transcend any concerns over bad teeth and obesity. In debates about energy drinks amongst politicians and regulators, the sugar content of energy drinks is low down over the other contentious ingredients of too much caffeine and mysterious herbals. The sector is booming. More than half of the global market is dominated by two brands: Red Bull and Monster. According to market researcher Euromonitor International, global sales of energy drinks in 2015 were more than €38 billion. More than one third of the global market is the US. China had lower sales than Western Europe in 2015 (€6 vs €7 billion), but is the fastest growing market, predicted to double by 2020 and overtake the US by 2025. Interestingly, two of the top three brands are privately owned: Dietrich Mateschitz owns Red Bull and Russ Weiner owns Rockstar - perhaps they swim in the stuff. The number two brand, Monster, is coowned by the Coca Cola Company.
The success of energy drinks must be due to the many meanings of the word ‘energy’. Dietitians need no review of the meaning of food energy. However, the consumer meaning drives the communication of these products: take your pick of the string of synonyms: vigor/forceful effect/power/capacity to do work/ oomph/ get-up-and-go/ drive/vim - and many other terms. Clearly, a drink that delivers these traits is valued, rather than the dietetic interpretation that the drink contains calories. However, the energy contents of energy drinks are very similar to levels found in other sweet beverages (Table 1). The quandary is that the drinks correctly state that they contain energy (kcals); however they are strongly communicating other meanings of the word. And this is the meaning that (young, male) consumers are receiving loud-and-clear. So what do food labelling experts mean by the word ‘energy’. Statements about energy are permitted on food labelling, but relate entirely to absolute
Table 1: Sugars and caffeine contents Per 100ml
kcals
sugars
caffeine
Red Bull
46
11g
32mg
Monster
42
11g
32mg
Rockstar
59
13.5
32mg
Lucozade energy*
70
8.7g
12mg
Coca cola
42
10.6g
10mg
Orange Juice
36
8.6g
-
-
-
50mg
Pro Plus tablet (1)
* Lucozade Energy contains less sugars but more energy than other similar drinks. This is because some of the carbohydrate in the ingredient ‘glucose syrup’ is in the form of oligosaccharide.
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and relative amounts in relation to kcals content. They are defined by Regulation (EC) No 1924/2006, amended by Regulation (EU) No 1047/2012. Low energy means less than 40kcals per 100g (or half this for liquids). Energy-reduced means a value lower by at least 30% (compared to a standard or reference food). Lastly, energyfree means less than 4.0kcals per 100ml. And that is all. But there is an interesting development on the labelling of nutrients in foods versus nutrients in the body. An article 13.5 claim just approved by the European Commission in June 2016, allows statements on ‘lower blood sugar rise’ for products where at least 30% of sugars are replaced by non-digestible carbohydrates. The merge of labelling statements of (sugar) contents in foods to (sugar) levels in blood, suggests possible future concepts between energy contents in foods and ‘energy’ in the body. The term energy on food and drink labels appears to be multi-meaning and the Australian shopper is also confused.com. In a detailed interview of more than 400 shoppers in Sydney, packets of breakfast cereals, muesli bars and frozen meals were used to tease out the understanding of terms energy and calories. Results reported by Wendy Watson and colleagues were bizarre, but also very logical and understandable from the consumer viewpoint. Higher energy breakfast cereals were judged as healthier, as were, in contrast, lower energy ready meals. Participants with lower 58
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incomes were significantly more likely to state that higher energy products were healthier, the main reason being that these products were best for sustaining energy. Shockingly, only 40% of participants correctly recognised that kilojoules and kilocalories were different units for the same thing. The researchers were anxious that food energy concepts and units of measurement were a mystery to Australia shoppers and were concerned that further food and menu labelling initiatives expanding energy content declarations may result in accidental promotion of less healthy foods. A nutrition education campaign was needed (they concluded.) What else can be said about energy drinks? Caffeine is a well-described stimulant, and the content in energy drinks is about three times the levels in cola drinks per 100ml, although portion sizes in bullet cans may be smaller that cola cans or bottles (Table 1). All drinks containing more than 15mg caffeine per 100ml require labelling statements that the product is not suitable for children, or pregnant or breastfeeding women, and such statements are displayed. But there have been many concerns over the high caffeine content in energy drinks. And particularly their consumption by children. There is particular alarm that the promotion of (valid) claims about the effects of the stimulant caffeine, may lead people to believe in the (not valid) super-powers of energy drinks. In July 2016, the European Commission in Strasbourg was asked to adopt four health claims labelling statements on caffeine, approved by the
Table 2: EFSA approved health claims for caffeine Contributes to an increase in endurance performance Contributes to an increase in endurance capacity Helps increase alertness Helps to improve concentration
European Food Safety Agency (EFSA) (Table 2). These claims had been ‘on hold’ for more than five years. Although scientific data supporting stimulant effects is strongly based in evidence, approving such communication on food labels promises another marketing boost for energy drinks. The Danish MEP, Christel Schaldemose, strongly opposed the official yes-to-caffeine claims on labelling: survey data shows that nearly 80% of under-18 teens and nearly 20% of under10s, consumed energy drinks and further (mis) communication suggesting better performance in school or sport was irresponsible. In the vote, the concerns were accepted and approval of caffeine claims on labelling were rejected by the MEPs. The energy drinks industry was angry that caffeine in coffee was acceptable, but caffeine in non-coffee drinks was opposed. They called the outcome of the vote a disgraceful victory of politics over science, and taunted that energy-boosting claims could be made on such drinks regardless, by the additions of small amounts of B vitamins. Another marketing ingredient in energy drinks is taurine (except ‘marketing ingredient’ is unfair on caffeine, as it does have proven physiological effects). Between 2009-2011, various health claims regarding taurine were submitted for consideration to EFSA. Proposed statements included descriptions supporting physical and mental performance, and enhancing vitality. However, the substantiating evidence for all eight proposed claims was judged to be inadequate, and all labelling statements for taurine were not authorised. Some further specific assessments were made by EFSA in relation to the safety of the ingredient taurine. There had been anecdotal and case
reports of acute and adverse effects from drinking energy drinks, and an opinion was requested from the Panel on Food Additives and Nutrient Sources Added to Food. They calculated that the mean daily intakes of taurine from omnivore diets was at most 400mg per day, whereas the levels in a 250ml can was 4,000mg, so levels 10fold that of dietary intakes. Review of possible adverse cases suggested that very high amounts of energy drinks had been consumed (six cans per occasion) always combined with other factors such as intense exercise or alcohol. The Panel concluded that the possible adverse effects reported were more likely due to well described side effects of very high caffeine intakes; the possible relationship with high intakes of taurine lacked any scientific evidence. So, what is so get-up-and-go about energy drinks? They contain carbohydrates (sugars) and caffeine, but you could easily get this in a more enjoyable form, for example, with the classic combo of coffee and cake/cookie. They contain taurine and other marketing ingredients, which are not harmful, but which have not been demonstrated as effective either. Unlike other food and drinks, however, energy drinks do contain magic sparkle and ‘wings’ developed by many millions of pounds of sponsorship and advertising, communicating risk taking and physical vigour. The association between these images and these products explains why so many people are willing to pay £££s for small cans of fizzy drinks. It is time for more energy to be put into the critiquing of energy drinks and dietitians should be lassoing in the misleading and over-hyped claims of… bull.
Information sources: • Arens U (2009). A load of old bull. Network Health Dietitians Magazine; 59, 16 • EFSA (2009) Panel on Food Additives and Nutrient Sources Added to Food. The use of taurine and D-glucurono-gamma-lactone as constituents of the so-called ‘energy’ drinks. DOI: 10.2903/j.efsa.2009.935 • Harrison-Dunn AR. MEPs brew final caffeine claims battle as approval beckons. www.beveragedaily.com - 14 June 2016 • Harrison-Dunn AR. MEP caffeine vote ‘disgraceful’ victory of politics over science: Industry. www.foodnavigator.com - 8 July 2016 • Watson WL et al (2013). How well do Australian shoppers understand energy terms on food labels? Public Health Nutrition, 16, 03, 409-417
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NHD EXTRA: FOOD & DRINK
FUTURE FOODS FROM EDIBLE INSECTS Michèle Sadler 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.
For article references please email info@ networkhealth group.co.uk
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Locally available edible insects are regularly eaten by around two billion people (over a quarter of the global population) across continents such as Africa, Asia and Latin America. Over 1,900 insect species are eaten, helping to improve the quality of traditional diets.1 With future food production needing to double in order to sustain the growing population (estimated to reach nine billion people by 2050) and to reduce chronic hunger, edible insects are seen as part of the solution. Production systems and the science of insects are currently at a pioneering stage. By merging modern scientific methods with traditional knowledge, both developing and developed countries can benefit from insects as a food source. This begs the question, can insects overcome their taboo in Western cultures, to become mainstream foods? WHICH INSECTS AND WHICH PRODUCTS?
Edible insects include familiar ones such as grasshoppers, ants and crickets, through to locusts, mealworms and termites. Table 1 shows the contribution to global consumption of the main orders of insects. After harvesting, insects can be freeze-dried, sundried, or boiled. They can be eaten whole, e.g. stir-fried or roasted, or they may be processed into powders, granular or paste forms that can be incorporated into combination foods such as breads, tortillas and snack bars. There is also potential to extract protein, fats and chitin from insects for use as food ingredients that can be added to enrich foods. Insects are already eaten as food in the USA and the UK. The current offer is mainly niche products and novelty snacks. Examples are cricket and mealworm powders, whole
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roasted crickets and mealworms, frozen blanched locusts for use in stir-fries and Bodhi protein bars made with cricket powder. Top end restaurants are also experimenting with whole insects and insect powders. And of course, cochineal (carminic acid) is a long-standing food colouring that is extracted from scale insects (Dactylopious coccus). WHY EAT INSECTS?
Human entomophagy (eating of insects) tends to be traditional where conventional sources of protein such as meat and fish are unavailable or in low supply. While insects can make a significant nutritional contribution to many human populations they are also viewed as a delicacy. Two main advantages of potential relevance to developed countries are their high nutritional value and their contribution to sustainable diets. Nutritional value The Food and Agriculture Organisation of the United Nations (FAO), working with INFOODS (the International Network of Food Data Systems), established in 1984, has collected available nutritional data for edible insects as part of its programme to promote biodiversity. This includes collecting data on wild and underused foods at various levels including variety, cultivar and breed.1 Insects have a number of favourable nutritional attributes. The wide variation in nutritional content not only reflects the large variety of different species, but also differences within
Table 1: Commonly consumed insects
Insect Order
Proportion of global insect consumption
Insects
Coleoptera
31%
Beetles (inc mealworms)
Lepidoptera
18%
Caterpillars
Hymenoptera
14%
Bees, wasps, ants
Orthoptera
13%
Grasshoppers, locusts, crickets
Hemiptera
10%
Cicadas, leafhoppers, planthoppers, scale insects and true bugs
Isoptera
3%
Termites
Odonata
3%
Dragonflies
Diptera
2%
Flies
Other orders
5%
Other insects
Data from: FAO, 2013. Edible insects - Future prospects for food and reed security. FAO Forestry paper 171. Rome: FAO, 2013.
individual species which may be due to the metamorphic stage of the insects at harvesting (e.g. adult stage, larvae, pupae or eggs), to their habitat (e.g. wild or farmed), differences in their diet and how they are processed. Uniform feeding and controlled production leads to more reliable quality and consistency, which is important for food labelling and quality control. In general, edible insects provide useful amounts of energy, protein of high value, unsaturated fats and an array of micronutrients. Reported energy values for a number of insect species range from 293 to 762kcal/100g dry weight.2 On a fresh weight basis, the protein content of adult locusts, termites and grasshoppers compares favourably with beef and fish.1 As to protein quality, edible insects can provide a useful addition to traditional diets by increasing intake of the limiting amino acid. For example, many insect species are a good source of lysine and can thus supplement diets where the key staples are cereal proteins which are often low in lysine. In the UK, the limiting amino acid in the overall diet is threonine and many insect foods are a good source of this amino acid. Edible insects are also a useful source of unsaturated fat and frequently provide the essential fatty acids linoleic and a-linolenic acid, the fatty acid composition being influenced by the insects’ diet. The micronutrient content varies considerably by species and
more research is needed, particularly into bioavailability. However, many edible insects are rich in iron and zinc, some providing more than red meats. Some species provide high levels of vitamin E and many insects are a good source of B vitamins, including some that provide useful amounts of vitamin B12. Of particular interest is the generally high fibre content of insects. This is mainly in the form of chitin, a long-chain polymer of N-acetyl glucosamine which is a derivative of glucose. Chitin forms the main component of the exoskeleton of insects. Table 2 overleaf shows the nutritional content of two example insect powders currently on the market in the UK, sourced from a controlled production system in Canada. Sustainability With increasing emphasis on sustainable diets, i.e. diets that contribute to food and nutrition security, while having a low environmental impact and respecting biodiversity and ecosystems,3 edible insects are generally considered to be prime candidates as both food staples and dietary supplements.1 Rearing insects is thought to result in lower ammonia and lower greenhouse gas emissions than arise from farming pigs or cattle, with less land and water required. There is also the possibility to rear insets on organic side-streams and the potential to reduce environmental contamination.1 www.NHDmag.com August / September 2016 - Issue 117
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. . . the use of insects as food certainly has potential as an emerging food source, depending of course on consumer acceptance. It goes without saying that introducing a new food comes with a range of challenges. The Food Standards Agency (FSA) has recently called for information about insects for human consumption and attention is being focused on knowledge development for the possibilities of consuming insects in the UK. CURRENT REGULATORY STATUS IN EUROPE
Whole insects and whole insect powders do not currently fall within novel foods provisions. However, they will fall under the scope of the new novel food regulations that were adopted in 2015,4 that come into force in January 2018. As insects are already on the EU market, there is a two-year period to submit a dossier requesting authorisation. Extracts such as proteins and oils are not currently allowed to be sold in the EU and will also require novel foods approval. A further main use for insects is as a feed source for animals and fish and the regulatory status of insects for this purpose is currently being reviewed. EFSA published an opinion on the risk profile of insects as food and animal feed.5 It was noted that there is no systematically collected data on human consumption of insects. EFSA reviewed a wide range of potential safety issues and recommended that research is undertaken to address the gaps in the data. However, the FSA has indicated that it is not aware of any public health concerns. 62
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NEW FOODS AND CONSUMER ACCEPTANCE
There are various examples of new foods introduced to the UK market in recent decades. Foods may be classed as ‘new’ for different reasons. An obvious example is food produced by a new technology, e.g. genetic modification (GM). Tomato puree produced from GM tomatoes introduced in the 1990s was initially well accepted, being slightly cheaper than conventional tomato puree. However, the introduction of the more ubiquitous GM soya with no consumer benefits resulted in rejection of GM foods and a prolonged absence of GM technology from the market.6 A number of novel foods and ingredients, i.e. not previously on the EU market before May 1997, have also been granted approval, such as chia seeds, noni juice, plant sterols, new sweeteners and new sources of micronutrients. The genuinely new food Quorn was successfully introduced in the 1980s, gaining consumer acceptance as a meat alternative. It has since become well established in many different global markets, offering the clear consumer benefits of excellent eating quality, combined with a low fat content and containing useful amounts of fibre.7,8 Exotic meats have also been introduced to the UK in the past decade or so, such as kangaroo, crocodile and bison, though these remain as niche products.
Table 2: Nutritional value of insect powders available in the UK
Nutrient
Cricket Powder
Mealworm Powder
472
436
Fat (g)
24
18.9
Saturates (g)
8.5
4.1
Monounsaturates (g)
5.1
6.5
Polyunsaturates (g)
9.1
7.3
Omega – 3 fatty acids (g)
2.8
N/A
Omega – 6 fatty acids (g)
6.3
N/A
Carbohydrates (g)
8.4
15.4
Sugars (g)
0.5
0
6
8.7
Energy (kcal)
Fibre (g) Protein (g)
59
55
Salt (g)
0.9
0.5
110/0
81.0
Iron (mg)
2.5
3.7
Potassium (g)
1.1
1.1
Vitamin B12 (ìg)
31.0
N/A
Calcium (mg)
Data from Mophagy (www.mophagy.com).
So, the use of insects as food certainly has potential as an emerging food source, depending of course on consumer acceptance. Alongside crustaceans, insects are also classed as arthropods. This raises the question that if as a society we are okay with eating shellfish, such as winkles, lobsters, crabs and crayfish, and with eating snails, then why not insects? We tend to view insects as pests and carriers of diseases and the thought of eating insects is initially repulsive to many people. So can this be overcome? Consumer research suggests that processing insects so that they are unrecognisable may make them more acceptable, and that males are more likely than females to consider trying them, as are people interested in food sustainability, those already familiar with insects from other food cultures and those who want to reduce their intake of red meat.9 CAN INSECT FOODS PLAY A ROLE IN THE UK DIET?
As well as the challenge of consumer acceptance, insect foods are relatively expensive in
comparison with traditional meats. Scaling up production to reduce costs will involve many different disciplines and such challenges are currently being addressed. Can we overcome these barriers to accept insects as foods and if so, what roles could they play in the UK diet where we already have a varied food supply and a large choice of nutritious foods? Insects undoubtedly have novelty value and will be of interest to ‘foodies’ and the more adventurous among the population. But can they become more than niche products? Edible insects are certainly valuable nutritionally and could supply additional protein, fats and micronutrients to population groups with specific needs such as the elderly and patient groups on special diets or recovering from illness. They could also be useful for sports foods. Use of insect powders to enrich traditional foods that we are used to eating may be a way to introduce them to the diet in a more acceptable way for consumers. So, how adventurous is the UK population well, let’s wait and see! www.NHDmag.com August / September 2016 - Issue 117
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NHD EXTRA: NUTRITION MANAGEMENT
CASE STUDY: SPORTS NUTRITION Helen Phadnis Freelance Dietitian and Sports Nutritionist Helen’s practice is underpinned by over 10 years of previous clinical experience at a senior specialist level and five years in private practice. She provides workshops for local clubs and teams and runs clinics in Brighton and Hove. helen@nomnomn e rd.com http://www.nomn o mnerd.com/
The effects on body composition of a K2 summit attempt by an experienced climber Climbing at altitude puts additional energy demands on climbers, estimated at an extra 536kcal/d just for acclimatising to altitude,1 and 1,610kcal/d for climbing activities.2 Alongside these demands come welldocumented changes in taste perception and reduced appetite,3 making weight loss inevitable when climbing above 5,000m. K2 is the second highest mountain in the world, at 8,611 metres above sea level. It is known as the ‘Savage Mountain’ due to the extreme difficulty of ascent.
Matt is a 38-year-old experienced mountain climber planning a second attempt at reaching the summit of K2. Matt was seeking nutritional advice in an attempt to minimise weight loss experienced during his previous attempted summit of K2 two years prior. His trip had resulted in 17% weight loss from 100kg to 83kg. After initial basic dietary advice was provided, Matt requested an in-depth body composition assessment pre- and post- K2 expedition out of curiosity, to see the anthropometrical effects on his own body of climbing at altitude.
Identification of Nutritional Need 1. Assessment Medical diagnosis: Susceptibility to cold sores Anthropometric measurements: Body fat and lean mass measurements were taken via multiple frequency bioelectrical impedance, using Body Composition Monitor (BCM), Fresenius Medical Care (see Table 1). Skinfold thickness measurements were taken at seven sites using Harpenden Skinfold Calipers. Girth measurements were taken with a tape measure. Takei 5001 hand grip dynamometer was used to assess muscle strength. Seven-point Subjective Global Assessment scale was used to assess nutritional status. Dietary Intake Analysis Planned daily intake during climbing is documented in Figure 1. This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. This would provide approximately 2,500kcal, 64g protein. From previous experience, in keeping with what is commonly reported in climbers at altitude, Matt knew he could tolerate carbohydrates in preference to fat when eating during a climb. Recommended Body Weight: BMI 18-25kg/m2 = 64-88kg Recommended body composition based on published elite sport climbers and high altitude climber anthropometry data4,5 is recorded in Table 1. Estimated energy needs: Using actual body weight (as client is not obese) BMR (Schofield) 11.5 (101.7) +873 = 2042 x 1.9 PAL = 3880kcal/d Nitrogen (Elia) 0.17 x 101.7 = x6.25 = 108g/d Based on ACSM Nutrition in Sport Position stand6 Very high carbohydrate needs (mod-high intensity exercise over >4-5 hours). Target 8-12g/kg/d = 813-1229g carbohydrate = 3,089-4,670kcal Protein = 1.2-2g/kg/d = 122-203g protein = 488-812kcal Total discounting fat = 3,577-5,482kcal/d Medications: None Supplements: Centrum multivitamin and mineral supplement.
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2. Identification of nutrition and dietetic diagnosis Diagnosis: Inevitable cachexia expected during planned K2 climb. Aims: To minimise negative effects of altitude on dietary intake and resultant muscle loss and fatigue during K2 climb. To assess body composition and compare to that documented for high altitude climbers. 3. Plan nutrition and dietetic intervention Nutrition Prescription: I. Prevent injury and illness during trip. a. Take probiotics e.g. Actimel daily for two weeks prior to trip to reduce likelihood of contracting diarrhoea. b. Probiotic tablet daily during trip. c. To take a broad spectrum multivitamin and mineral supplement daily during trip and pre-trip to reduce susceptibility to cold sores and upper respiratory tract infections. This will cover all micronutrient requirements when the effects of altitude cause a reduction total diet intake. d. Aim for adequate calories and protein during trip: supplement planned nutritional intake with Complan meal replacements and some medium Glycaemic Index snacks such as chocolate, fruit and nut bars. II. Optimise performance during climb. a. Match food intake to energy expenditure as far as is possible: i. Pack familiar palatable food to tempt into eating as much as possible: small frequent snacks to optimise intake. ii. Include high fat foods if possible: cheese, chocolate, fish in oil. III. Prevent loss of lean body mass during climb. a. As above. IV. Prevent dehydration a. Rehydration is more effective when there are some electrolytes and/or calories present: always drink when take food, preferably salty snacks. Aim for 4-5L when at altitude if possible. 4. Implement nutrition and dietetic intervention I talked Matt through the above nutrition prescription, alongside advice on basic principles of sports nutrition and how they could be applied on the trip as well as to his pre-expedition training. A key element when considering 10-15 hour climbs with no stop for a proper meal was aiming for 30-60g carbohydrate per hour to minimise fatigue. 5. Monitor and review See Table 1: Anthropometry I. Matt’s body mass index was above the healthy range before the trip. Abdominal circumference and sum of skinfolds were also high, indicating excess fat before the trip. After the trip, total fat stores fell by 8.0kg, the most significant loss being from abdominal stores, indicating healthy weight loss. II. Results from the body composition monitor show that a far larger proportion of weight lost was fat (about 8.0kg), compared to muscle (about 2.0kg). This is attributable both to Matt’s persistence with taking on board nutrition during the trip, and also due to the fact that he was exercising daily during the expedition. III. Subjective global assessment classed Matt as ‘at risk’ of malnutrition post-expedition. Also the rate at which he lost weight during the expedition was 12.5% loss body weight in three months. This is clinically significant for malnutrition. However on his return: a. Matt was unlikely to be deficient in vitamins and minerals due to daily supplementation during the trip and did not display any symptoms of micronutrient deficiency; b. daily exercise led to fat loss in preference to muscle loss. Body mass index within the healthy range for athletes; c. despite a lack of appetite, Matt was not suffering from any other adverse gastro-intestinal symptoms. IV. Muscle bulk was reduced post-trip and as a result Matt lost some power, as indicated by reduced handgrip strength. Matt was counselled on recovery snacks containing 20g protein along with carbohydrate to encourage regain of muscle stores. He was also encouraged to self-monitor his nutritional status via waist circumference measurements, aiming to minimise fat regain in this area. It was recommended that his multivitamin and mineral supplement was only necessary at times of intense training or life stress. 6. Evaluation Loss of both fat and muscle are inevitable whilst climbing at high altitude. This can be minimised by good planning and implementation of a calorie dense diet comprised of tried and tested meals, snacks and supplements. www.NHDmag.com August / September 2016 - Issue 117
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NHD EXTRA: NUTRITION MANAGEMENT Table 1: Nutrition Assessment Data Reference range *Elite sport climbers5 # High altitude climbers4
Pre-trip
Post-trip
Height m
*1.72
1.884
1.884
Weight kg
*65.5 #69-85
101.7
88.5 on immediate return 92.5 at appointment
Body Mass Index (BMI)
WHO 18.5-25kg/m2
28.6 kg/m2
25kg/m2 on immediate return 26kg/m2 at appointment
% weight loss past 3 months
Stable = <5%
4%
9% (12.5% total)
Hydration L
Euhydrated = 0
-0.4 L
+1.2L
Body fat %
*6.8-12.7
26.4 7.3% (from skinfolds)
21.9 5.7 (from sfs)
Fat mass kg
*8.6 #4.9-13.1
7.4kg (from sfs) 36.6
5.3kg 27.5
Lean mass kg
#20.7-42.2
66.1
64.2
Subjective Global Assessment
Well nourished = 6-7, at risk = 4-5, Malnourished = 1-3
6
5
Hand Grip Strength
76-176
138
117
Triceps Circ (+-flex) cm SF mm
# 28-34 6.5-19
35.7, flex 36.4 7.2
33, flex 34.5 6.2
3.8
5.5
Biceps skinfold mm Chest skinfold
# 5-13.5
3.8
3.2
Abdomen Circumference skinfold
# 82-96 7-21
94 13.0
87.5 11.0
Subscapular skinfold
# 8-16
13.8
9.0
Suprailiac skinfold
# 8-21.5
7.2
4.95
Thigh Circumference skinfold
# 55-61 7-14
65.1 4.8
56.4 5.2
Calf Circumference skinfold
# 37-39
46.2 11.5
44.5 8.0
57.5
44.35
Sum of 6 skinfolds
Abdomen circ: <94cm = healthy, 94-102cm = increasing health risks, >102cm = high health risks.
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Figure 1: MGâ&#x20AC;&#x2122;s original planned dietary intake when climbing
Planned daily intake during climbing . . . This was based on previous experience of what is possible to carry with regards to weight during a climb, as well as what is palatable. References 1 Pulfrey SM and Jones PJH (1996). Energy expenditure and requirement while climbing above 6,000m. J Appl Physiol 81: 1306-1311 2 Westerterp KR, Saris WHM, Van Es M and Ten Hoor R (1986). Use of the doubly labeled water technique during sustained heavy exercise. J Appl Physiol 61: 2162-2167 3 Anonymous (1938). Nutrition panel of the food group. J Soc Chem Ind 57: 1230-1234 4 Reynolds RD, Lickteig JA, Howard MP and Deuster PA (1998). Intakes of high fat and high carbohydrate foods by humans increased with exposure to increasing altitude during an expedition to Mt Everest. The Journal of Nutrition pp50-55 5 Romero et al (2009). Body fat measurements in elite sport climbers: Comparison of skinfold thickness equations with dual energy X-ray absorptiometry Journal of Sports Sciences 27(5): 469-477 6 American College of Sports Medicine, Dietitians of Canada, the Academy of Nutrition and Dietetics (Feb 2006). joint Position Stand on Nutrition and Athletic Performance
dieteticJOBS.co.uk To place an ad or discuss your requirements please call
0845 450 2125 (local rate)
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PAEDIATRIC NHD EXTRA: COMMUNITY
A DAY IN THE LIFE OF . . . A MEALS ON WHEELS NUTRITIONIST Annabelle de la Bertauche Registered Nutritionist Hertfordshire Independent Living Service (HILS)
Annabelle is currently working for Hertfordshire Independent Living Service (HILS), the largest meals-on-wheels provider in the country. She has held a variety of roles including nutrition research, Government policy and advice, healthy eating education for children and, most recently, with older people who are living with dementia and/or depression in the community at Age UK Hertfordshire.
ANNABELLE’S DIARY
9am - 12noon: I spend a busy morning delivering our Referrer Training to a team of charity workers. The team requested our specialist training as their work involves supporting older people in their homes, and they are always keen to improve their knowledge to better help their clients. We provide this training to any groups in Hertfordshire that want to support older and vulnerable people to eat well and help prevent dehydration and malnutrition. Taking just a few hours, our training covers how to identify the signs of malnutrition and what they can do to help. The team are so enthusiastic and curious about the subject matter that we have a fantastic morning of active discussion. 12:30 - 13:45: Lunch meeting I pop back to the office for a working lunch meeting to discuss our next project around eating well with dementia. We don’t have these meetings that often, but when we do, we choose one of our own (HILS) meals. Today I have chosen the vegetarian sausage casserole followed by ginger sponge and custard. It was delicious and I am now recharged and ready for the rest of the day. 14:00 - 15:00: I visit a client (accompanied by her daughter) to carry out a Nutrition and Wellbeing check. Our free Nutrition and Wellbeing check involves calculating Body Mass Index (BMI), by taking a weight and height measurement, assessing
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www.NHDmag.com August / September 2016 - Issue 117
Nutrition training
for malnutrition risk using the Malnutrition Universal Screening Tool (MUST) and also exploring health and dietary needs through an informal questionnaire and discussion. The client has a healthy BMI and a good appetite and, importantly, she is enjoying our meals. However, we do identify that she isn’t drinking the recommended six to eight cups of fluid each day. The client knows how much she should be drinking and her daughter admits to have been ‘nagging her for months’ about it. After some enquiry about continence issues she reveals that she has been holding back from drinking due to having not made it to the toilet in time on a few occasions. I reassure her that this is a very common problem, but keeping herself in a state of dehydration will not help with this and will put her at increased risk of some very serious issues such as urinary infections and falls. They were both unaware of the dedicated NHS Continence Service that we have in Hertfordshire, and they agree for me to refer her directly. She also happily accepts one of our free water jugs and agrees that it would be useful if a drink could be prepared for her by the HILS Community team member who delivers her meal each day.
15:15 - 15:45: I carry out another client Wellbeing check; however, this time it’s a followup review for a client who I saw three months ago. At that time, he had an underweight BMI and had reported significant weight loss in the few months prior to my visit. He has since been receiving both our higher energy
meals and our ‘Nutrition Boost’ snacks, which we provided at no extra cost. Our ‘Nutrition Boosts’ are a few free extra items of food delivered with his meal each day. They are given to clients who are identified as being at risk of malnutrition. Nutrition Boost items include fortified soups, milky drinks and a variety of tasty snacks, all carefully selected so that they are small portions, but contain at least 200kcal each. Today, three months on, I find that he has put on 8lb which is great news.
16:00 - 17:30: I write up the summary letters to send to the clients I have seen and catch up on a few emails. An urgent email explains that we have a client who is allergic to Capsaicin (present in chilli peppers, bell peppers and paprika). I use our supplier’s dedicated nutrition software to run a search on these ingredients and send a list of our meals that do not contain them to our support teams, so that they can remove all of these meals from the client’s personalised menu profile. I also have several emails in my inbox from the support teams letting us know about new clients who would like a Wellbeing check, as well as messages from community groups who would like training. And so the work continues!
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www.NHDmag.com August / September 2016 - Issue 117
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