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EXTRA

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

December 2016 / January 2017: Issue 120

VITAMIN D UPDATE Recommendations for UK and Europe

PROMOTING THE WORK OF DIETITIANS

By Claire Irlam, student at Coventry University

NHD-EXTRA: PUBLIC HEALTH

VITAMIN D RECOMMENDATIONS FOR EUROPE AND THE UK Gemma Sampson Rd, Senior R&D Dietitian, Vitaflo International

Gemma has experience as a registered dietitian in a variety of clinical and industry settings, with personal interests in sports nutrition, gluten-related disorders and plant-based lifestyles. She runs the nutrition blog Dietitian without Borders.

Vitamin D recommendations for both Europe and the UK were updated in 2016. The Scientific Advisory Committee on Nutrition (SACN) released its updated vitamin D and health report to establish whether the existing UK dietary recommendations from 1991 were still applicable to today’s population.1 The European Food Safety Authority (EFSA) also produced dietary reference values for vitamin D for.2 The updated recommendations for both SACN and EFSA reference incorporates all dietary sources of vitamin D including natural food sources, fortified foods such as infant formula milk and dietary supplements.

When comparing vitamin D recommendations between SACN, EFSA, or any other international governing body, it is important to consider any assumptions behind the evidence included or excluded during their analysis. SACN produced safe intakes (SI) and reference nutrient intake (RNI) values for vitamin D, while EFSA concluded that there was insufficient evidence to define reference nutrient intakes and produced adequate

intakes (AI) of vitamin D for various age groups within the population. The EFSA tolerable upper limits4 for vitamin D were established in 2012, four years prior to the release of the DRVs. It will be interesting to see whether these are values change when next reviewed.

The dietary reference values (DRVs) for vitamin D produced by SACN and EFSA are not directly comparable.

Despite having an overlapping pool of evidence to form their guidance, both bodies produced different recommendations for dietary vitamin D, based upon how they graded the evidence, thresholds chosen and health outcomes measured. The EFSA assessment took place between 20132016, with SACN evaluating the evidence assessed in its report between 2011-2016.3 Neither SACN or EFSA took

Table 1: Vitamin D recommendations and tolerable upper limits SACN vitamin D recommendations for the UK population (2016)1

EFSA recommendations for the EU population (2016)2

EFSA Tolerable Upper Limits (2012)4

Infants birth to 6 months

8.5-10µg (SI)

-

25µg

Infants 7 to 11 months

8.5-10µg (SI)

15µg (AI)

25µg

1 to 4 years

10µg (SI)

15µg (AI)

50µg

5 to 11 years

10µg (RNI)

15µg (AI)

50µg

12-17 years

10µg (RNI)

15µg (AI)

100µg

18 years +

10µg (RNI)

15µg (AI)

100µg

Pregnant and lactating women

10µg (RNI)

15µg (AI)

100µg

Age group

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NHD EXTRA: PUBLIC HEALTH

From a dietary perspective, when exposed to sunlight or UV lamps, mushrooms have the magical ability to synthesise vitamin D. into account vitamin D synthesis from exposure to sunshine and both considered serum 25(OH) D to be the best indicator of skin synthesis and dietary intake.

The EFSA panel established that the majority of the adult population would achieve serum 25-hydroxyvitamin D (25(OH)D) concentrations near or above the target of 50nmol/L when consuming an adequate intake (AI) of 15µg.2 However, SACN decided that serum 25(OH)D concentrations of 25nmol/L was an appropriate reference value to minimise the event of negative musculoskeletal health outcomes for 97.5% of the population.

A meta-analysis of data used by EFSA to determine adequate intakes was conducted under conditions where there was assumed minimal subcutaneous vitamin D synthesis, thus assuming that all vitamin D would be required through the diet. EFSA states that ‘true’ adequate intake values of dietary vitamin D may be lower than those set, perhaps even zero, in the presence of adequate sunlight exposure for vitamin D production.

RECOMMENDATIONS FOR INFANTS

A notable difference between the approach used to set DRVs between EFSA and SACN is demonstrated in infants. EFSA did not set an AI for infants from birth to six months due to the 58

lack of research conducted on this population, particularly in breastfed infants. Most research within this age group is conducted on formulafed infants using formula and/or foods that have been fortified by vitamin D. This made it difficult to form a conclusive evidence-based recommendation about how much this age group actually requires. SACN, however, decided upon a safe intake of 8.5-10µg for the same age group as a precautionary value, based on current intakes and current practice to reflect insecurities and lack of data within this age group.

The influence that a threshold for vitamin D has on requirements was demonstrated in a recent study in UK adolescents.6 An intake of 10-30µg was found necessary to maintain blood serum 25(OH)D concentrations over 25nmol/L or 50nmol/L, depending on which threshold was chosen.

The most recent NDNS survey found an increased risk of vitamin D deficiency based upon serum vitamin 25(OH)D concentrations below 25nmol/L across all age groups, ranging from 7.5% in children to 24% in girls and women.7 Dietary intakes of vitamin D met 27% of the previous RNI for children aged 1-3 and 33% for adults 65 and older of 10µg6. Supplemental vitamin D increased this proportion, but not substantially enough to meet the RNI. Meat and meat products, milk and milk products, fortified

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NHD EXTRA: PUBLIC HEALTH Table 2: Converting vitamin D between micrograms (µg) and International Units (IU) micrograms (µg)

International Units (IU)

10µg

400IU

15µg

600IU

20µg

800IU

25µg

1,000IU

50µg

2,000IU

fat spreads and fortified cereal products were the main contributors of dietary vitamin D.7 A recently published study comparing the different practices and knowledge of white Caucasian and South Asian living in Manchester, indicated the importance of cultural beliefs and advice tailored to suit.8 Those from South Asian backgrounds had a greater understanding of the importance of vitamin D for bone health and that it could be obtained from sunlight, than white Caucasian groups. Despite this knowledge, few within this population group used vitamin D supplements.

PRACTICAL MESSAGES REGARDING VITAMIN D

When recommending vitamin D intakes for a population, it is important to consider the approaches used to set a dietary reference value, whether it is based upon evidence or current intakes in the absence of any research.

From a dietary perspective, when exposed to sunlight or UV lamps, mushrooms have the magical ability to synthesise vitamin D. Vitamin D rich mushrooms are becoming more common in mainstream supermarkets. As a fat soluble vitamin, absorption of vitamin D in

mushrooms can be enhanced by cooking them with a little extra virgin olive oil. Egg yolks are a good dietary source of vitamin D, but recent health scare-mongering has resulted in many individuals shying away from eating eggs regularly. Oily fish and cod liver oil contain vitamin D; however, these do not feature heavily in today’s western diets. Providing clients and patients with suggestions on how to prepare these foods in palatable ways and incorporate them into their diets on a regular basis can help to increase their dietary vitamin D intake.

With regards to supplements, some declare vitamin D content in International Units (IU) rather than micrograms (µg). Supplements can be a quick and convenient way to ensure that a consistent intake of vitamin D is achieved on a daily basis throughout the entire year. This is particularly important for individuals who don’t get much sun exposure due to their environment or cultural beliefs. Education plays an important role in advising appropriate food sources of vitamin D, appropriate sun behaviour practices to enhance vitamin D synthesis and indicate whether an individual would benefit from taking a supplement.

References 1 SACN (2016). Vitamin D and Health report, Scientific Advisory Committee on Nutrition. www.gov.uk/government/publications/ sacn-vitamin-d-and-health-report 2 EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies) 2016. Scientific opinion on dietary reference values for vitamin D. EFSA Journal 2016;14(10):4547, 145 http://onlinelibrary.wiley.com/doi/10.2903/j.efsa.2016.4547/full 3 EFSA & SACN (2016). Joint explanatory note by the European Food Safety Authority and the UK Scientific Advisory Committee on Nutrition regarding dietary reference values for vitamin D. www.efsa.europa.eu/sites/default/files/documents/news/explanatory_note_EFSA_SACN_vitaminD.pdf 4 EFSA Scientific Opinion on the Tolerable Upper Intake Level of Vitamin D (2012) EFSA Journal;10(7): 2813 www.efsa.europa.eu/en/efsajournal/ pub/2813 5 EFSA (European Food Safety Authority) (2016). Outcome of a public consultation on the Draft Scientific Opinion of the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) on Dietary Reference Values for vitamin D. EFSA supporting publication 2016: 13(10): EN-1078 http:// onlinelibrary.wiley.com/doi/10.2903/sp.efsa.2016.EN-1078/full 6 Taryn J Smith, Laura Tripkovic, Camilla T Damsgaard, Christian Mølgaard, Christian Ritz, Saskia L Wilson-Barnes, Kirsten G Dowling, Áine Hennessy, Kevin D Cashman, Mairead Kiely, Susan A Lanham-New, and Kathryn H Hart (2016). Estimation of the dietary requirement for vitamin D in adolescents aged 14-18 y: a dose-response, double-blind, randomised placebo-controlled trial. The American Journal of Clinical Nutrition, 104: 1301-09 7 Public Health England (2014). National Diet and Nutrition Survey Results from Years 1, 2, 3 and 4 (combined) of the Rolling Programme (2008/20092011/2012) www.gov.uk/government/uploads/system/uploads/attachment_data/file/310995/NDNS_Y1_to_4_UK_report.pdf 8 Webb AR, Aseem S, Kift RC, Rhodes LE and Farrar MD (2016). Target the message: a qualitative study exploring knowledge and cultural attitudes to sunlight and vitamin D in Greater Manchester, UK. Br J Dermatol http://onlinelibrary.wiley.com/doi/10.1111/bjd.14800/full

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PAEDIATRIC NHD EXTRA: SKILLS AND LEARNING

LOVE WHAT YOU DO! Claire Irlam Student, Coventry University

The British Dietetic Association (BDA)’s ‘Dietitians Week’ campaign,2 is the annual week of promoting the work of dietitians and spreading healthy lifestyle advice.

Claire has just completed her second placement and third year studying Dietetics at Coventry University.

Her passion is multi-disciplinary working and promoting the profession of dietetics. @ClaireIrlamRD2b.

As well as the usual ‘trust a dietitian’ message,3 (Figure 1) this year’s theme also promoted workplace health, including physical activity in the workplace and protection of break times. Dietitians and dietetic students across the country were out in force to present displays to colleagues and the public.

So why is this campaign needed? As soon as I was considering applying for a career in dietetics, I was met with puzzled looks from friends and family. Not only does this resonate with every dietitian or dietetics student I have met since, it is also reflected in literature surrounding the topic. For example, Crocker found in 20008 that when supermarket customers were asked about the role of a dietitian, responses included “completing menu cards for patients” (26% of those asked) and “meal preparation” (21% of those asked).

As well as raising awareness of our role to the public, knowledge of each

Figure 1: ‘Trust a Dietitan’ logo3

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other’s capabilities is essential within a multi-disciplinary team. A study in America (Semans 2014)13 investigated medics’ perceptions of dietitians, which were found to be very positive. However, the research also found that service users most entrusted doctors when seeking nutritional advice, placing them ahead of both dietitians and nutritionists. As medics’ training of nutrition is limited, it is vital that all healthcare professionals are aware that dietitians are the clinical specialists in this area to ensure appropriate referrals. However, with less than 9000 registrants, dietetics is a small profession within the UK compared to others in healthcare, as shown below.

Therefore, it is important that each and every one of us strives to create a positive image of the profession and promote this image wherever possible (Figure 2).

Despite dietitians being around for centuries (BDA 2016c),4 promoting our profession has become more crucial than ever with a recent influx of dietary information freely available in print, on television and online. Through the eyes of the unknowing public, “dietitian” has just become another meaningless title lost within a sea of nutrition advice from nutritionists (qualified or otherwise), juice promoters and celebrity brand advocates. In this updated version of the Hierarchy of Evidence to reflect current sources of nutrition used by the public,9 The Dietitian’s Pantry demonstrated this observation by omitting dietitians from it altogether (Figure 3).

However, this isn’t merely a case of arguing about which “experts” are better. It would be naïve to

Figure 2: Breakdown of UK Registered Professionals 11

60000 40000 Number of UK registered professionals

20000 0

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sio

y Ph

s OT

s LT

SA

imagine that alternative nutrition advice will disappear overnight and more importantly, a lot of it has its place if we each work within our individual capabilities and recognise our limitations. I am more than happy to trust a celebrity chef when seeking a tasty recipe, but not if it boasts “superfood ingredients” with “detoxing properties”. Similarly, it is important not to dismiss nutritionists with accredited qualifications – but dietitians need to make their own mark, rather than standing in the nutritionists’ shadow.

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an

iti iet

D

So with all of these sources to choose from, why should the public ‘trust a dietitian’?

• Dietitians work in a variety of settings including: clinical, public health, freelance, industry, research and sports. Within these, they can advise specifically for many different health conditions from diabetes and irritable bowel disease to chronic kidney disease and cystic fibrosis. Therefore, it is important to inform others that the work of dietitians is not limited to weight management, as many seem to believe.

Figure 3: The Dietitian’s Pantry9

The new and very much Unimproved ‘Health and Nutrition

Wellness Blogger

Hierarchy of Evidence’

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NHD EXTRA: SKILLS AND LEARNING

Another great way to spread the word about dietetics is to take any opportunities available for meeting new people and explaining our role.

• Contrary to faddy diets, dietitians use a complete diet and lifestyle approach. They combine nutritional assessment with patient values and behaviour change techniques to enable realistic sustainable changes which don’t require restricting a particular food group or relying heavily on another.

• Dietitians are the only professionals who are qualified to assess, diagnose and treat dietary and nutritional conditions (BDA 2014b).7 Referrals can be made via medical professionals or patient self-referrals if seeking freelance dietitians.

• Advice is evidence-based so their advice will always reflect the latest credible research.

• “Dietitian” is the only nutrition title which is protected by the law within the UK, guaranteeing consistency of quality amongst them (BDA 2014a).6 They must also comply with ethical standards, which ensures that dietitians are honest and work to the service users’ best interests.

• Anybody practising under this title within the UK has completed university training which complies with specific standards, including experience of clinical placements.

Undergraduate dietetic degree courses comprise of many modules, encompassing topics such as psychology, social health, food production, communication techniques, biochemistry and physiology, alongside the underlying nutrition, which gives us a unique set of skills.

It seems that dietitians can boast a lot of expertise which many other nutrition experts cannot. So if this is the case, why are we so rarely turned to by the public when seeking advice?

As Off-Duty Dietitian12 explains, many of the techniques used by self-acclaimed diet experts are unavailable to dietitians, who must comply with standards of practice set by their professional bodies. Therefore, whilst we are often successful 62

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Claire helps out at university open day14

in achieving goals for our service users, our confidentiality-respecting accomplishment statistics cannot compete with before and after photos of crash dieters in bikinis.

Raising the profile of dietetics is not only beneficial to the overall profession and to the public who will be educated on where to receive accurate dietary advice. It can also be to each individual dietitian and student’s advantage to have the positive work of dietitians more widely publicised. Any extra-curricular activities which showcase yours and other dietetic students’ hard work would be a shining addition to any professional portfolio. In addition to this, the more understood and respected we are by colleagues and the public, the more accurate referrals we will receive, which promotes positive working relationships and increased job satisfaction. Amongst the countless benefits of raising our profiles, wouldn’t it be great to be able to simply state your job title to somebody and not be met by a blank face?

There are many ways in which student dietitians can help to raise the dietetic profile further. An easy and flexible way to get involved is to begin a blog or have a positive social media presence. Online interactions are becoming increasing popular, allowing people to communicate outside the constraints of time and location. It is best to choose a medium with which you are familiar and comfortable, whether that be Facebook, Twitter, Youtube or something else.

A great way to get started is by following other dietitians and students to familiarise yourself with suitable content and to get ideas. Hashtags are useful for connecting with wider communities and trending topics, and including photographs can make your account visually appealing.

However, it is also important to obtain consent before uploading any images of others and to maintain patient confidentiality. It is also key to remain polite and professional and ensure that any information spread is accurate and that sources of information are cited.1 For further guidance on using social media professionally, refer to codes of conduct from the BDA5 and HCPC.10 Another great way to spread the word about dietetics is to take any opportunities available for meeting new people and explaining our role. Universities often offer extra-curricular events which are useful for this, or alternatively you could collaborate with other students or dietitians to take part in existing community or national events. At my university, I work as a student ambassador for Dietetics as well as for Health and Life Sciences, a position which is available at most universities. As well as discussing my course at open days (see below), this role has also allowed me to explain our career to school children at a community health event, as well as to adult carers while delivering a healthy eating presentation.

Remaining engaged with professional organisations including the BDA, HCPC and NHS helps when staying updated with current hot topics and events in the world of dietetics, as well as healthcare and nutrition. Plenty of ways for students to get involved are included on websites of these groups.

Other examples of extra involvement include giving presentations about topics you find interesting, taking on charity or volunteer work, becoming involved in projects, writing articles and taking on student roles within organisations (Jones 2016).11 Although extra involvement is extremely beneficial for professional development, the main thing is that you choose something which you find enjoyable.

Whether you are engaging with others through media or face-to-face, it is really useful to find your niche. Remember the reasons which set dietitians apart from others and find a topic which really interests you so that you appear passionate.

Confidence is also key when networking but utilise communication techniques taught throughout dietetic training and take every opportunity and practice will soon make perfect!

Promoting the hard work which each dietitian and dietetic student does is such a worthwhile and rewarding experience. Remember that if dietitians aren’t spreading nutritional messages to the public, somebody less qualified will be – so get out there!

References 1 Barth, C. and Seher, C. (2012) ‘The Power of Social Network – Here’s How You Can Use It to Market Your Brand’. Today’s Dietitian May 2012, 36 2 British Dietetic Association (BDA) (2016a) Dietitians Week. [online] available from <https://www.bda.uk.com/improvinghealth/trustadietitian/dietitiansweek> [6th June 2016] 3 British Dietetic Association (BDA) (2016b) Trust a Dietitian Campaign. [online] available from <https://www.bda.uk.com/improvinghealth/trustadietitian/home> [6th June 2016] 4 British Dietetic Association (BDA) (2016c) The History of the BDA and Dietetics. [online] available from <https://www.bda.uk.com/about/about_bda/history> [22nd June 2016] 5 British Dietetic Association (BDA) (2013) Making Sense of Social Media: BDA Professional Guidance on Social Media. Birmingham: BDA 6 British Dietetic Association (BDA) (2014a) Dietitian, Nutritionist, Nutritional Therapist or Diet Expert? A Comprehensive Guide to Roles and Functions. Birmingham: BDA 7 British Dietetic Association (BDA) (2014b) What is a Dietitian? Birmingham: BDA 8 Crocker J (2000) A1. The public perception of the role of dietitians compared with physiotherapists and radiographers. Journal of Human Nutrition and Dietetics, 13 (5), 363.

9 The Dietitian’s Pantry (2016) The New and Very Much Un-improved Health and Nutrition Hierarchy of Evidence. [online] available from <https://www.facebook.com/ TheDietitiansPantry/photos/a.392287844195600.91456.389216224502762/1046633988760979/?type=3&theater> [22nd June 2016] 10 Health and Care Professions Council (n.d.) Focus on Standards: Social Media Sites.

11 Jones, L. (2016) Future Proofing Our Profession through Making your Mark – Stories from my Career to Date [online lecture] Nutricia Symposium on Nutrition Support – Translating the Evidence into Best Practice, 17 May 2016. Manchester: Museum of Science and Industry. available from <http://i.emlfiles1.com/ cmpdoc/9/2/6/4/7/files/374190_talk-5-lucy-jones-.pdf?utm_source=nutricia%20ltd&utm_medium=email&utm_campaign=7191753_manchester%2017th%20 may&utm_content=lucy%20jones&dm_i=1LL1,4A5PJ,N7K78T,FNLMO,1> [22nd June 2016] 12 Off-duty Dietitian (2015) Why dietitians suck at social media. [online] available from <http://www.offdutydietitian.com/2015/06/why-dietitians-suck-at-social-media> [22nd June 2016] 13 Semans, D. (2014) ‘Academy of Nutrition and Dietetics Registered Dietitian Brand Evaluation Research Results’ [online] 114 (10), 1640-1646. available from <http:// www.sciencedirect.com/science/article/pii/S2212267214012325> [6th June 2016] 14 Tighe, B. (2015) Thanks to @bethanydoda @claireirlamrd2b @danjgriffith & @kathleenhp2 for your help. A great #covopenday for #rd2b. [Twitter] 13 June. available from <https://twitter.com/bernicetigherd/status/609733043583102976> [22nd June 2016]

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