NHD Extra March 2016

M

AR

C

EXTRA

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

H

20 16

NHDmag.com

March 2016: Issue 112

NUTRITION AND DIETETICS IN

TANZANIA Thoughts on Casual Dining

by Ursula Arens

Norma Lauder remembers Pat Torrens

NHD-Extra: PUBLIC HEALTH

Nutrition in Tanzania Zohra Lukmanji Registered Dietitian After training as a Dietitian and short work spell in the UK, Zohra, a Tanzanian national, returned to her home in 1978 to work with the Tanzania Food and Nutrition centre.

Since then, her work in nutrition and dietetics in development, emergencies and academia, within and outside of Tanzania, has been diverse. She acquired her MSc in Community Nutrition at the University of Queensland in Australia.

Tanzania is dietitian Zohra Lukmanji’s homeland. She works in many dietetic areas in the country, helping to support nutritional advances and developments.

Here she gives an overview of Tanzania’s nutritional status, needs and requirements, as well as the interventions that have already been put in place.

Tanzania, also known as the land of Kilimanjaro (the highest mountain in Africa), is the 31st largest country in the world and the largest country in East Africa. It borders the Indian Ocean to the east and has land borders with eight countries: (anti-clockwise from the north) Kenya, Uganda, Rwanda, Burundi, the Democratic Republic of Congo (across Lake Tanganyika), Zambia, Malawi and Mozambique.

The country includes Zanzibar (consisting of the main island Unguja, plus Pemba and other smaller islands).

Dodoma is the political capital of Tanzania and Dar es Salaam (DSM) is the largest city and the principal commercial capital

Figure 1: Geographical and Administrative maps of Tanzania

2

www.NHDmag.com March 2016 - Issue 112

Tanzania is one of the poorest countries in the world, with the United Nations classifying it as one of the least developed countries. Its population of 51.82 million (2014) is diverse, composed of several ethnic, linguistic and religious groups. Urban population accounts for more than 25%, 7% of which live in urban agglomerations of more than a million people. The population annual growth rate stood at 2.8% (20141 estimated). Average life expectancy in 2012 was 61 years (51 in 1990).

Disease burden

The burden of diseases in Tanzania is high, with communicable diseases still

Overall, urban children are more likely to enjoy better nutrition than rural children; accordingly 31.5% of urban children below five years were stunted, compared with 44.5% of rural children. prevailing. Communicable, maternal, perinatal and nutritional conditions account for 65% of total deaths in all ages. HIV/AIDS, tuberculosis and malaria, all with nutrition implications, are among the most important.

Increasingly, the country is confronted with the ‘double burden of disease’ due to noncommunicable diseases which are estimated to account for 27% of all deaths and the remaining 8% of deaths occur due to injuries (World Bank, 2008; WHO NCD).

The prevalence of HIV/AIDS as estimated in 2012 was 5.1%, lower than that reported at 7% in 2008 (World Bank), and was higher among women than men (7% and 5%, respectively).

Tanzania is one of the 22 high burden countries for TB prevalence. The TB mortality rate (excluding HIV) is 13 per 100,000 populations; its prevalence is estimated at 183 per 100,000 populations (WHO TB). However, its treatment success rate has reached the WHO global TB control target of 85%. More than 50% of TB patients in the country are co-infected with HIV (WHO Cooperation).

Malaria is a leading public health problem and cause of death in 36% of all deaths in children under-five in the mainland and accounts for about 40% of total OPD attendance. However, in Zanzibar, since the scaling-up of multiple interventions, including Long-Lasting InsecticideTreated Nets (LLINs) to vulnerable groups and the deployment of Indoor Residual Spraying (IRS), malaria is no longer the number one cause of child mortality (WHO Cooperation).

Non-communicable diseases (NCDs) are on the rise in Tanzania, particularly in the urban areas, where more than 25% of the population resides (WHO Cooperation). According to 2008 data, the total number of deaths due to NCDs was 757,000 among males and 588,000 among females. Out of this number, 42.8% of

all deaths in males and 28.5% of all deaths in females under age 60 are due to NCDs (WHO Tanzania website).

Diabetes prevalence is reported to be high in the urban Tanzanian community where prevalence of overweight is also growing (Aspray et al 2000).

Nutrition status

Tanzania has been at the forefront in promoting multidisciplinary2 nutrition interventions through its national institution, the Tanzania Food and Nutrition Centre (TFNC) since 1977. Tanzania has made progress in reducing undernutrition in children under five since 1991. Despite progress made, however, malnutrition remains one of the most serious health problems affecting infants, children and women of reproductive age. Major problems such as one or more forms of undernutrition, including low birth weight, stunting, underweight, wasting, anaemia, iodine and vitamin A deficiency, still persist. According to data3 from the Tanzania Demographic and Health Survey (TDHS)4 2009/10, child underweight5 was 16% (27% in 1996) and stunting6 was 42% (48% in1996). Nevertheless, the prevalence of child underweight and stunting in 2010 was still unacceptably ‘high’ according to criteria of the World Health Organisation (WHO, 1995). Wasting (low weight for height)7 was prevalent among 4.8% under-fives (2010) Overall, urban children are more likely to enjoy better nutrition than rural children; accordingly 31.5% of urban children below five years were stunted, compared with 44.5% of rural children.8 Malnutrition is associated with 56% of childhood mortality losses of up to 13% of intelligence1 in Tanzania.9 Stunting in early childhood is usually associated with poor development in young children, and delayed neurosensory integration, low IQ and school achievement in older children.10 The percentage of children above +2 SD for weight for height (overweight) was 5%; urban 5.8% and rural 4.9%, and although low it is likely to increase.

Vitamin A, iron and iodine deficiencies are also prevalent in Tanzania. According to the TDHS 2009/10, national prevalence of vitamin A deficiency was 33% among children under five years of age; approximately two-thirds of children had iron deficiency. The same survey indicated that just over half the households consumed salt www.NHDmag.com March 2016 - Issue 112

3

NHD-extra: PUBLIC HEALTH Table 1 Area

BMI less than 18.5 (kg/m2)

BMI greater than 18.5 (kg/m2)

Urban

8%

36%

Rural

13%

15%

which was adequately iodized. This, interestingly enough, correlated with mother’s education and high income households (HHs).

Women

According to TDHS survey 2010, 11.4% of women age 15-49 years were reported to be thin (BMI <18.5kg/m2). Those having BMI of 25 or more was just over 20%, which is five times more than that reported in 1991. The women in the highest income group were most affected (41% as compared with most affected poorest 8%).

Overall, the survey indicated a lower proportion of thin women than the overweight/obese women (Table 1).

The urban vs rural difference in the proportion of women with BMI less (8% vs 13%) and more than 18.5 (36% vs 15%) were also noted. Forty four percent of women in Dar es salaam, the city with the most urbanised population, were reported to be overweight/obese and this cuts right across all socio-economic groups of the population. Almost two-thirds of these women have no concept of their nutritional status.

Overall, national prevalence of obesity among adult population (25 years and over) was 5% in 2008 (CIA world factbook).

Interestingly, less than 3% of the Tanzanian adults, age 25-64 years11 consume fruit and vegetables as per WHO recommendations of five servings and 400g/day.

School children

At national level, there is no data available on the nutritional status of school children age six to 15 years. The data from ad hoc surveys carried out in specific urban and rural areas clearly indicated the existence of underweight, ranging from 2050% and an increasing trend of overweight and obesity (specific to urban areas 9-22%).

The proportion of malnourished children has reduced since 1991, but the overall calorie intake has increased marginally since 2001. The diets of the majority remain undiversified, hence increasing 4

www.NHDmag.com March 2016 - Issue 112

the risk of nutrient deficiencies diseases. At the same time, advent of rapidly growing fast food industries (street foods to giant supermarkets) has led to the increasing consumption of processed foods rich in refined sugar and saturated fats, no matter how expensive. The majority have no concept of the ingredients or risk of these foods.

The sugary beverages reach even the most remote villages in Tanzania. School children have easier availability of junk foods sold by street vendors or small shops outside of the schools.

Agriculture and nutrition status

Agriculture is the main source of employment and livelihood in 77.5% of the rural population.

However, for the urban population, agriculture related activities are illegal and, therefore, home gardens are found on any unused land are often at the risk of being evicted. In Dar es Salaam, it is reported that more than 90% of leafy vegetables available in the markets originate in open spaces and home gardens, hence urban agriculture accounts for almost 20-30% HH food supply.

In the south and west of the country, surplus food is produced and is known as ‘food basket regions’, but, sadly, there is a relatively high rate of malnutrition. Poverty is pervasive in Tanzania and rural households are disproportionately poor. Not surprisingly, under-nutrition in children is most prevalent among rural households and in the poorest households. According to the TDHS 2010/11, 26% of children in households in the highest wealth quintile were stunted, contrasting with 39-48% in households in the bottom four wealth quintiles.

There is a pattern of declining malnutrition with higher income, but several analysts have pointed out that increasing income accounts for only part of the decrease in malnutrition rates.12 Similar results have been found in analyses of the relation between higher national income (GDP) and rates of child malnutrition. Factors other than income alone are clearly at play.

Ironically, the same ‘food basket regions’13 and highest wealth quintile HHs were noted to have higher

proportion of overweight under-fives (indicated by weight for height >+2 SD14). The number of children in this category is still at its low level of 5%, similar to children <-2SD). The highest prevalence of HIV in adults, both male and females was observed to be predominant in food basket regions.15 Nutrition interventions

The challenges above have broadly been addressed since the establishment of the TFNC and nutrition interventions have focused on: • prevention of low birth weight • promotion of exclusive breastfeeding • growth monitoring in children below five years • vitamin A supplementation • anaemia control • salt iodation • food fortification • management of severe acute malnutrition • community-based nutrition rehabilitation • immunisation • control of infectious diseases such as diarrhoea, HIV and AIDS • School health • household food security In recent years, the nutrition interventions have been implemented under the three key themes: ‘Scaling up of nutrition’ (SUN), Feed the future and First 1000 days. The implementation of the above interventions has had support from key stakeholders.

UNICEF supported nutrition interventions

UNICEF’s top priority is to ensure that local government authorities genuinely own and effectively lead their work to improve nutrition status. UNICEF’s work includes: • working with district health departments to ensure that they prioritise nutrition and helps them to build their skills in planning, budgeting and coordinating the delivery of nutrition services for children and women; • working with the government to develop an in-service training program for a recently introduced new cadre of nutrition officers16 at district and regional level; • assisting the district health departments in building the skills of health services providers in delivering services to children and women; • working through district health and community development departments, health providers and communities in the field, to help families learn17 essential skills and basic knowledge in the nutritional care of young children; • working with the Ministry of Health and Social Welfare (MoHSW) and with districts to ensure that18 vital nutrition supplies and equipment are available in health facilities.

References 1 Estimates consider the effects of excess mortality due to AIDS; resulting in lower life expectancy, higher infant mortality, higher death rates, lower population growth rates, and changes in the distribution of population by age and sex than would be otherwise 2 National Nutrition Strategy - JULY 2011/12 to JUNE 2015/16 3 National Bureau of Statistics (NBS)[Tanzania] & ICF Macro, 2011 4 2015/2016 DHS recently completed 5 Low weight for age - composite measure of long- and short-term under nutrition 6 Low height for age an indicator of chronic under nutrition 7 Low weight for height an indicator of acute malnutrition 8 Alderman H, Hoogeveen H, Rossi M. Reducing Child Malnutrition in Tanzania: Combined Effects of Income Growth and Program Interventions. World Bank 2007 9 A study in the Kagera region (border Lake Victoria found that malnourished children lose up to two years of education compared to their adequately nourished peers (World Bank, 2007) 10 SM Grantham-McGregor, SP Walker, JH Himes, CA Powell. Stunting and mental development in children. Workshop: Health and functional consequences of stunting 11 Tanzania step survey - 2012 - Fact sheet 12 Mkenda A. The Benefits of Malnutrition Interventions: Empirical Evidence and Lessons to Tanzania, Report for the World Bank, 2004 13 3 regions - Rukwa, Mbeya and Iringa in Southern Tanzania (Figure 1) 14 Expressed in standard deviation (SD) from the median of the WHO child growth standards 2006 15 Tanzania HIV and AIDS and Malaria Indicator Survey 2007-08 16 None with formal dietetic qualifications or academic background - up until now a handful in the country and those recently qualified and employed 17 This includes best practices in breastfeeding and complementary feeding, the promotion of iodized salt consumption and health-seeking behaviour 18 1including vitamin A supplements, deworming tablets, highly nutritious therapeutic foods to treat severe acute malnutrition, and equipment to measure nutrition status

www.NHDmag.com March 2016 - Issue 112

5

NHD-Extra: WEIGHT management

CASUAL THOUGHTS ON CASUAL DINING Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company.

She was also a nutrition scientist at the British Nutrition Foundation for seven years.

Ursula helps guide the NHD features agenda as well as contributing features and reviews

6

In late February, more than 170 companies exhibited at the ‘Casual Dining’ show at the Business Design Centre in Islington. Every kind of food and drink supplier to the eating-fast trade was there. Food choice has never been wider, and food speed has never been faster, says Ursula Arens.

Of course there was excitement and buzz at the Casual Dining show, because the sector is booming. This is less because of the genius of beguiling products on offer, but rather because the sector offers the perfect match to the siren calls of time-poor consumers, burdened with declining skills in the kitchen and the demands of screenenslavement*.

Fast-and-easy is the food solution most highly valued by consumers of today. In fact, Islington residents even have trouble leaving the sofa to go out to eat at restaurants or takeaways; restaurant collection scooters are everywhere.

The ‘Just Eat’ delivery service had an increase in revenue in the year to 2015 by nearly 60% to £248 million and nearly 65 thousand restaurants are now ‘on call’ through their mobile phone app. Food choice has never been wider, and food speed has never been faster.

So, what where the diet or nutrition themes revealed at Casual Dining? Star foods are still the twin offspring of the low carb craze: coconut and avocado.

A coconut flavour vodka drink won the new products competition, but even as the award was announced, the developer stated that the sample product was going to be changed: 128 calories in the 250ml bottle was creating anxiety in the young female target, and reformulation is planned to allow ‘only 99 calories’ per serving claims on labelling. Another competition winner was frozen ready-to-serve avocado halves, which will allow time-pressed caterers an instant menu update.

www.NHDmag.com March 2016 - Issue 112

The themes of gluten-free and dairyfree rumble on, and other prizewinners in the new products competition were a dairy-free coconut-based ice cream and gluten-free sweet pastry cases for dessert menus. Gluten-free tags also link hot dogs, myriad pasta shapes and a variety of specialist beers and ales.

Flavours are more and more important, but within the strong remit of sugars-with-caution. So, herbal-foradults soft drinks are poised to replace traditional juices and soft drinks and the Japanese Yuzu super citrus is the betting favourite amongst flavorologists. Tea is another booming target for the flavour industry as the British public shows boredom for the straight brew and black tea, plus was very evident in the displays (which means plus, for example, bubble gum or butterscotch or chocolate and nut or elderflower and grapefruit flavours).

Allergen anxiety was evident, and several companies offered allergencompliant menu management software systems. Another nice idea was the provision of menu cards for caterers in pubs and restaurants supporting the provision of special diet requests (such as gluten-free). Clearly, the everdemanding customer has resulted in far greater thought and sensitivity to special diet requests, and the greater professionalism in catering for these requirements is a welcome outcome.

One stand in particular left me shamefaced. Reynolds is a catering supplier to restaurants and canteens and they had an amazing display of fresh fruits and

Top 10 casual dining brands; turnover, 2015, in £million Pizza Express

406

Frankie & Benny’s

398

Nando’s

395

Harvester

326

Pizza Hut

225

Beefeater Grill

176

Prezzo

175

TGI Fridays

174

Jamie’s Italian

144

Weatherspoon

133

The top 20 brands own 68% of the UK eating-out market

vegetables. But hardly any were familiar to me.

White carrots or parsnips? Purple potatoes or beets? A kindly chef talked me though many of the items, with unpronounceable names. But the seed planted is the astonishing variety of vegetables that are theoretically available to customers of today, and the possibility that veg-expertise could become as acclaimed as wine-expertise in culinary elites…which hopefully could contribute to a wider sourcing and consumption in supermarket shoppers, in the way that wine has in the past few decades. The questions dietitians may ask is whether veg-snobbism is a help or hindrance in greater total intakes in the UK population.

CEOs of companies such as Wagamama, Gourmet Burger Kitchen and Carluccio’s gave presentations on how they saw the future (= rosy).

Success was all about identifying the ‘sweet spot’ between the triangle of speedy service, quality interesting foods and perceived-value prices. Most eater-outers preferred international cuisine to classic English/British menus, and Italian, Indian and Chinese were still the favourites. Casual Dining providers needed to assess their offerings in relation to time of day and age groupings, to keep interest and custom, and (yawn) the importance of digital marketing was the common theme: “email does not cut it anymore.”

A report commissioned by the company Sacla Italia provided data from in-depth interviews with more than 2,000 consumers. Eating-out

occasions were described to be increasingly fluid, flexible and informal - something that was termed, the deregulation of life. Of interest to dietitians was that one of the 10 ‘certainties’ about the future, was the greater focus by consumers on optimising individual health and wellness: this would become mainstream (or mandatory).

Also in the conclusions section of the report of seven do-immediately actions for Casual Dining providers, was to explore health partnerships, as this would continue to be a constant theme of consumer interests. Jobs for dietitians.

Every retailer knows that the customer always wants it all, and is always right (or they are not your customer). The main themes of the show that water must be coconut, pasta must be gluten-free and pork must be pulled, do not really fit in with current public health messages, but clearly the Casual Dining sector is sensitive and responsive to perceived health concerns; the only problem is one of translation, as nutrition messages via media and customers are mixed and muddled. There is a great urgency for some pragmatic and trend-aware dietitians to join this sector as friends-not-foe. A few inside wins could do much to steer decisions towards a healthier diet for the population, and no profession is better placed to make a much-needed impact.

A diary date for interested dietitians is the next Casual Dining show in Islington, London on 22-23 February 2017.

* Average UK adult spends over eight hours a day (521 minutes) on screen-based activity (smartphone, TV, tablet, console etc). Reported in trajectory research ‘Eating Out - Today and Tomorrow - the key insights and trends shaping the UK eating-out market’, funded by Sacla Italia.

www.NHDmag.com March 2016 - Issue 112

7

NHD-Extra: obituary

OBITUARY

Patricia (Pat) Elizabeth Torrens 17th October 1921 to 26th November 2015 Written by Norma Lauder Registered Dietitian, Retired

Norma retired from her role as Head of Nutrition and Dietetics at Doncaster Royal Infirmary in 2010, after 42 years with the Trust. Norma was also Fellow and former Honorary Chairman of the British Dietetics Association (BDA) and was the BDA’s representative on the Whitley P&T ‘A’ Council for NHS employment relations for nearly 20 years.

8

Pat was brought up in Market Rasen where her father was a GP and Medical Officer at the Racecourse. Her mother had been a nurse before marriage, but had decided, with Pat in agreement, that Nursing was not for her daughter.

However, Pat’s mother had heard of the newly emerging profession of Dietetics and after enquiries, Pat went off to train, firstly at the Edinburgh and East of Scotland College of Domestic Science (Athol Crescent), and then at the Royal Infirmary of Edinburgh, qualifying in 1942.

After a period working in Catering, Pat moved to the Westminster Hospital as a dietitian in 1951, becoming Chief Dietitian, a post she held until 1972 when she became the first full-time Dietetic Adviser to the Department of Health. Previously, there had been Catering Advisers who were also dietitians, but this post made Dietetics unique among the Allied Health Professions in having its own professional adviser, a post she held with distinction until her retirement in 1984.

www.NHDmag.com March 2016 - Issue 112

As preparations were made for the first reorganisation of the Health Service in 1974, Pat, as a member of the BDA’s Progress and Development Committee, worked hard to ensure that a new viable structure for the profession would emerge, creating the post of District Dietitian. This saw the profession expand from the mainly hospital/clinical sphere, (there had been a very few Community Dietitians in the 60s and early 70s), to become the profession we would recognise today with its broad input into Clinical, Community and Public Health.

Crucially, recognising that senior members of the profession needed to make a huge transition in knowledge and skills if they were to be successful in filling these posts, Pat obtained the resources from the Department of Health to run role development courses at the NHS Training Centre in Harrogate for all the newly appointed District Dietitians. Some other senior members of the profession had been sceptical of their colleague’s ability to make the transition to the wider

sphere of influence, but the courses led the way, enabling dietitians who had worked for many years to take on and successfully develop new ideas for the delivery of dietetic services.

As Dietetic Adviser, Pat travelled extensively, giving advice and support to both local management and their dietetic staff.

She sat on the management side of the P&T ‘A’ Whitley Council, respected by both sides, steering a balance between the needs of the service and the aspirations of the profession.

Pat was a supportive colleague and many remember her nodding in agreement with them as they spoke at meetings. She was also great fun to be with, enjoying food and company, always travelling with The Good Food Guide in case of emergency. Both management and staff had cause to be grateful for this during one not-to-be-forgotten joint visit to Glasgow when she rescued us from a miserable situation by producing the Guide, enabling us to have a convivial evening between two very trying days.

For many reading this, it will be difficult to remember the women of Pat’s generation, who in the first world war lost the men who would have gone on to be husbands. Pat never repined, becoming instead a devoted Godmother whose Godchildren remember her with affection and gratitude. She provided

them with experiences, some must have been very hard to organise, which they remember with a smile.

Pat’s father’s links to the Market Rasen Racecourse meant that she enjoyed horseracing throughout her life, preferring National Hunt and Three-Day events like Burghley. I have happy memories of a bitterly cold January day at the course, when a Hip flask of Cherry Brandy was produced to keep out the cold.

She travelled extensively with friends and maintained lifelong friendships.

Pat held office in the British Dietetic Association as Hon Secretary (1963-67), then Chairman between 1968 and 1970 and was made a Fellow in 1979. In retirement, Pat became Church Treasurer for a number of years and volunteered in a local charity, the Ham and Petersham SOS which supports the elderly and who in turn supported her in recent months. She continued to drive into her 90s, but latterly her arthritis became very troublesome. She refused to take painkillers on a regular basis, living independently in her home of many years, but and as she said to her beloved Goddaughter Jane, ‘it was time to move on’.

There can be few dietitians who touched the lives and careers of so many other dietitians.

NH-eNews plus NHD eArticle with CPD

com

Issue 103

April 2015 NHDm

ag.com

m

Issue 105

NHDmag.co

June 2015

NH Dm ag Issu .ceom 107

August

/Septe

o.uk OBS.c ieteticJ 9 www.d Since 200

NHDmag.com

NHDmag.

.uk co BS. JO 09 tic iete e 20 w.d Sinc ww

To register please visit

.uk .co BS JO 9 tic 200 iete ce w.d Sin ww

The UK’s only weekly enewsletter for dietitians and nutritionists.

mber 201

5

Issu

e 10

9N

ov

ENEFITS EH IONALEBNTG RIT U AR L TFEED NUTRIT FOOFLYO A LOWVIN PAING GMSIN E TRDOIN KEDPIR ATEG RIC NAN FO CY OD AL LE RG Y

em

be

r 20

15

ISSN 1756-95 67 (Online)

ISSN 1756-956 (Online)

7

p25 ISSN Phillips 1756-9567 Frankie n and(Prin t) Carrie Ruxto ISS N 175 ITION 6-9 E NUTR DO DIET 567 MarionSTUDY ITIAN CARE HOM (On MA Ireland FEED PRES S NEED line LN CASE ELDERLY ) CRIBERS? TO BE SIP FEEDING: ELD UTRITWTH and Shubha PEG ER Moses GROION AN . . . p18 GLY. DimpROL p9 . . p17 HT CONT le Thakrar D TH FALTERIN ITIONMILK Prescribin E WEIG E INTENSIV ME . . . p20 ALTERNA PA g Supp CARE NUTR Bolton ort Dietit TIVE RE Corde CANCERAnna Fitz CCG PROGRAM ian MALNUT INTES NTE lia Wo Prescr Gib N RA RITIO odw ibing bon CHILDHO tt Pe N SIVE L N PR ard DIETETIC*/ Supp OD OBE te CAR UTRETER p13 Helen Kinge ARCH N ian ort FOL "3 Turn NU RESE utSITY Dietit W LOW s W Dietitia TR ITIO M INF EU s NE EB WAT -ON Bariatric DIETET ITI oyalritiona er ANT n FORR NON CH s NE N MUL B WATCH IC* FEED AS Live l Su DYSPHAIT . . ANOD W RES /"3 N CH "3 s WE ING EARCH s W YL pp GIA. p2 TH rp DIETETIC*/ EB WA ooCOMM PR4OD E OTHO UN l U ort D RAX TCH DI UCT nive ietitICATIO ETET UPDA s N ia NS IN rs EW n ity IC*/RE DIETE TE Hos "3 SEARCH TICS pita s l W Miri W DY EB am SP EIG WAT Ta HT HA KE rkin CH G M TO MY p1 s N GE CO IA IN ANA 3 GE CA NIC PR EW ME DIE OTE RE RES T & IN B HOM NT EA ALZ EN ES RC H HE EFITS IM ER ’S

www.NHDmag.com March 2016 - Issue 112

9