NHD May 2015 issue 104 by NH Publishing Ltd

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NHDmag.com

Issue 104 May 2015

Optimal diet for bone health Dr Carrie Ruxton p11

ISSN 1756-9567 (Online)

Rethinking dairy . . . p29

Dr Justine Butler Senior Researcher and Writer Viva!Health

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References 1. WHO World Health Organisation. Report of a Joint WHO/FAO/UNU Expert consultation. WHO Tech Rep Ser 2007(935): 1-265. 2. Clarke SE et al. J Hum Nutr Diet 2007; 20: 329-339. 3. Van Waardenburg DA et al. Clin Nutr 2009; 28: 249-255. 4. de Betue CT et al. Arch Dis Child 2011; 96: 817-822. 5. Bueno AL et al. Euro J Clin Nut 2010; 64(11): 1296-1301. 6. Black RE et al. Am J Clin Nut 2002; 76: 675-680. 7. Greer FR, Krebs NF Pediatrics 2006; 117(2): 578-585. 8. Leach JL et al. Am J Clin Nut 1995; 61: 1224-1230. Nutricia Ltd White Horse Business Park, Newmarket Avenue, Trowbridge, Wiltshire, BA14 OXQ, UK Tel 01225 711677 | Fax 01225 711972 | nutricia.co.uk

from the editor The ‘Marathon season’ has truly started. Several of my friends and work colleagues recently ran the Sheffield half marathon - an incredibly scenic route - and the London marathon. Those who participate are really willing, able and ready.

Chris Rudd NHD Editor Chris Rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCT Medicines Management Team, as a Dietetic Advisor.

@NHDmagazine

Their pre-marathon physical activity and dietary intake help maximise their performance and their aim to perform a ‘personal best’, or raise money for a charity, offers real motivation. Support and encouragement from family, friends and work colleagues helps throughout the preparation phase as well as in the actual run and enhances that proud moment when all has been achieved. There are common threads here with other dietary interventions, such as with weight reduction or the treatment of diabetes. This month we offer Introducing the PREVIEW study: PREVention of diabetes through lifestyle intervention and population studies in Europe and around the World by Nicky Gilbert and her supporting team. This collaborative research project began in January 2013 and runs through until December 2018. Dietary changes, physical activity and integration with behaviour modification thread throughout this study. The team in Nottingham so far has found this work to be ‘exciting, exhilarating and intensive’. You can find out more by reading the article. If you are not familiar with the new hospital food standards in England Editor Chris Rudd RD Features Editor Ursula Arens RD Design Heather Dewhurst Sales Richard Mair richard@networkhealthgroup.co.uk Publisher Geoff Weate Publishing Assistant Lisa Jackson

then Andy Jones tells us about what they really mean. There is a difference between ‘eating for good health’ and ‘healthy eating’ which Andy explains as well as the ‘Last 9 yards’. The article emphasises the importance of dietitians and caterers working together to ensure that there is an effective Hospital Food Plan. Last month I mentioned that I had been to Professor Pat Judd’s celebration of life service. Moira Nash (nee Taylor) paid tribute to Pat and I am so pleased that Pat’s husband Tony agreed for Moira to share that tribute with us (see page 38). For those of you who knew Pat this tribute will offer a reflection of her great passion for dietetics. What else is available to read? Optimal diet for bone health by Carrie Ruxton and an update on Specialist infant formulas by Emma Coates are covered. Ruth Passmore tells us about Coeliac Disease Awareness Week 2015 and how we can become involved to help diagnose the half a million people living with undiagnosed coeliac disease. There is a wide variety of articles this month which I hope will be interesting and informative for you.

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NHDmag.com May 2015 - Issue 104

Contents

COVER STORY

Optimal diet for bone health 5

News

35 Web watch

Coeliac disease

36 In memory of Pat Judd

16 Hospital food and nutrition

38 dieteticJOBS

20 Diabetes

40 Events and courses

25 Specialist infant formulas

41 The final helping

29 Rethinking dairy

42 Subscribe to NHD Magazine

33 British Cohort Report

Editorial Panel Chris Rudd Dietetic Advisor

Ruth Passmore Health Policy Officer, Coeliac UK

Neil Donnelly Fellow of the BDA

Andy Jones Chairman of Hospital Caterers Association

Ursula Arens Writer, Nutrition & Dietetics

Nicky Gilbert Lead Research Dietitian, University of Nottingham

Dr Carrie Ruxton Freelance Dietitian

Kate Harrod-Wild Specialist Paediatric Dietitian

Dr Emma Derbyshire Nutritionist, Health Writer

Dr Justine Butler Senior Researcher and Writer Viva!Health

Dr Anita MacDonald Consultant Dietitian in IMD

Moira Nash (née Taylor) Nutrition and Dietetics, University of Nottingham

Emma Coates Senior Paediatric Dietitian

Cheryl Percival and Laura Helm University of Nottingham

NHDmag.com May 2015 - Issue 104

news

Protein and children’s health

Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd

High protein diets have been linked to childhood obesity, although for adults some health benefits have been seen, e.g. possible satiety effects. Now, a new review of 56 studies has looked into links between protein and health in the under 18s. Data extracted from 56 studies did not find any significant links between protein intakes and insulin sensitivity or blood lipids. Some studies found associations between higher protein intakes and lower blood pressure, although the evidence was not strong. Four of the studies looked at animal protein intakes and health, but findings were inconsistent. Overall, there could be a trend towards reduced blood pressure with higher protein intakes, but better designed studies are needed controlling rigorously for confounders. Possible mechanisms of action also need to be investigated. For more information see Voortman T and Vitezova A et al (2015). British Journal of Nutrition, 113(03), pg 383-402.

Latest on tea and health

Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

Tea is renowned for its health and wellbeing benefits, with two new studies looking into this further. One study tested whether green tea epigallocatechin-3-gallate (EGCG) could help to improve energy metabolism in patients with multiple sclerosis, as muscle weakness and fatigue are common symptoms. Eighteen patients with MS symptoms took part in a double-blind randomised trial, taking either EGCG (600mg per day) or a placebo for 12 weeks with a four-week washout period in between. Metabolic responses were measured at rest and during 40 minutes of exercise. Results showed that EGCG provided over 12-weeks improved muscle metabolism during moderate exercise for men (energy expenditure after eating

Early years’ report

Nearly every aspect of human development is laid down in early childhood. This includes nutritional exposures before, during and after pregnancy, all of which have lifelong effects on the health and wellbeing of the next generation. A new report by the All-Party Parliamentary Group on a Fit and Healthy Childhood, which includes contributions from Nutritional Insight Ltd, discusses and makes recommendations in relation to aspects of maternal nutrition, infant nutrition, early years following weaning, childhood obesity and the education and training needs of health and education professionals. Points such as the need to establish anti-obesity strategies from infancy, target micronutrient deficiencies, e.g. vitamin D in childhood and train health visitors in nutrition are discussed. For more information see: www. nutritional-insight.co.uk/publications/ (click on the Early Years’ Report image).

was lower and carbohydrate oxidation more stable), but not amongst women, possibly due to hormonal differences. A second study looked into tea (and coffee) drinking in relation to endometrial cancer risk. The study pooled data from 560,356 subjects who had taken part in the UK Million Women Study and a meta-analysis was also carried out on the results. Overall, it was found that there was no significant association between tea consumption and endometrial cancer risk, although a weak association was found for coffee. For more information see: Merinio J et al. (2015) The American Journal of Clinical Nutrition, 101(3), pg440-448 and Owen Yang TY et al (2015) The American Journal of Clinical Nutrition, 101(3), pg570-78. NHDmag.com May 2015 - Issue 104

news

New survey data on blood folate levels Folate in the diet is found naturally in certain foods and is also provided from certain fortified foods and supplements. A new report, using data from the National Diet and Nutrition Survey now provides a valuable source of information about blood folate levels in the UK. The report includes data from 1,769 adults and 902 children who provided blood samples. Using these, serum total folate, red blood cell folate and free (unmetabolised) folate were measured. Around one-fifth of boys and girls aged 11 to 18 years had serum total folate levels be-

low cut-offs used to indicate deficiency (below 10nmol/L). Equally, 22 percent of women aged 16 to 24 years, 18 percent of those aged 25 to 34 years and 13 percent of those aged 35 to 49 years were also deficient. Overall, it can be seen that folate deficiency is still a problem in the UK as this has wider implications in relation to infant health and if teenagers or women of childbearing age should fall pregnant. For more information see: Public Health England (2015) National diet and nutrition survey supplementary report: Blood folate. Available at: www.gov.uk/government/statistics/nationaldiet-and-nutrition-survey-supplementary-report-blood-folate

Sodium and health

Sleep and weight management

It is well known that we need to cut-back on our sodium intakes. This is mainly due to high intakes being linked to high blood pressure; a risk factor for cardiovascular (CV) disease. Now, a new study has looked into this further. Scientists from the PREDIMED study measured sodium intakes using a food-frequency questionnaire amongst subjects (n=3,982) at high risk of CV disease. Sodium intakes were then categorised into low, intermediate or high, with changes in sodium intake recorded after one and three years. Results showed that sodium intakes of less than 2.3 grams per day were associated with reduced mortality risk. For those whose sodium intakes increased after one year, this was associated with a 72 percent higher risk of CV problems. Overall, findings indicate that people at high risk of CV disease could benefit from reducing daily sodium intakes, ideally to less than 2.3 grams. Combining this with a Mediterraneanstyle diet could also help to support heart health. Further studies are now needed to see if similar results are reported. For more information see: Merinio J et al (2015) The American Journal of Clinical Nutrition, 101(3), pg440-448. 6

NHDmag.com May 2015 - Issue 104

Sleep is central to health and well-being. Modern day stresses, however, such as irregular working hours and general worries can lead to poor quality or insufficient sleep. Given that 42 percent of UK adults are now overweight and more than 25 percent are obese, a new review has looked into links between sleep and body weight. From the studies identified, it was found that encouraging people to sleep for six to nine hours daily, ideally seven to eight hours, and to reflect on their sleep quality could go some way towards helping to regulate body weight. Interestingly, short night-time sleep also seems to be related to body weight in children. Data from the Early Childhood Longitudinal Study-Birth Cohort has shown that obesity risk was significantly higher for children sleeping less than 9.4 hours each night, going to bed later than 9pm (at age five years) or waking before 6.30am. On the whole, promoting earlier and longer sleep durations could be a potential means of regulating body weight in both children and adults. The importance of this now needs to be communicated alongside messages to eat a healthy balanced diet and keep active. For more information see: Ruxton CHS and Derbyshire EJ (2015) Complete Nutrition, 15(1), pg12-14 and Scharf RJ and DeBoer MD (2015) Pediatric Obesity 10(2), pg141-8.

Coeliac disease

Awareness Week 2015

Ruth Passmore, Health Policy Officer, Coeliac UK

Coeliac disease is an autoimmune disease associated with chronic inflammation of the small intestine which can lead to malabsorption and nutritional deficiencies. In people with coeliac disease, gluten, a protein found in wheat, barley and rye, elicits an abnormal immune response. The only treatment for coeliac disease is lifelong adherence to the gluten-free diet and undiagnosed coeliac disease can result in long-term complications including osteoporosis, unfavourable pregnancy outcomes and a small increased risk of intestinal malignancy. Prevalence

One in 100 people in the UK are estimated to have coeliac disease (1); however, the latest statistics show that only 24 percent of those with the condition are diagnosed (2). Rates of diagnosis are also known to vary by socio-economic status, with children living in more socio-economically deprived areas in the UK less likely to be diagnosed with coeliac disease (3). With only 24 percent of people with coeliac disease currently diagnosed, there are around half a million people in the UK who are living with undiagnosed coeliac disease. This year, Coeliac UK’s awareness week will take place on 11th to 17th May and will focus on reaching the people currently living with undiagnosed coeliac disease in the UK. Symptoms

Coeliac disease affects different people in different ways. Signs of coeliac disease can affect any part of the body and are not always limited to gastrointestinal symptoms. Symptoms range from mild to severe and can include the following:

• Frequent diarrhea • Anaemia • Fatigue • Nausea • Vomiting • Bloating • Constipation • Weight loss • Mouth ulcers • Gas • Cramping • Abdominal pain Coeliac disease can present at any age but is most commonly diagnosed in people aged 50 to 69 years (2). From initial onset of symptoms, it can take several years for a patient to have a confirmed diagnosis with coeliac disease and research has shown that, on average, it takes 13 years from the initial symptoms to diagnosis (4). Awareness Week 2015 aims to create a stronger link between these symptoms and coeliac disease and to encourage people who are experiencing these symptoms to seek a diagnosis. Some gastrointestinal symptoms of coeliac disease are similar to the signs of irritable bowel syndrome (IBS) and misdiagnosis of IBS in coeliac disease is common. Research shows that one in four people diagnosed with coeliac disease have previously been treated for IBS (5). Because of this, the NICE guideline for Diagnosis and Management of Irritable Bowel Syndrome in Primary Care (2015) (6) recommends that coeliac disease is ruled out before diagnosing IBS. NHDmag.com May 2015 - Issue 104

coeliac disease

There is a genetic association between coeliac disease and the HLA (human leukocyte antigen) gene.

Role of genes and associated conditions

There is a genetic association between coeliac disease and the HLA (human leukocyte antigen) gene. Two variants of the HLA DQ gene are associated with coeliac disease, HLA DQ2 (found in 95 percent of people with coeliac disease) and HLA DQ8 (found in three to six percent of people with coeliac disease) (7). The absence of these genes can rule out a diagnosis of coeliac disease, but cannot be used alone to confirm a diagnosis as 30 percent of the general population also carries the HLA-DQ2 gene (7). Because of this genetic component of coeliac disease, the chance of having the condition is higher (one in 10) for people with a first degree family member diagnosed with coeliac disease than for the general population (one in 100).

Serving suggestion

NHDmag.com May 2015 - Issue 104

The genes that predispose people to coeliac disease are also linked to other autoimmune diseases and there is a higher prevalence of coeliac disease in people with other autoimmune disorders such as Type 1 diabetes and autoimmune thyroid disease. The NICE 2009 guidelines for Recognition and Assessment of Coeliac Disease (8) recommend serological testing for coeliac disease in patients with autoimmune thyroid disease, Type 1 diabetes or people with first degree relatives with coeliac disease. Getting diagnosed

A full medical diagnosis is important to: • provide the benefit of regular follow-up care; • Maximise adherence to the gluten-free diet; • Ensure that symptoms are not due to other unsolved medical problems; • Identify and treat any complications. Coeliac disease is diagnosed by biopsy following a positive blood test. The blood tests measure endomysial antibodies (EMA) and tissues transglutaminase antibodies (tTGA) which are produced by people with coeliac disease in response to gluten ingestion. It is important to inform people who are undergoing testing for coeliac disease that they must continue to eat a gluten-containing diet before testing, as eliminating gluten from the diet could result in a false-negative test result. Once diagnosed, patients should be referred to a dietitian to receive advice on following a gluten-free diet, as adhering to a gluten-free diet requires significant dietary modification. As part of the initial consultation, patients should also be given advice about gluten-free foods available to them on prescription. Rates for adherence to the gluten-free diet can vary between 42 to 91 percent (9) and gluten-free staples on prescription have been re-

Coeliac disease lated to lower intentional gluten consumption Scottish gluten-free food scheme (10). Prescriptions play an important role in In most parts of the UK, prescriptions for gluten-free following the gluten-free diet, as availability foods are issued by the GP and dispensed by the and cost remain a barrier to accessing gluten- pharmacist. However, in Scotland and some other free food. Gluten-free staple foods in super- parts of the UK, innovative pharmacy-led supply markets are three to four times more expen- schemes are in place which demonstrate cost savsive and are not readily available in budget ings, time savings for GPs and improved access to supermarkets and corner shops (11). Gluten- gluten-free food for people with coeliac disease. free food on prescription can, therefore, be es- The Scottish Government has developed a pecially important to people with limited mo- national Gluten-Free Food Service across Scotbility or limited access to large supermarkets land. The service has been running as a pilot since April 2013 and is currently under review. and to people living on a restricted budget. After diagnosis, current guidance from Under the scheme, people with coeliac disease the British Society of Gastroenterology (12) order and receive gluten-free foods directly suggests an annual review of symptoms and through their pharmacist, giving greater condietary management and assessment of the trol over the amount and type of gluten-free patient’s risk of complications. The current staple foods ordered each month. The Scottish NICE guidelines for Recognition and Assess- pilot scheme has created interest from other ment of Coeliac Disease (8) do not cover man- areas including Wales where the results of the agement of coeliac disease; however, an up- pilot are awaited with interest. Northamptondated version of the NICE guidelines which shire, Cumbria, the Isle of Wight and Bedfordcover recognition, assessment and manage- shire are also running successful pharmacy-led ment of coeliac disease are currently under schemes which serve as excellent models for public consultation and are to Clinical10:40 Commissioning Groups looking to Glutafin NHD 1-2 page ad expected HR aw.pdf 1 be 28/04/2015 published in September 2015. implement similar schemes.

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NHDmag.com May 2015 - Issue 104

coeliac disease How to get involved in Coeliac Disease Awareness Week 2015

If you would like to help raise awareness of coeliac disease and help diagnose the half a million people living with undiagnosed coeliac disease, you can get involved in a number of ways: • Screen your IBS, Type 1 diabetes and autoimmune thyroid disease patients for coeliac disease. • Refer patients to www.isitcoeliacdisease. org.uk which provides information and advice for the general public on the symptoms and risk factors associated with undiagnosed coeliac disease. The site also

features a new self-assessment tool to help people undiagnosed with coeliac disease to decide whether they need to seek further medical advice about a diagnosis of coeliac disease. • Refresh your knowledge of coeliac disease by visiting the healthcare professional resources section of www.isitcoeliacdisease. org.uk. • Join the Coeliac UK Healthcare Professional (HCP) Network (free) for access to the latest research findings into coeliac disease and the gluten-free diet www.coeliac.org.uk/ HCPNetwork.

References 1 Bingley PJ, Williams AJ, Norcross AJ et al (2004). Undiagnosed coeliac disease at age seven: population based prospective birth cohort study. BMJ 328(7435): 322-3. doi: http://dx.doi. org/10.1136/bmj.328.7435.322 2 West J, Fleming KM, tata LJ et al (2013). Incidence and prevalence of coeliac disease and dermatitis herpetiformis in the UK over two decades: population-based study. Am J Gastroenterol 2014;109:757-768 3 Zingone F, West J, Crooks CJ et al (2014). Socioeconomic variation in the incidence of childhood coeliac disease in the UK. Arch Dis Child; 0:1-8. doi: 10.1136/archdischild-2014-307105 4 Gray AM and Papanicolas IN (2010). Impact of symptoms on quality of life before and after diagnosis of coeliac disease: results from a UK population survey. BMC Health Serv Res 10: 105. doi: 10.1186/1472-6963-10-105 5 Card TR, Siffledeen J, West J et al (2013). An excess of prior irritable bowel syndrome diagnoses or treatments in coeliac disease: evidence of diagnostic delay. Scand J Gastroenterol 48(7): 801-7. doi: 10.3109/00365521.2013.786130 6 National Institute for Health and Clinical Excellence (2015). Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care www.nice.org.uk/guidance/cg61 (accessed 13 March 2015) 7 Kang JY, Kang AD, Green A et al (2013). Systematic review: worldwide variation in the frequency of coeliac disease and changes over time. Alimentary Pharmacology & Therapeutics 38: 226-245 8 National Institute for Health and Clinical Excellence (2009). Coeliac disease: recognition and assessment of coeliac disease. www.nice.org.uk/ guidance/cg86 (accessed 13 March 2015) 9 Hall NJ, Rubin G and Charnock A (2009). Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease. Alimentary Pharmacology & Therapeutics, 30, 315-330. 10 Hall N, Rubin G and Charnock A (2013). Intentional and inadvertent non-adherence in adult coeliac disease. A cross-sectional survey. Appetite 68 5662 11 Singh J and Whelan K (2011). Limited availability and higher cost of gluten-free foods. Journal of Human Nutrition and Dietetics, 24, 479-486 12 Ludvigsson JF, Bai JC, Biagi F et al (2014). Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology Gut 2014; 63:1210-1228 doi:10.1136/gutjnl-2013-306578

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OPTIMAL DIET FOR BONE HEALTH Dr Carrie Ruxton p11

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cover story

Optimal diet for bone health

Dr Carrie Ruxton PhD, RD Freelance Dietitian

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com

@drcarrieruxton

Osteoporosis occurs when bone becomes thinner and weaker over time, leading to pain and fracture. Figures suggest that around three million people in the UK are affected (1). Osteomalacia, a less serious condition, is when bones are softer and weaker than normal, leading to painful bending and cracking of bone tissue. Despite the hard structure of bone, it remains in a constant state of turnover - a cycle known as bone remodelling. Special cells known as osteoclasts break down (resorb) bone, while other cells called osteoblasts (bone-forming cells) build bone back up. This is difficult to measure directly which is why indirect markers, such as bone mineral density (BMD), parathyroid hormone (PTH), insulin-like growth factor 1 (IGF1), urinary calcium and carboxy-terminal collagen crosslinks (CTX) are used to assess bone health. In the first two decades of life, bone is built up until the maximum capacity is reached, known as peak bone mass. After this time, bone begins to resorb, a process that accelerates with age and exposure to certain lifestyle and hormonal changes (2). With age, both men and women are at risk of bone loss as a result of declining levels of sex hormones. However, in women this tends to be more pronounced, as oestrogen deficiency is one of the main causes of postmenopausal bone loss (3). Osteoporosis was historically seen as a normal burden of ageing, but the evidence now suggests that weight-bearing exercise and appropriate diet can sustain normal bone density and reduce the risk of fractures What influences bone health?

Several lifestyle factors impact on the risk of developing osteoporosis, in-

cluding low physical activity, smoking, excess alcohol consumption and low intakes of bone health nutrients. The most important of these nutrients are vitamin D and calcium which work in combination to strengthen and stabilise bone tissue. Calcium and vitamin D act directly, by modifying bone turnover, as well as indirectly, through changes in hormone secretion and mineral absorption (4). Calcium is essential for the formation of strong bones, giving them strength and rigidity, while vitamin D works by boosting calcium absorption in the gut. This, in turn, helps to maintain the correct ratio of calcium and phosphorus in blood. Other nutrients such as magnesium, phosphorous and fluoride also reinforce the processes of bone formation, while iron, zinc, boron, copper and manganese help support normal bone metabolism (5). Carotenoids (vitamin A), vitamins B, C and K are thought to support bone health, although the evidence for vitamin K is stronger than for the others. The role of many of these nutrients in bone health has been recognised by the European Nutrition and Health Claim regulations which have authorised bone maintenance claims for protein, vitamins C, D and K, calcium, magnesium, zinc and phosphorous (Table 1) (6). Food and drink products can, therefore, make a bone health claim as long NHDmag.com May 2015 - Issue 104

bone health

Contributes to the maintenance of normal bones.

Vitamin C

Contributes to normal collagen formation for the normal function of bones and cartilage.

Vitamin D

Contributes to normal absorption and utilisation of calcium and phosphorous. Contributes to normal blood calcium levels. Contributes to the maintenance of normal bones.

Calcium

Calcium is needed for the maintenance of normal bones.

Calcium plus vitamin D*

Calcium in combination with vitamin D may reduce the loss of bone mineral in postmenopausal women. Low bone mineral density is a risk factor in the development of osteoporotic bone fractures.

Vitamin K

Contributes to the maintenance of normal bones.

Magnesium

Contributes to the maintenance of normal bones.

Zinc

Contributes to the maintenance of normal bones.

Phosphorous

Contributes to the maintenance of normal bones.

as they contain sufficient amounts of at least one of these nutrients, i.e. at least 15 percent of the recommended daily allowance (RDA) per 100g for vitamins and minerals, or at least 12 percent total energy as protein. Adequacy of bone health nutrients

Data from the UK National Diet and Nutrition Survey (NDNS) (7) suggests that a significant proportion of adults and teenagers have inadequate intakes of bone health minerals, while vitamin C intake is satisfactory (Table 2). As the NDNS did not report intakes of vitamin K and phosphorus, no comment can be made on these; however, deficiency is likely to be rare. Average protein intakes far exceed recommendations and are not a problem for most people. It is more difficult to comment on dietary inadequacy of vitamin D, as the UK has not yet set dietary reference values for most of the 12

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population. However, compared with the labelling RDA of 5µg, intakes of vitamin D are low at 2.4µg in children and 3.6µg in adults. Elderly people, who should be consuming 10µg daily, have a mean intake of 5.1µg. As most vitamin D in the body is synthesised in response to regular summer sunlight, serum 25-hydroxyvitamin D is a better indicator of vitamin D adequacy. In the latest NDNS, 12 to 24 percent of participants were vitamin D deficient (7). Improving bone health

Several studies have investigated the effect of vitamin D and calcium on the risk of fractures or falls. One controlled trial (8) supplemented over 3,000 elderly women with 20µg vitamin D and 1,200mg calcium daily for two years, with findings demonstrating a 43 percent lower risk of hip fractures compared with the control group. A three-year trial (9) which supplemented 9,600 elderly women with 10µg vitamin D/1000mg

bone health

As falls are the biggest contributor

Table 2: Percentage of people with inadequate1 intakes of bone nutrients 19-64 years

11-18 years

Nutrients

Male

Female

Male

Female

Vitamin C (mg)

Calcium (mg)

Magnesium (mg)

Zinc (mg)

to fracture risk, improving muscle strength and balance in older people are important preventative measures.

Key: inadequacy defined as intakes below the Lower Reference 1

Nutrient Intake.

Source: Bates et al (20

calcium per day reported a 16 percent reduction in risk of fracture. Other supplementation trials have not found significant changes in the incidence of fractures, perhaps due to an inadequate vitamin D dose or lack of adjustment for baseline vitamin D status. Greater success has been seen when BMD is NHD reported Magazine_0415.ai 1 14/4/15 targeted. As in a review (10), five5:11 outPM of nine clinical trials of vitamin D supplementa-

tion, and 16 out of 22 studies on combined vitamin D and calcium supplementation produced statistically significant improvements in BMD, with particular benefits seen in those with poor baseline vitamin D status. As falls are the biggest contributor to fracture risk, improving muscle strength and balance in older people are important preventative measures (11). Vitamin D and calcium seem to have the

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bone health

Giving additional vitamin D and calcium was associated with a 12 percent reduction in risk of fracture, or a 24 percent reduction when compliance was high. greatest effect on risk of fracture when given in combination. Tang et al (12) performed a meta-analysis on 29 randomised trials involving nearly 64,000 participants aged ≥50 years. Giving additional vitamin D and calcium was associated with a 12 percent reduction in risk of fracture, or a 24 percent reduction when compliance was high. For BMD, reduced rates of bone loss at the hip and spine were noted following vitamin D and calcium. Daily intakes of 1,200mg calcium and 20µg vitamin D seemed to produce the most consistent effects on bone health. A similar finding was reported by a pooled analysis of seven trials involving 68,500 participants (13). Given the low vitamin D intakes in the UK, it is unlikely that these optimal levels could be achieved without supplementation or fortification.

Two recent studies have focused on the impact of fortified dairy products on bone health in older women. One randomised controlled trial (14) reported a significant increase in IGF1, a bone formation marker, and a reduction in tartrate-resistant acid phosphatase, a marker of bone breakdown, when postmenopausal women consumed two daily servings of soft cheese fortified with vitamin D. A similar trial (15) in elderly women found improvements in vitamin D status and IGF1, while markers of bone breakdown were seen to reduce. Taken together, these findings indicate that calcium and vitamin D have a consistent, positive effect on bone health, as evidenced by improvements in bone markers and BMD, as well as a reduced fracture risk.

Table 3: Key messages for supporting bone health Patients should be advised to eat a balanced diet, containing sufficient amounts of bone nutrients from a variety of food sources. Calcium and vitamin D are the most important bone nutrients and work best in combination. Both natural and fortified sources should be considered. Vitamin D3, the most bioavailable form of vitamin D, is present in few natural foods. Therefore, patients should be encouraged to eat oily fish and eggs, as well as choosing fortified foods and supplements that contain vitamin D3, rather than D2. Patients should be advised to follow a lifestyle that supports bone health, e.g. engaging in regular weightbearing exercise and avoiding smoking and excess consumption of alcohol. Postmenopausal women, particularly elderly women in care homes, remain the group most at risk of osteoporosis and will benefit from a combination of dietary and lifestyle options to help prevent bone loss. Regular summer sun exposure is vital for ensuring good all-year vitamin D status. Fair skinned people require around 15 minutes of summer sun exposure daily without sun cream. Darker skinned people require more than this.

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BONE HEALTH Advice to patients

The ageing population in the UK, combined with risk factors such as low intakes of minerals, sedentary lifestyles and obesity, represent a growing threat to bone health. Yet, many risk factors are modifiable, creating an opportunity for dietitians to give appropriate advice to patients as suggested in Table 3 (16). Positive changes to diet and lifestyle during childhood and young adulthood can help to optimise peak bone mass, while the strategy in older patients should focus on minimising bone loss to prevent fractures and to maintain normal muscle function. In conclusion, combinations of vitamin D and calcium appear to work better than when given alone, except for the risk of falls, which is influenced mainly by vitamin D status. Fortified dairy products offer a foodbased route for delivering additional vitamin D and calcium, while supplements are a simple, low cost way to top up calcium and vitamin D intakes. At present, year-round vitamin D supplements are recommended for children aged ≤5 years, as well as pregnant and lactating women and people aged ≥65 years (17). References 1 National Osteoporosis Society (2011) Key Facts and Figures. www.nos. org.uk 2 Jimi E et al (2012). International Journal of Dentistry Doi: 10.1155/2012/148261 3 Rizzoli R et al (2010). Bone 46: 294-305 4 Rizzoli R (2008). Clinical Endocrinology & Metabolism 22: 813-29 5 Palacios C (2006). Critical Reviews in Food Science and Nutrition 46: 621-628 6 European Commission (2012). Commission Regulation (EU) No 432/2012. http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L :2012:136:0001:0040:en:PDF 7 Bates B et al (2014). National Diet and Nutrition Survey: headline results from Years 1-4. London: FSA/DH 8 Chapuy MC et al (1992). New England Journal of Medicine 327: 16371642 9 Larsen ER et al (2004). Journal of Bone and Mineral Research 19: 370378 10 Laird E et al (2010). Nutrients 2: 693-724 11 Gillespie LD et al (2003). Cochrane Database of Systematic Reviews 4: CD000340 12 Tang BM et al (2007). The Lancet 370: 657-666 13 DIPART Group (2010). British Medical Journal 340: b5463 14 Bonjour JP et al (2012). Journal of Nutrition 142: 698-703 15 Bonjour JP et al (2011). Journal of Nutrition, Health and Aging 15: 404409 16 Ruxton CHS (2013). Nursing Standard 27: 41-49 17 Chief Medical Officers of the UK (2012). Vitamin D - Advice on Supplements for at Risk Groups. www.dh.gov.uk/health/2012/02/ advice-vitamin-d

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Hospital food and nutrition

Hospital food standards: what do they really mean to you? The new hospital food standards only cover England, with the other three nations having their own standards currently in place or in the process of being reviewed. But what is so pleasing and different this time is that they have all involved those who are delivering the service, from nurses to dietitians to caterers. Andy Jones Chairman of Hospital Caterers Association, ISS Facilities Services (Healthcare)

However, to me it’s about not what we say but what we do that is more important. Let me explain what I mean by this. It’s great having the standards, but we have to ensure that they are followed and that we are all committed to them from bottom to top and vice versa, but above all, they must meet the NEEDS of the PATIENTS we serve. Of course, the standards include areas which impact on the social welfare of the staff working within our Trusts and, of course, the patient’s visitors. This is a key area; as we all know, well-looked after and well-nourished staff members are better able to look after the patients. The key elements - required standards

Andy has been a stalwart of patient catering for over 30 years, with the key influence being the delivery of a nutritious and wholesome food and hydration service at ward level. He has been one of the key leads in the Nutritional and Hydration weeks and currently sits on the Government-led Hospital Food Panel. Andy is also a member of the cost sector caterers’ top 20 public sector caterers.

Patient catering EATING FOR GOOD HEALTH • 10 key characteristics of good nutritional care, Nutrition Alliance • Nutrition and Hydration Digest, The British Dietetic Association • Malnutrition Universal Screening Tool or equivalent (BAPEN) Staff and visitor catering HEALTHY EATING • Healthier and More Sustainable Catering – Nutrition Principles (Public Health England) All catering • Government Buying Standards for Food and Catering Services, HMG standards developed by the Department of Environment, Food and Rural Affairs

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We all know that the standard of catering in hospitals is a very high priority and sadly, one of the things not reflected in the report is that food and drink is an integral part of the patient’s recovery plan and I will continue to campaign for this; after all, food is the best form of medicine. One area within the standard that we ALL have to ensure is in place, is a trust-wide Board-led FOOD and DRINK POLICY, which is essential and involves a multidisciplinary team including dietitians and caterers, but must be the responsibility of the Director of Nursing to ensure its delivery. I am convinced that by working together in implementing this plan, we will succeed in the final outcome. Yes, there are issues and we understand that we will never be able to appease (or satisfy) everybody, but what we have to do is to get the basics right and I believe this standard incorporates the potential to do just that. So what can dietitians do?

Nothing that they do not do already, i.e. work closely with the catering team and patients. After all, we all have our favourite foods when we’re not feeling well, whether it’s a bowl of soup or rice pudding; we naturally gravitate to comfort foods and that is what patients do when in hospital. Patients don’t come into hospital to be adventurous; they come in knowing that the progress of their recovery will be based around nutritious foods which will help them. The new Hospital Food Plan goes a

It is key that our menus and beverage choices meet and are suitable for the patient groups we serve, as well as being flexible in both their offering and adaptability. long way in helping to achieve this, although we know that we have people out there who want nutritional standards made mandatory. The Plan incorporates this aspiration by using the powers of the mandatory NHS Contract and local commissioners. I have often remarked that this is a base mandate to enable us to move forward, but be assured, this is only the beginning of the journey - not the end. In my view, clear and unequivocal standards for nutrition are in place in the British Dietitians Association’s Nutrition and Hydration Digest, developed by Food Counts Specialist BDA Group along with HCA, and these clearly give us caterers our nutritional standards. These are the standards which every NHS caterer in the UK is to achieve in all the menus they provide and when I say the UK, I do mean the four Nations who are covered by this. So, when people call for mandatory standards, just take a step back and think; we already have them, so what we don’t need is more standards, we just need to ensure that people adhere to the standards we have already. How do we do this? We do it by working and listening to the patients we serve with the menus and dishes they want to eat. We must remember that one size does not fit all; we must also look at the names we use in the menus. I believe that in some areas we have become ‘too posh to nosh’ and it’s not about giving different foods, it’s about what we call them. For example, I cast my mind back to the Better Hospital Food Plan; Lamb and Flageolet Beans? I spent almost two hours trying to explain to a patient what flageolet beans were and going back into the kitchen to explain to the chefs. Basically, it was just an enhanced lamb casserole. But taking that aside, we still use ‘posh’ words; creamed potatoes on the

menu when at home we call it mash. Don’t you? I certainly do. Think about it; use simple words which can make such a difference to patients, especially the elderly. How will it be measured?

The Panel recommends that required standards should be monitored via annual Patient Led Assessments of the Care Environment (PLACE) and that PLACE should be amended to include a more detailed evaluation of the taste, flavour and presentation of hospital food. However, whilst I believe that patient involvement is essential to providing a more accurate perspective of views on food, drink and general catering services and to identifying where improvements should be made, we must not allow ourselves to become distracted by overly focusing on scoring and league tables. It is key that our menus and beverage choices meet and are suitable for the patient groups we serve, as well as being flexible in both their offering and adaptability. The advantage of the PLACE data is that it enables us to take a step back and explore in-depth patient feedback on NHDmag.com May 2015 - Issue 104

Hospital food and nutrition

Improved screening of patients’ nutritional status on admission is called for, so that special dietary conditions or needs can also be identified. specific aspects of the service and to work with the patients on those individual areas that have been identified as weaker. But PLACE scores should not be used as yet another stick, but ‘the carrot’ to catalyse continuous, quality improvements. However, in order to achieve this across the board, a view needs to be taken about how some of the catering service is managed in future, such as night time ward snacks and drinks, as these fall under ward budgets and are outside of the caterer’s area of responsibility. In order to improve the quality of all aspects of patient food and drink provision, the caterer should be allowed to take responsibility for the whole of the ward service. What the Hospital Food Plan clearly shows is that, because of the multidisciplinary nature of a patient’s nutritional care, we must continue to work across all departments to ensure consistency and support for a patient’s total food and drink provision. For example, we need to encourage Trusts to seek CQUIN payments to help fund improvements to areas where we need to raise standards. Consequently, there is a need for greater understanding of the wider challenges of producing and delivering food to patients on our hospital wards. In order for nutritional care to be more ‘personalised’ to an individual patient, it is important for all members of the clinical care team, as well as caterers, to recognise the role that food can make to improving the patient’s clinical outcome and to imbed food and drink as part of every patient’s recovery plan. ‘Last 9 Yards’

All of the above can be undone in what we are calling the ‘Last 9 Yards’. In essence, good food can be ruined/spoilt in those last few steps, whether due to lack of care taken in serving the food or drink, or communication with the 18

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clinical teams and/or patients, or to giving the wrong diet. Also serving food without a smile, or showing concern for a patient’s comfort and ability to readily manage and enjoy their meal. So, the work that the group are doing for this is going to be core to moving forward. The 6 Cs are also a major influence to this area and show how the HCA are rising to meet this ‘end stage’ challenge by convening a working group of caterers, nurses, dietitians and SALT representatives from all four nations to focus on this topic on behalf of their professional colleagues. A great example of one outcome of us all working for the same common goal is the study day with NNNG where we join forces with nurse colleagues and which took place at the end of March during Nutrition and Hydration Week. It was a successful example of a multidisciplinary event. The HCA is still calling for a mandatory minimum expenditure on all patient meals to also be introduced in ALL TRUSTS across the UK. The deployment of ward hostesses on more wards, too, would ensure better monitoring and communication of individual patient food and drink requirements and intake. Improved screening of patients’ nutritional status on admission is called for, so that special dietary conditions or needs can also be identified. With a better protocol in place for every single patient which can be followed by all members of the team - from ward to kitchen - and throughout a patient’s stay, patients will then receive the optimum nutritional care that they expect and deserve. This Hospital Food Plan is the beginning and not the end of the process and we as caterers and dietitians have to lead on this. What I am already so pleased to see is the close links and bonds that exist between the BDA and HCA becoming even stronger.

M With the seca mBCA.

diabetes

Introducing the PREVIEW study:

PREVention of diabetes through lifestyle intervention and population studies in Europe and around the World

PREVIEW: PREVention of diabetes through lifestyle intervention and population studies in Europe and around the World Nicky Gilbert Lead Research Dietitian, Intervention Co-ordinator and Group Instructor PREVIEW study, University of Nottingham

Dr Moira Taylor, Associate Professor of Human Nutrition (Dietetics), University of Nottingham PREVIEW team

PREVIEW is an acronym of PREVention of diabetes through lifestyle Intervention and population studies in Europe and around the World. This collaborative research project (led by Professor Anne Raben from the University of Copenhagen) is funded by the European Union in its 7th Framework Programme. Eight European (Bulgaria, Denmark, Finland, Germany, Great Britain, Netherlands, Spain, Switzerland) and three overseas countries (Australia, Canada, New Zealand) are involved in the project, which started in January 2013 and will run until December 2018. Background

Cheryl Percival, Group Instructor PREVIEW study University of Nottingham

Laura Helm, Research Dietitian PREVIEW study University of Nottingham

Please see end of article for details of other contributors.

In the last century, Type 2 diabetes (T2D) was named ‘adult-onset diabetes’, because it was mainly older people who suffered from it. However, T2D is now affecting children and adolescents and having T2D not only means living life in a rigid manner (e.g. by having to watch what to eat), but also confers a higher risk of developing diseases such as high blood pressure, coronary heart diseases and chronic kidney failure, to name a few. Despite this global rise in T2D, it is a condition that may be prevented. Type 2 diabetes accounts for about 90 percent of all cases of diabetes, primarily caused by the worldwide obesity epidemic (1). The relative risk of getting T2D rises exponentially with increasing body mass index (BMI); a BMI above 23kg/m² already doubles the risk of getting T2D (2). The increasing prevalence of obesity is caused by general food abundance together with increased seden-

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tariness (sitting time in front of the TV, computer, etc) and decreased physical activity during work and leisure time (3). Recent studies have also indicated that stress and certain sleeping patterns may also promote overweight and obesity. Indeed, short sleep appears to increase appetite and may be particularly pertinent in increasing obesity and its related diseases (4, 5). Diabetes is a costly condition; according to WHO, the direct healthcare costs of diabetes range from two and a half percent to 15 percent of annual national healthcare budgets (6). This worrying trend calls for action and a need for a variety of innovative approaches to address the problem. One key to success is the prevention of overweight and obesity. Another is to help obese people lose weight and maintain a reduced body weight. In order to successfully fight against T2D, there are two major questions that still need to be answered: “What type of diet is most effective?” and “How intense should physical activity be performed to be able to maintain weight loss?” Both questions are addressed in the PREVIEW study and the public health and socio-economic impact of PREVIEW is expected to be significant. Aims

The primary goal of PREVIEW is to identify the most efficient lifestyle pattern for the prevention of Type 2 diabetes in a population of pre-diabetic,

diabetes Figure 1: Six work packages

overweight or obese individuals in Europe and overseas countries. The project comprises of two approaches: 1) A multicentre randomised lifestyle intervention trial of three-year duration, with a recruitment target of 2,500 pre-diabetic participants, including children and adolescents, adults and the elderly. 2) An epidemiological project, investigating the natural history of T2D and its cardiovascular consequences, according to specific dietary and exercise factors (i.e. protein and GI of diet as well as physical activity intensity), using a large database comprising information that covers the whole lifespan. Randomised Control Trial

PREVIEW consists of six work packages, fig. 1 (see the PREVIEW website http://preview.ning. com/). At the University of Nottingham, led by Professor Ian Macdonald (Principal Investigator), we are focusing on Work package 1 (WP1) which is a randomised controlled and multicentre trial directed by Professor Mikael Fogelholm (Helsinki University). Participant recruitment In Nottingham we have recruited 265 adults between the ages of 25 and 70 years. Participants

were selected by GPs from details held on their databases and were approached by letter inviting them to participate in an initial telephone screening. Using a scoring system (Diabetes Risk Questionnaire), suitable participants were then invited for diagnostic tests at the Medical School in the Queen’s Medical Centre. Those meeting the study inclusion criteria were invited to join the study. Weight reduction phase For the first eight weeks of the intervention, participants attend fortnightly group meetings with a registered dietitian. The emphasis of these group meetings is to support and guide participants towards achieving a target weight loss of eight percent of their initial body weight by following a prescribed low energy diet (approximately 800kcal per day), with products supplied free of charge by the Cambridge Weight Plan Ltd. The content of each group meeting is carefully planned to develop and improve knowledge of T2D and lifestyle modification, whilst also introducing behavioural modification techniques and tools to support the required changes in lifestyle after this phase. Group dynamics are especially nurtured to promote a supportive and friendly environment that will continue throughout the NHDmag.com May 2015 - Issue 104

diabetes

Several studies have indicated that protein promotes greater satiety and weight loss, but higher protein diets can be more expensive and there is a need to assess safety, acceptability and effectiveness in the longer term. study. Exercise is not encouraged during this phase, but participants are prepared for increasing activity when this phase is finished. The weight maintenance phase Those who achieve their eight percent weight loss target enter the 136-week weight maintenance phase of the intervention and are introduced to their randomisation group for diet and exercise. Dietary recommendations

There are two dietary approaches being compared in PREVIEW. One diet includes foods with a medium GI and a moderate protein intake of 15 percent of energy intake, whilst the alternative incorporates foods with a lower GI and modestly more protein (25 percent of energy). Several studies have indicated that protein promotes greater satiety and weight loss, but higher protein diets can be more expensive and there is a need to assess safety, acceptability and effectiveness in the longer term. Lower GI diets have been associated with greater body fat loss in some studies, but the evidence is not consistent. The GI concept has been criticised as ‘too complex’ for the average person to translate into practice. Therefore, the PREVIEW intervention compares two healthy diets with slightly different protein content and GI, to determine which is the most efficient at reducing the risk of developing T2D. Both diets are healthy and varied, high in fibre, low in total fat, saturated fat and added sugar. We hypothesise that one diet will be more satiating and help to maintain weight loss over a long period of time. If this is realised, this diet is also likely to reduce the risk of developing Type 2 diabetes. 22

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Making the dietary changes Participants are initially supported in following their dietary prescription by using a structured two-week menu plan with recipes. A unit ‘swap’ system for each food group is then introduced, allowing participants control and flexibility to personalise their meal plans to suit their preferences, appetite and lifestyles. Mindful eating and related behaviour are fundamental to the dietary interventions. Participants are strongly encouraged to eat ‘ad libitum’ and to ‘eat to appetite’ and also to stop eating before they feel full. Physical activity recommendations

There is good evidence that physical activity (PA) is a crucial behaviour to keep healthy and, in many cases, it is an efficient and inexpensive way to regain health. Despite persuasive evidence, PA seems to be very difficult to realise with the majority of adults and an increasing proportion of young people, failing to achieve sufficient volume of PA for health. Instead of being active, they have a sedentary and inactive lifestyle. PA is any movement that involves the skeletal muscles and results in increased energy expenditure. Exercise is a subcategory of PA that is planned, structured, purposeful, and repetitive. Sedentary time is more difficult to define, but generally involves sitting or lying where energy expenditure drops to around one and a half times the resting level. The volume of PA is composed of intensity, duration and frequency. The question for PREVIEW is, how much and how intense should PA be, in order to prevent a severe disease like Type 2 diabetes? The World Health Organisation recommends 150 minutes moderate intensity activity and/or 75 minutes of high intensity PA per week. PREVIEW will investigate which of these two recommendations is more effective at preventing Type 2 diabetes.

diabetes After the weight reduction phase, participants meet with their group fitness instructor and are introduced to their physical activity recommendations; either high intensity (HI) or moderate intensity (MI). During the next few months of the intervention participants are supported by fitness instructors in group meetings to become fitter and more active, eventually achieving the required PA behaviours. Participants are encouraged to take up a variety of structured activities to suit their lifestyles, as well as becoming more active in everyday pursuits and less sedentary. Integration with behaviour modification Emphasis on behaviour modification strategies is a key feature of PREVIEW and all group instructors, dietitians and fitness instructors have been trained in the specific package of techniques, designed for PREVIEW by our partners at Stuttgart University, known as PREVIEW PREMIT (PREVIEW Behaviour Modification Intervention Toolbox). These techniques are utilised in group meetings through all aspects of the intervention. The ‘phasing out’ approach of the intervention means that group meetings, which initially occur fortnightly, gradually stretch out to six monthly by year three. Participants are strategically guided to acquire skills which will promote maintenance of their PREVIEW lifestyle behaviours. Our experiences so far

The two years that we have been working on PREVIEW have been nothing less than exciting, exhilarating and intensive for our team in Nottingham. Members of the team were involved from the start in shaping aspects of the dietary intervention programme. For example, how we would achieve specific individual protein and glycaemic index targets for participants across relatively diverse cultures, whilst ensuring that the intervention programme remains practical

for application at a population level. We also contributed to the development of centrally produced documents and resources and the refining of inclusion and exclusion criteria. Detailed lesson plans for use in Nottingham were developed for all group meetings, which integrated dietary targets and behavioural techniques at each stage in the intervention. Comprehensive materials were, and continue to be, developed to support and inspire participants to follow their diet and exercise programmes. Contributions and suggestions are also obtained from participants and these are published in a newsletter distributed to all participants bimonthly. Group meetings are frequent and the timetable is busy; in the first six months of this year, we will have run nearly 70 group meetings across 16 cohorts of participants. In order to ensure consistency in delivering the intervention with our colleagues worldwide, we co-lead the Instructor’s Network which operates as an email-based discussion forum, with monthly teleconferences to share experiences and solve any problems which may arise. Recruitment has finally finished, but has been a major logistical challenge; around 50, 000 letters have been sent out to potential participants, resulting in 980 screenings to recruit 265 participants. Our team have had many skills to develop, as well as frustrations and trials to overcome, to ensure smooth running of the study. On a daily basis, there are ongoing challenges to ensure participant motivation, interest and compliance prevails. However, the formation of a stable team of dedicated and enthusiastic individuals is making PREVIEW possible. We are ever grateful to all our participants and are motivated and encouraged by the strength, determination and successes of many, who have not only changed shape, size and body composition, but are enjoying improved health and embracing a better quality of life. We look forward to sharing further information and findings in due course.

Other contributors to the article: Liz Simpson, Nottingham, UK; Wolfgang Schlicht, Stuttgart, Germany; Jennie Brand-Miller, Sydney, Australia; Gareth Stratton, Swansea, UK References 1 Wild S, Roglic G, Green A et al (2004). Global prevalence of diabetes. Diabetes Care, 27: 1047-1053 2 Hu FB, Manson JE, Stampfer MJ et al. New Eng J Med, 2001;345 (11): 790-7 3 Swinburn BA, Sacks G, Hall KD et al. Lancet, 2011: 378:804-14 4 Kobayashi D, Takahashi O, Deshpande GA et al. Sleep Breath, 2012;16: p 829-33 5 Fogelholm M, Kronholm E, Kukkonen-Harjula K et al. Int J Obes (Lond), 2007: 31:1713-21 6 WHO (2015). Diabetes: the cost of diabetes fact sheet No 236

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Coming soon

ON AN INNOVATI

N O � � I � � U � M � � T E IN PR ITH NT FOR USE W EIN SUPPLEME D ONLY PROT ULA RM FO M ER THE FIRST AN ET OR PR

For the dietary management of extremely low birth weight infants Designed specifically to help meet increased protein requirements, as recommended by ESPGHAN, for infants <1,000g1

BREAST MILK

e complet t s o m The rm range prete lable avai

Adaptable dose to help meet the needs of each extremely low birth weight infant

Practical advice for healthcare professionals from

Important notice Cow & Gate Nutriprem Protein Supplement is a food for special medical purposes for the dietary management of extremely low birthweight infants who require additional protein. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. For enteral use only. Reference 1. Agostoni C et al. Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85-91.

infant formula

Specialist infant formulas ‘Breastfeeding is the most appropriate method of feeding the normal infant and may be suitable for sick infants with a variety of clinical conditions.’ (1) However, there are numerous clinical conditions where specialist infant formulas play an important role. Emma Coates Company Dietitian, Dr Schar UK Mevalia Low Protein

In these circumstances breast milk has some limitations. For example, in preterm infants with a birth weight less than 1,500g (1), some rare metabolic conditions such as phenylketonuria (PKU) and in children with allergy, breast milk may need to be limited, fortified or excluded all together either through necessity or due to mother’s choice. Over the last 20 years, specialist infant formulas have evolved to meet the diverse and complex range of nutritional requirements that we are presented with in clinical practice. Getting the correct nutritional balance for our most vulnerable infants is a challenge, but the current range of specialist infant formulas can provide a helping hand. Regularly reviewing feed requirements ensures that the infant is receiving the most appropriate formula for their nutritional needs. They may benefit from the temporary support of a specialist formula, for example, for a few months to manage acute lactose intolerance, or for a longer term where the infant will remain on the specialist formula until they are over one year of age, or until other suitable alternatives can be introduced. This article will look at the current range of specialist infant formulas that are available and their intended uses.

Emma has been a registered dietitian for almost nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, Preterm infant formulas and working in the NHS. She has breast milk fortifiers recently moved Preterm and low birth weight infants into industry and currently works as are some of the most nutritionally vulMetabolic Dietitian nerable patients a dietitian will care for. for Dr Schar UK, Mevalia Low Protein. Breast milk offers numerous benefits

for these infants and maternal or donor breast milk is advocated wherever possible. The breast milk is often given as expressed breast milk (EBM) but may be referred to as MEBM (mother’s expressed breast milk), or DBM (donor breast milk). The incidence of necrotising enterocolitis (NEC) and respiratory infections can be significantly reduced in preterm infants when breast milk is given. Other benefits can include improved bone mineralisation and neurological development (2). Many very premature infants require parenteral nutrition and minimal amounts of breast milk can be given as trophic feeds via the oral or enteral tube feeding route. The use of breast milk may help to reduce the duration of the parenteral nutrition as breast milk is better tolerated than preterm formula. However, breast milk does have its limitations in preterm nutrition. Breast milk fortifier may be used to increase calorie and protein content, which is often required by low weight preterm infants to ensure nutritional needs are met and growth is adequate. Breast milk fortifiers are only available for hospital use, see Table 1. Additional vitamin and iron supplementation is required by all preterm infants who are breast fed, which are prescribed by medical staff. Preterm formulas are used when breast milk is not available. These formulas are more calorie dense than standard infant formulas and contain increased amounts of various nutrients, e.g. protein, iron, calcium and vitamin A and D. They are designed to promote NHDmag.com May 2015 - Issue 104

Infant formula Table 1: Preterm formulas and breast milk fortifiers Product name (manufacturer)

Usage

Preterm formulas Aptamil Preterm (Milupa) Nutriprem 1 (Cow & Gate)

Hospital only

SMA Gold Prem (SMA Nutrition) Nutriprem 2 (Cow & Gate) SMA Gold Prem (SMA Nutrition)

Post discharge

Breast milk fortifiers Cow & Gate Nutriprem Breast Milk Fortifier (Cow & Gate) SMA Breast Milk Fortifier (SMA Nutrition)

Hospital only

growth and development similar to that of a foetus in the womb (3). There are two types of preterm formulas 1) Preterm/low birth weight formula for hospital use only and 2) nutrient enriched post discharge formula (see Table 1). Prior to discharge, post discharge formula will be introduced and preterm infants can be prescribed this formula up to six months of corrected age. Some infants require nutritional support from specialist formulas, for example, high energy formulas, for longer than six months and this should be reviewed regularly by their dietitian and medical team. High energy formulas

High energy formulas are useful when feeding infants with various feeding complications, such as fluid restrictions or those who have limited oro-motor skills when feeding, which can lead to fatigue during feeds. High energy formulas offer more calories and protein than standard formulas. Standard infant formulas provide approximately 66-68kcal per 100ml and around 1.3-1.5g protein per 100ml*. However, for some infants with increased energy needs, e.g. infants with cystic fibrosis, prematurity or those who need to achieve catch up growth, this is not always sufficient. See Table 2 for the current range of high energy formulas plus their calorie and protein content. * based on standard first stage and follow-on formulas from SMA and Cow and Gate - April 2015.

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Allergy and intolerance formulas

This is the largest range of specialist formulas available today. For many years, soya based formulas, e.g. Cow and Gate Infasoy or SMA Wysoy were used as a first line treatment for infants with cows’ milk protein allergy (CMPA) or lactose intolerance. However, they have been superseded by specialist formulas which are better tailored to the infant’s diagnosis. Soya formulas are no longer recommended for most infants who are less than six months due to the potential risk of developing a secondary sensitivity to soya and the undesirable exposure to phytoestrogens, which may cause developmental changes in infants less than six month old (4). It is thought that between seven and 50 percent of children with CMPA may have a secondary soya allergy (5), which throws a questionable light on whether soya formula is appropriate to use in these patients beyond the age of six months. Sheep and goats milks are not advised due to their similar allergenicity as cows’ milk (6). However, in infants with galactosaemia, soya formulas are often used from birth. Although there are specialist formulas available for infants with galactosaemia, use of soya formulas is supported by ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition) (7). They may be used in infants with CMPA or lactose intolerance above six months who do not have sensitivity to soya but are not considered to be a first line choice. Lactose intolerance can be a short-term condition and infants may be prescribed low lactose formula to treat symptoms and standard formula can be reintroduced after six to eight weeks. Lactose-free formulas such as SMA LF or Enfamil O-Lac are cows’ milk based, but their carbohydrate source is glucose rather than lactose. Long-term use of lactose-free formula is required if there is a diagnosis of congenital lactase deficiency, which is rare. This is a permanent condition and the infant will need to remain on lactose-free formula until over 12 months when adult lactose-free milk can be introduced. Lactose-free formulas are also used where primary lactose intolerance is indicated. However, this condition is rare in children below two years of age.

infant formula Table 2: High energy formulas Product name (manufacturer)

Calories/ 100ml

Protein (g)/100ml

Infatrini (Nutricia SHS) Similac High Energy (Abbott Nutrition)

100

2.6

SMA High Energy (SMA Nutrition)

Features Contains LCPs*. Suitable for preterm infants Contains LCPs. Suitable for preterm infants

Meet WHO/FAO guidelines for protein/energy ratio for catch up growth (4)

Contains LCPs. Not suitable for preterm infants

*LCP – Long Chain Polyunsaturated Fatty Acids

Table 3: Allergy and intolerance formulas Product name (manufacturer)

Composition

Indications for use

Lactose-Free Formulas SMA LF (SMA Nutrition)

<6.7mg lactose per 100ml

Enfamil O-lac (Mead Johnson Nutrition)

<7.0mg lactose per 100ml

Lactose intolerance, galactosaemia

Extensively Hydrolysed Formulas SMA Althera (Nestle Health Science)

Extensively hydrolysed whey protein with LCPs

From six months. Cow’s milk protein allergy/ intolerance

Aptamil Pepti 1 Aptamil Pepti 2 (>6 months) (Aptamil)

100% hydrolysed whey protein. Contains lactose

Cow’s milk protein allergy/ intolerance

Infatrini Peptisorb (Nutricia SHS)

1kcal/ml ready-made feed. Extensively hydrolysed whey protein. Contains lactose

Whole protein intolerance, short bowel syndrome, malabsorption, catch-up growth

MCT Peptide MCT Peptide 1+ (>12 months) (Nutricia SHS)

Main fat source is MCT. Protein source is hydrolysed pork collagen and soya

Whole protein intolerance and/ or fat malabsorption, short bowel syndrome, pancreatic insufficiency

Nutramigen Lipil 1 Nutramigen Lipil 2 (>6 months) (Mead Johnson Nutrition)

Extensively hydrolysed casein protein

Whole protein and/or disaccharide intolerance

Peptide Peptide 1 + (>12 months) (Nutricia SHS)

Contains small amount of MCT* fat. Protein source from soya & hydrolysed pork collagen

Pepti-Junior (Cow & Gate)

50% of fat content is MCT. Semielemental

Pregestimil Lipil (Mead Johnson Nutrition)

55% of fat content is MCT. Extensively hydrolysed casein

Whole protein and/or disaccharide intolerance, short bowel syndrome, malabsorption

Amino Acid Formulas SMA Alfamino (Nestle Health Science)

Free amino acid. High MCT content

Neocate LCP (Nutricia SHS) Neocate Active (Nutricia SHS)

Free amino acid. Contains a small amount of MCT

Puramino (formerly Nutramigen Lipil AA) (Mead Johnson Nutrition)

Free amino acids. No peptide chains. Contains MCT

Whole protein/hydrolysate intolerance, short bowel syndrome, malabsorption

MCT* - Medium Chain Triglycerides NHDmag.com May 2015 - Issue 104

infant formula Table 4: GOR formulas and thickeners Product name (manufacturer)

Composition

Advantages

Disadvantages

Enfamil AR (Maed Johnson Nutrition)

Pre-gelatinised rice starch

Nutritionally balanced with the same energy content as standard formula, thickens on contact with the stomach, teat size may not need to be increased

May cause colic, wind and constipation

SMA Staydown Infant Milk (SMA Nutrition)

Pre-cooked corn starch

Extensively hydrolysed protein formulas (see Table 3) are suitable for use in some infants with CMPA. Symptoms such as vomiting, diarrhoea, reflux and eczema can be relieved by introducing these formulas which contain peptides as opposed to whole proteins. Peptides are less likely to promote an allergic response and they are more palatable than amino acid (AA) based formulas. AA based formulas (see Table 3) are used in infants with CMPA if symptoms are not resolved by introducing the extensively hydrolysed protein formula, or the infant’s symptoms are considered to be severe at diagnosis. However, their use and efficacy has been under closer scrutiny in recent years due to their high cost. A significant amount of any spe-

cialist infant formula budget is spent on cows’ milk allergy and lactose intolerance formulas. It is estimated that up to almost five percent of young children are allergic to cows’ milk protein (8) and as many as one in five patients will experience symptoms indicating lactose intolerance (9). Gastro-oseophageal reflux (GOR) formulas

GOR is a common condition in infants where regurgitation and vomiting can compromise growth and development. Thicker formulas (see Table 4) may help to reduce these symptoms, but are unlikely to reduce the volume of acid reflux for the infant (10).

References: 1 Shaw V ed (2015). Clinical Paediatric Dietetics 4th edition. Wiley-Blackwell 2 Jones E and King C (2005). Feeding and Nutrition in the Preterm Infant. Elsevier/Churchill Livingstone 3 Agostini C et al (2010). Enteral nutrient supply for preterm infants: commentary from the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr, 50(1) 85-91 4 British Dietetic Association. Paediatric Group Position Statement on the Use of Soya Protein for Infants. Birmingham: British Dietetic Association 2003, updated 2010 www.bda.uk.com/publications/PaediatricGroupGuidelineSoyInfantFormulas.pdf (accessed 03/04/15) 5 Mayer R (2013). Cows’ milk protein allergy in infants and paediatrics: Which option to use and when. CN. Vol 13 No 2: 12-14 6 Fiocchi A et al (2010). World Allergy organisation (WAO) diagnosis and rationale for action against cows’ milk allergy (DRACMA) guidelines. World Allergy Organ. J, 3 (4): 57-161 7 Agostoni C et al (2006). Soy Protein infant formulae and follow-on formulae: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr, 42 352-61 8 Venter C and Arshad SH (2011). Epidemiology of food allergy. Padiatr Clin North Am. 58(2): 327-49 9 www.allergyuk.org/common-food-intolerances/dairy-intolerance#lactose-intolerance <accessed 03/04/15> 10 Hovath A et al (2008). The effect of thickened feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomised controlled trials. Pediatrics, 122(6) 1268-1277

dieteticJOBS.co.uk The UK’s largest dietetic jobsite To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) 28

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Dairy

Rethinking dairy

Dr Justine Butler Senior Researcher and Writer Viva!Health

While more and more people are choosing alternatives to cows’ milk, government policy and healthcare workers continue to promote dairy. However, an increasing body of evidence now threatens the public image of the white stuff. We know about the health risks associated with fish contaminated with pollutants (1). The links between red and processed meats and bowel cancer are well-documented (2). However, dairy continues to slip under the net. It’s as if the white stuff is so pure, natural and wholesome its beneficial properties are beyond question. It is portrayed as liquid calcium for bones, an elixir of goodness for the young, the fussy, the poorly and the elderly. However, a large body of evidence links cows’ milk and dairy products to a wide range of illnesses and diseases including heart disease, diabetes and cancer, right through to acne, allergies and even osteoporosis, suggesting that cows’ milk could be doing more harm than good. Heart disease

Dr Justine Butler is a Senior Researcher and Writer at Viva!Health. Justine holds a PhD in Molecular Biology, BSc Biochemistry and Diploma in Nutrition. She has published an extensive list of reports, guides and factsheets for Viva!Health and written articles for health journals, regional and national press.

The number of people in the UK with heart disease has remained relatively constant over the last decade. The benefits we should be seeing (due to advances in medical treatment and the reduction in smoking) are being negated by the increase in obesity and diabetes. We are smoking less, but we are eating more, and not just that, we are making poor dietary choices. Heart disease is linked to poor diets including high levels of saturated fat, salt and refined carbohydrate and low levels of fruit and vegetables (3). Foods high in saturated fat include: meat pies, sausages and fatty cuts of meat, butter, ghee, lard,

cream, hard cheese, cakes and biscuits and foods containing coconut or palm oil (4). Interestingly replacing saturated fat with polyunsaturated fat may be more effective in lowering the risk of heart disease than reducing the total amount of fat in the diet. This means moving away from saturated animal fats to unsaturated vegetable oil-based fats. A move that offers major health benefits according to the World Health Organisation (5). So go dairy-free, while increasing the intake of fibre, fruit and vegetables is a simple way of reducing saturated fat intake, losing weight and lowering the risk of diabetes and heart disease. Soya protein, nuts, plant sterols and soluble fibres from wholegrain foods, fruit and vegetables can all help lower cholesterol which is a risk factor for heart disease (6). Vegetarians (who eat a diet based on cereals, pulses, nuts, fruits and vegetables) tend to have lower cholesterol levels and a lower mortality from heart disease. The widespread adoption of a vegetarian diet could prevent approximately 40,000 deaths from heart disease in Britain each year (7). This means a healthy plant-based vegetarian diet and not one based on cream cakes and cheesy pizzas. NHDmag.com May 2015 - Issue 104

dairy

Over the last 60 years, the worldwide incidence of Type 1 diabetes has risen by over three percent a year, doubling every 20 years, with a rapid rise in the number of children affected

Diabetes

Over the last 60 years, the worldwide incidence of Type 1 diabetes has risen by over three percent a year, doubling every 20 years, with a rapid rise in the number of children affected (8). In 2035, the NHS could be spending 17 percent of its entire budget on treating diabetes (9). Type 1 diabetes is an autoimmune condition whereby the immune system attacks the body’s own insulin-producing cells in the pancreas. It is thought to involve a genetic predisposition (diabetes in the family) coupled to an environmental trigger. Putative triggers include: viral infection, vaccines, low levels of vitamin D, increased insulin demand and the early exposure to cows’ milk protein. It is only in recent years that cows’ milk protein has been identified as a potential trigger for Type 1 diabetes (10, 11). Candidate milk proteins in milk include casein (12), bovine serum albumin (13) and bovine insulin (14). Even a short duration and/or a lack of breastfeeding may constitute a risk factor for Type 1 diabetes (15). The World Health Organisation recommends that infants should be exclusively breastfed for the first six months of life. Yet the government continues to scrap funding for infant feeding coordinators (who encourage breastfeeding in parts of the country with the lowest uptake) and withdrew funding of the National Breastfeeding Awareness Week in 2011. Last year, figures from the Department of Health revealed that the number of new mothers who are breastfeeding fell for the first time since they began collecting statistics in 2004. From 2012-2013, nearly half of all new mums were not breastfeeding their baby at all by their eight week check-up (16). The Royal College of Midwives have expressed concern over the lack of promotion of breastfeeding under the current Government, saying there is a shortage of 5,000 midwives. 30

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Strategies to promote breastfeeding could confer important and widespread health benefits and not just with respect to Type 1 diabetes. Type 2 diabetes (normally affecting adults over 40) is occurring in young adults at the level of a global epidemic driven by the increasing burden of obesity (17, 18). The risk factors for Type 2 diabetes (obesity, poor diet and lack of exercise) are well-documented and one obvious preventative measure is to reduce the amount of saturated fat in the diet. This means cutting down on meat and dairy and increasing the intake of fruit, vegetables, wholegrains, pulses, nuts and seeds. Vegetarian and vegan diets offer significant benefits for diabetes management, including weight loss and improving blood lipid profile and glycaemic control (19, 20). Increasing dietary fibre can help and should be encouraged as a disease management strategy (21, 19, 22). Cows’ milk and cancers

Selective breeding and modern intensive farming practices have significantly changed the nature of cows’ milk. Modern dairy cows are routinely impregnated while still producing milk (23), so over two-thirds of UK milk is taken from pregnant cows, the rest coming from cows that have recently given birth (24). As a consequence, commercial milk products contain considerable levels of hormones (25) which may be linked to the development of some hormone-dependent cancers. Furthermore, cows’ milk stimulates the production the growth hormone IGF-1 in the liver and so drives up circulating levels of this hormone. IGF-1 has been shown to stimulate the growth of human cancer cells in the laboratory (26) and increased levels are linked to cancers of the bowel, breast and prostate. Professor T Colin Campbell, Jacob Gould Schurman Professor Emeritus of Nutritional Biochemistry at Cornell

dairy

Female breast cancer incidence rates in Britain have increased by almost 70 percent since the mid-1970s. Just in the last 10 years they have increased by six percent. University, New York, says that IGF-1 may turn out to be a predictor of some cancers in the same way that cholesterol is a predictor of heart disease (27). While dairy increases IGF-1, avoiding milk and dairy products can reduce the level of circulating IGF-1. A study published in the British Journal of Cancer found that vegan men had a nine percent lower IGF-1 level than meateaters and vegetarians (28). The significance of this needs to be further investigated, but it seems reasonable to assume that going dairy-free may lower the risk of certain cancers. Bowel Cancer

Some reports suggest that dairy products may very slightly lower the risk of bowel cancer (29). However, this effect may be attributable to vitamin D (30) and/or calcium (31) which can be obtained from plant-based sources. Furthermore, dietary calcium increases the risk of prostate cancer (32), so recommending dairy to men to lower their risk of bowel cancer would not be advisable. As stated, milk increases IGF-1 in the blood and higher IGF-1 levels are linked to an increased risk of bowel cancer (33, 34, 35). On a positive note, it is well-documented that increasing the intake of fruit and vegetables can significantly lower the risk of bowel cancer (36, 37). Breast cancer

Female breast cancer incidence rates in Britain have increased by almost 70 percent since the mid-1970s. Just in the last 10 years they have increased by six percent. The lifetime risk for women in the UK is now one in eight. Only five to 10 percent of all breast cancers are caused by genes (38), the vast majority are caused by environmental factors. Research from Harvard School of Public Health suggests that nearly a third of all breast cancer deaths in high-income countries

are caused by preventable lifestyle factors: alcohol, overweight/obesity and lack of exercise (39). Indeed, the global rise in breast cancer is often attributed to the adoption of a more Western-style lifestyle. A significant number of breast cancers could be prevented by changing the diet (40). Dietary modification may also affect progression of the disease in those who already have breast cancer (41). Women with breast cancer tend to have higher levels of oestrogens in their blood (42, 43, 44). A typical Western-style diet, rich in meat and dairy, increases the levels of these hormones (45, 46). Saturated fat intake has been implicated and, as stated, dairy products are a major source. Researchers at the Department of Preventive Medicine at the University of Southern California Medical School in Los Angeles published a review of 13 studies that investigated the effect of fat intake on oestrogen levels. Results showed that decreasing dietary fat intake (to just 10 to 25 percent of the total energy intake) reduced circulating levels of oestrogen by as much as 10 percent. They suggest that reducing fat intake to lower hormone levels may help prevent breast cancer (47). However, low-fat dairy products may not be the answer. Numerous studies have focused on the hormone content of milk. Cows’ milk contains hormones and increases the level of IGF-1 in the blood (by increasing endogenous production from the liver). Increased IGF-1 levels are linked to cancers of the bowel, prostate and breast. Author of the book Your Life in Your Hands, Professor Jane Plant, from Imperial College London, is so convinced that the low-fat yoghurt and skimmed organic milk she was eating was responsible for her breast cancer that she now advocates the complete avoidance of all dairy products. Her cancer NHDmag.com May 2015 - Issue 104

dairy

. . . a dairy-free plant-based diet can reduce the risk factors associated with breast cancer and may help those who have been diagnosed with the disease. specialist agrees and recommends a dairy-free diet to his cancer patients. On the other hand, high-fibre, low-fat diets may offer some protection against breast cancer (46, 48) possibly by lowering hormone levels (49, 47). Soya foods may also reduce breast cancer risk (50) and improve the prognosis in women with breast cancer (51). In summary, a dairy-free plant-based diet can reduce the risk factors associated with breast cancer and may help those who have been diagnosed with the disease. Prostate cancer

The lifetime risk of prostate cancer for men in the UK is about one in nine (52). Just five to 15 percent of prostate cancers are linked to genes (53). So, like breast cancer, the majority of cases are caused by environmental and/or lifestyle factors. We know that obesity and lack of exercise increases the risk, but less is known about the effect of diet. Prostate cancer rates are higher in countries consuming a typical Western diet. Men who eat a lot of saturated animal fats (including red meat such as beef, lamb and pork, eggs and dairy produce such as butter, whole milk, cheese and cream) have an increased risk of getting the disease (53). Diets high in calcium and dairy protein may also increase the risk of prostate cancer (54, 55, 56). It has also been suggested that regular exposure to oestrogen in milk from pregnant cows may explain the increased risk of prostate cancer in Western societies (57). IGF-1 signalling trouble

As stated, dairy products increase circulating IGF-1 levels (58, 59) and higher IGF-1 levels are associated with an increased risk for prostate cancer (60, 61, 62, 63). Furthermore, IGF-1 may transform pre-existing or benign tumours into a more aggressive form of cancer (64, 65). So, IGF-1 from 32

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cows’ milk may be a risk factor that could easily be avoided by eliminating dairy foods from the diet. Whether it is the saturated animal fat, the calcium, the hormones in milk or the hormones we produce in response to drinking milk, the fact remains that a high dairy diet appears to increase the risk of prostate cancer. On the positive side, a plant-based diet may slow prostate cancer progression and improve prognosis (66, 67, 68). In addition, specific plant foods, including flaxseeds (linseed) and lycopene-rich tomatoes (64) and soya foods (69), may help reduce the risk, along with a high level of physical activity (70). Summary

In summary, the research linking the consumption of cows’ milk and dairy products to numerous different types of cancer provides a convincing argument for eliminating all dairy from the diet, while increasing the intake of wholegrains, pulses (including soya), fruit and vegetables. The realisation is growing that changing our diet can have an enormous impact on health - for better or for worse. But what constitutes healthy or unhealthy food is not universally agreed and seems to change on a weekly basis. Cows’ milk is vigorously defended by the dairy industry, but the evidence paints a very different picture. If the huge numbers of people suffering from heart disease, diabetes and cancer could be reduced by one simple change in the diet, wouldn’t it be worth trying? This article presents a summary of an extensive fully-referenced scientific report called White Lies. All the facts presented are based on peerreviewed published research. To find out more, or to access the full references, visit: www.whitelies. org.uk/resources/white-lies-report-2014 For article references please email: info@networkhealthgroup.co.uk or click here . . .

British cohort study

Date of Birth: April 1970 If you feel that Big Brother is watching you, then you might just be overanxious and obsessive. But if you were born in April 1970, then your impression could be entirely correct: perhaps you are one of about 17,000 babies selected for life-long follow-up as part of the 1970 British Cohort Study. 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

The Centre for Longitudinal Studies based at the Institute of Education at the University of London manages three such population-tracking surveys (the others are the now-older group born 1958, and the still-young group born 2000), and collect data at regular intervals on every kind of life-as-it-is-lived topic affecting health and happiness. In November 2013, a report on health and lifestyles in middle age was launched (a.k.a.1970 British Cohort Study age 42 survey – BCS42)). The findings document a feast of fatness and other health issues facing the group born in April 1970. The data is very high quality: it is time for serious discussion of the issues raised and the actions agreed. Dietitians to the rescue! Firstly, the tools and mechanisms of BCS42. Of the 17,000 baby-recruits, nearly 10,000 42-years olds completed the survey interview carried out in the year to April 2013. The complete dataset was deposited with the UK Data Service in January 2014 and is now available for further analysis and dissection both for investigating developmental trends in the born-1970 group, but also for comparison with the born in 1958 and the 2000 groups. Secondly, the results. Being obese was defined in 23 percent of men and 20 percent of women, which is an alarming increase in obesity of 16 percent in both men and women aged 42, who were born 12 years earlier in 1958. The obesity hierarchy was highest for Welsh women (27 percent) and lowest for English women (19 percent). But alarm-

ingly, many people, especially men, seemed unaware or unconcerned about their excess weights. Of those classified as obese, twice as many men as women (50 vs. 25 percent) self-described themselves as slightly overweight (rather than ‘very’); an astonishing five percent of obese men, but only one percent of obese women suggested that they were the right weight. The whole gender divide continued, with four times as many rightweight men than women expressing concern about being underweight. Being obese was strongly linked to being less likely to report good physical and mental health than those who were the right weight and those who were obese confirmed medical diagnoses of many health risks. Confirmed also in the age42 subjects, was the strong association between obesity and social class. Director of the BCS42 study, Dr Alice Sullivan observed that, “carrying excess weight is far more socially acceptable for men than for women and men will not respond to health messages about weight and obesity if they do not recognise that they are overweight.” Another gender divide related to the topic of exercise. Men scored better. They were more likely to do any kind of activity, but were especially drawn to cycling and team sports; women did less and were drawn to walking-for-pleasure and yoga/pilates. Running was the activity associated with the lowest levels of obesity. Dr Sullivan observed that, “it may seem surprising that more men do vigorous exercise than women, even NHDmag.com May 2015 - Issue 104

british cohort study though they are more likely to be overweight: this suggests that poor diet is a key factor affecting men’s weight in particular.” It also opens up the need to balance communication between the extremes of being fat and fit versus being not fat and not fit. Results for diet were less detailed. Being busy and the easy availability of convenience foods are clearly documented. While 40 percent of the subjects ate home-cooked foods daily, nearly 20 percent of the subjects ate ready meals/takeaways at least several times a week. Being overweight seems connected to the more frequent choice of takeaway meals: one third of those who were overweight ate these at least weekly, compared to one fifth of those of the right weight. More than half of the subjects ate breakfast every day, but more than one in 10 reported ‘never’ for this meal. One project presented at the launch of the BCS42 report at the Department of Health, was

by Amanda Sacker, Professor of Lifecourse Studies at University College London. Looking at breastfed-or-not data from the cohorts born both in 1958 and in 1970, Professor Sacker calculated correlations into effects on social mobility (i.e. social classification of the adult subject vs their parent). After forensic matching of every possible other difference, a small but very consistent observation was made: breastfed babies had a two to three percent increased probability of being upwardly socially mobile. This stunning conclusion supports the strong encouragement to assume breastfeeding for every newborn whenever possible. More on the age 55 survey from the 1958 birth cohort can be found at: http://discover. ukdataservice.ac.uk/series/?sn=2000032. The next survey for the 1970 birth cohort is due is 2016. Hopefully, dietitians will be able to contribute to downward obesity statistics for BCS46 compared to the current data reported.

NHDmag.com . . .

. . . Your essential resource 34

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web watch

web watch Online resources and useful updates. Innovations helping health care The Kings Fund has published their latest digital report The Future is Now, which brings together examples of innovative practice from England and overseas to provide insight into future ways of changing health and healthcare for the better. www.kingsfund.org.uk/reports/ thefutureisnow/

prOmOting healthier dietS The World Health Organisation European Office has published Using price policies to promote healthier diets. This publication provides information on using price policies to promote healthy diets and explores policy developments from around the WHO European Region. It examines the economic theory underpinning the use of subsidies and taxation and explores the available evidence. The publication includes several case studies from WHO European Member States where price policies have been introduced, along with a European Union scheme. It concludes with some observations about the design of more effective price policies. www.euro.who.int/en/health-topics/disease-prevention/nutrition/ news/news/2015/03/using-pricepolicies-to-promote-healthier-diets Gynaecological cancers The National Cancer Intelligence Network has published three reports on gynaecological cancers. They provide an insight into the health and wellbeing of women living with and beyond cervical, womb and ovarian cancer. The reports aim to: improve

understanding of health-status related quality of life outcomes for women following treatment for gynaecological cancers; consider variations in outcomes, for example for different age groups or for those with comorbidities; start to enable health and care services at a national and local level; to measure the impact of interventions for people living with and beyond cancer over time, and link with hospital episode statistics, cancer registration and other data sets to begin to understand the relationship between health-status related outcomes and types of cancer treatment. www. ncin.org.uk/publications/ Impact of physical activity and diet on health The House of Commons Health Committee has published its Health - Sixth Report: Impact of physical activity and diet on health. The Committee recommended that the next Government prioritises prevention, health promotion and early intervention to tackle the health inequalities and avoidable harm resulting from poor diet and physical inactivity. The Committee also regarded it as inexplicable and unacceptable that the NHS is now spending more on bariatric surgery for obesity than on a national roll-out of intensive lifestyle intervention programmes that were first shown to cut obesity and prevent diabetes over a decade ago. The Committee were also disappointed that although NICE has produced a comprehensive raft of guidance on cost-effective interventions that can be introduced, either

by the NHS or by local government, to improve diet and physical activity, that to date there has been very little assessment of how far these guidelines are being implemented. www.publications.parliament. uk/pa/cm201415/cmselect/ cmhealth/845/84502.htm Healthy conversations and the allied health professionals The Royal Society for Public Health and Public Health England has published Healthy Conversations and the Allied Health Professionals. This report illustrates that allied health professionals are having a significant positive impact on the public’s health and with further support this could make a real difference to the health and wellbeing of the population. www.rsph.org.uk/filemanager/root/site_assets/our_work/ reports_and_publications/2015/ ahp/final_for_website.pdf Implementing a trust-wide healthy weight strategy NHS Employers have published a case study of how Northumbria Healthcare NHS Foundation Trust developed and implemented its Healthy Weight strategy. The strategy is based on staff feedback and also aims to take forward the NICE public health workplace guidance on tackling obesity and promoting physical activity in the workplace. www.nhsemployers.org/~/media/ Employers/Documents/Retain%20 and%20improve/Northumbria%20 healthy%20weight%20strategy%20 10%20April%20FINAL.pdf NHDmag.com May 2015 - Issue 104

obituary

In memory of Pat Judd Transcript of tribute paid to Pat Judd Kerr by Moira Nash (née Taylor) at Preston Crematorium on Monday 16th March 2015.

Tribute by Moira Nash (née Taylor)

“Tony has asked me to say a few words about ‘Professor Judd’. That is: ‘Pat the scientist and academic’. I am honoured to do this, but feel that my allotted two to four minutes may be somewhat inadequate. Preston Crematorium may just have to wait! In order to get a feel for the enormous contribution that Pat made in her role as a scientist and academic, I would like you to imagine that standing beside me on my right is a sizable group of PhD students, post docs (the first job after a PhD), and other research workers. Having benefited from Pat’s deep scientific knowledge, sound guidance and thoughtful support, they successfully completed the research studies they were undertaking. I am proud to say that I can stand in that group. On my left is another, not inconsiderable group consisting of colleagues, both in dietetics and the university setting, who benefited from research collaborations with Pat. Collaborations which were highly successful - again a group that I am proud to say that I am a member of. Behind me in an arc, are the large group of patients who benefited from Pat’s insistence on a scientific, evidence based approach to dietetics. We must not forget that Pat practiced as a dietitian for much of her working life. Behind the patients, stretching way back, is an enormous group of student dietitians trained by Pat to take a scientific, evidence based approach. She taught students to both critically review scientific studies undertaken by others and to aspire to contribute their own research to our discipline. At a conservative estimate,

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there are 1,500 undergraduate students from the UK, Malaysia and South Africa. One thousand five hundred- that is a lot of students and we must not forget the students that they have and will train in the ‘Pat mould’! Finally, behind them, stretching way, way back is the rest of the profession in the UK and other countries, who have benefited from Pat’s perspective as a scientist when working with the British Dietetic Association and the Health and Care Professions Council. Pat was Scientific editor of the Journal of Human Nutrition and a key contributor to the design of a radicle new curriculum in 2000; a new curriculum that put science and research very much at the centre of the pre-registration training of dietitians. However, Pat would not leave it there. She would say, ‘So you claim I did some good as a scientist and academic? Well, where is the EVIDENCE?’ I am sure that many of you in the audience could give me your own examples of ‘evidence’. Let’s start by looking at the first of the three areas of the academic’s role - research. You only have to ‘google’ ‘Judd PA’ to see the breadth, depth and quality of Pat’s scientific publications. It is a real credit to her that her last publication was only last year. Pat has worked alongside great names, including Truswell. I believe that Pat’s strength lay in her ability to see the important question and pursue it. To give but one example, she and I were jointly supervising a PhD student, who is not sitting far from me today. The then student and I were deeply and terminally bogged down in a discussion about the detail of a study we were trying to design. I suddenly be-

obituary

Pat was my colleague, then my mentor, but also my friend, aunty, big sister and, when required, ‘Mum’. came aware that Pat had gone very quiet and I looked around at her somewhat apprehensively. She had on her face that sunny look, that I am sure is familiar to you all, when she was about to throw back her head and really laugh! Laugh she did, without causing any offence, and said, ‘Just get on with it you two!’ That was perhaps one of the most important lessons she taught me about research and life: ‘Just get on with it!’ In the second academic role, a teacher, she had an equally precious talent. Many people have mentioned to me, an experience that I often had. You could knock on her door with an interesting but ill thought through idea, and you would leave with your idea gently translated into an interesting and workable plan. At no point would she have made you feel inadequate or have reduced your confidence, in fact quite the opposite. It would only be later that you would realise what a disaster you might have had on your hands if it had not been for Pat! Finally, the third role of an academic: administration and pastoral care. Pat was always highly organised with respect to administration and excelled in providing pastoral support to students. I was reminded only last week by Pat Howard, who was at one time our external examiner, of the concern Pat (Judd) had shown and effort she had invested in one of our weaker students. Pat was not just interested in the high flying members of the class. So, we have plenty of evidence of Pat’s success as a scientist and academic. However, again, she would not leave it there. She would be saying, ‘Moira, fine you have some evidence, but what is the MECHANISM?’ To answer this question we have to drill down to what was the essential essence of Pat that made her so special, not just as a scientist and academic, but in life. I’ll not apologise now for referring to something that has already been touched upon. I believe it was Pat’s incredible ability to take on multiple roles in the lives of those around her. She was not just the re-

search supervisor, for example, she would be so much more to that person. Taking myself as an example, Pat was my colleague, then my mentor, but also my friend, aunty, big sister and, when required, ‘Mum’. Pat would very much be there when times were tough. However, she would also rejoice at the good times in other people’s lives. When I finally married someone who Pat approved off and finally got around to having two children, Pat celebrated the birth of each, by sewing a beautiful and personalised quilt. Each was signed off with the quote ‘Made with love for…’. It is with the words of my children that I will round off. When I told my eight-year-old son Joseph of Pat’s death, he said, ‘But she was so lovely and she was not old.’ I think he voiced a feeling that I am sure many of you share with me, that Pat has left us too soon and in the middle of a conversation. I feel great sadness, but also frustration and disappointment that we will never finish the discussions that we were going to continue when we were next to meet. When I then asked my children what I should say today about Pat, they came up with four words. They said she was clever and hard-working. The truth of this is, I think, clearly demonstrated by her enormous success as Professor Judd - the scientist and academic. They then said that she was kind - clearly this is not in question. Then they added something that made me stop and think a moment. They said that Pat was calm. A picture came to my mind of Pat standing at our front door with a beautiful bunch of tulips, bringing calm to the chaos soon after Susannah was born. I realised that the children had hit on something important. In any situation, research, teaching or life, if Pat was involved, then there was a certainty that ‘everything will be alright’. I know that times are not going to be easy, but I feel that Pat’s legacy to us is to ‘just get on with it’ and that ‘everything will be alright’. Thank you.” NHDmag.com May 2015 - Issue 104

career

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk

PUBLIC HEALTH NUTRITIONIST/DIETITIAN BRIGHTON AND HOVE FOOD PARTNERSHIP Two vacancies available: one full time and one part time. Closing date: Friday 22nd May 2015 at 5pm. Are you interested in being part of a team of community-based public health nutritionists and dietitians within a not-for-profit organisation? The post holder(s) will be committed to the work of the Food Partnership and offer advice and support to groups and individuals around healthy eating and weight management. You will need to have at least one year’s relevant work experience post registration, using behavioural change skills and delivering 1-1 and group weight management programmes. For the full time post you will have experience working with children and families. You will be supported with regular supervision and CPD. Some evening working will be necessary. Post 1: full time, 37.5 hrs per week; salary £25,900 per annum. This post is initially offered on a one-year basis with a probable extension subject to funding. Post 2: part time, 22.5 hrs per week; salary £15,540 per annum. This post is a maternity cover post to 19th August 2016. Interviews: Post 1 full time: 24th June. Start date ideally 10th August. Post 2 parttime: 25th June 2014. Start date ideally 3rd August. Any queries can be emailed to info@bhfood.org.uk or call 01273 431700. EATING DISORDERS DIETITIAN PRIORY ROEHAMPTON, LONDON Permanent - Part Time. Hours: 22.5 hours per week (3 days). Salary: £34,000 pro rata. The Priory Hospital Roehampton, London SW15 5JJ, located in a stunning grade Grade 11 listed building, is a teaching hospital renowned for its clinical excellence in the field of Addiction, Eating Disorders and Acute Mental Health. Right now we have an exceptional opportunity for a dynamic and experienced dietitian to join our multidisciplinary team, working within our adult and adolescent eating disorder services. Join us and you will be responsible for the nutritional assessment, treatment, education and group work with all our eating disorders patients. You will become an active member of an established, committed and energetic

NHDmag.com May 2015 - Issue 104

team, participating in the ongoing development of the service and clinical governance issues. Excellent communication skills are, of course, essential, so too is evidence of post graduate mental health experience. Above all, you will need to be passionate about the role diet can play in treating eating disorders and ideally have experience in this field. We can offer you excellent opportunities to develop and broaden your skills within group and individual settings, CPD and training that supports best practice and professional and clinical supervision. Please apply online: https:// jobs.priorygroup.com/vacancies/2904/bda/dietician_ eating_disorders Public Health/Community Dietitian north west London Band 7 Public Health/Community position in North West London. Full time for three months. Applicant must be a registered Dietitian with a HCPC and have worked in Public Health/prevention role before, experience of planning and setting up and providing group education sessions and clinical consultations for adult patients at risk of developing chronic conditions. You will be required to work at various leisure and community centers in Hounslow. NO home visits required and NO car necessary. Please get in touch today to find out more - call Hayley Isitt on 01277 849 649 to discuss your availability and personal requirements and send your CV to hayley@eliterec.com. Child Weight Management Dietitian North West London Band 6 Paediatric Dietitian to cover a child weight management position across North West London. Start date is as soon as possible for three months. Applicant must have previous experience of working with paediatric patients including children requiring weight management advice and experience in providing both group education sessions and 1:1 clinical consultations. No car necessary for this role. Please get in touch today as excellent rates offered to the right dietitian. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com

career

dieteticJOBS continued Paediatric Dietitian - Children’s Hospital, Midlands Band 6 Paediatric Dietitian to start ASAP for a large children’s hospital in the Midlands, covering a clinical role for around three months. Accommodation is available on site and this is offering a high rate of pay. The applicant must have previous clinical UK paediatrics experience. Please get in touch today to find out more call Hayley Isitt on 01277 849 649 to discuss your availability and personal requirements and send your CV to hayley@eliterec.com. Not available for this position? Why not recommend a friend or colleague and earn a £250 referral bonus on successful placement (terms and qualifying period apply). Contact us now! Clinical and Community Dietitian South East London/Kent Band 5/6 Clinical and Community Dietitian required to cover a position starting on 5th May for six weeks in South East London/Kent hospital. This role is mainly Acute, so would be covering all wards, but undertaking GP clinics in the community may be required so car driver would be good but not essen-

tial. Applicant must have experience with Medical and Surgical wards. Please get in touch today as excellent rates offered to the right dietitian. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com Band 6 Paediatric Dietitian - Somerset Band 6 Paediatric Dietitian in the beautiful county of Somerset from May for around six weeks, Applicant must have previous experience in paediatrics in an outpatient setting and if possible diabetes experience also. The hospital can offer onsite accommodation and a high rate of pay. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com. Not available for this position? Why not recommend a friend or colleague and earn a £250 referral bonus on successful placement (terms and qualifying period apply). Contact us now! Community Dietitian - Paediatric North London Band 7 Paediatric Dietitian required for Community services in North London. The applicant must have significant experience of proving clinical con-

We urgently require dietitians for immediate vacancies To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk

• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health • Our aim is to find you the right person and the right job • We offer inpatient and community UK & NI coverage • Competitive rates

www.pjlocums.co.uk NHDmag.com May 2015 - Issue 104

career

dieteticJOBS continued sultations to paediatric patients in an outpatient and domiciliary setting. Start date is 5th May until 31st July 2015. To be considered for this role, you must be fully qualified with a minimum of 12 months’ recent experience within a UK-based hospital and HCPC registration. Please get in touch today to find out more - call Hayley Isitt on 01277 849 649 to discuss your availability and personal requirements and send your CV to hayley@eliterec.com Band 6 Community Dietitian - NHS Herts Band 6 Community Dietitian required for an NHS hospital in Hertfordshire, providing a dietetic service to GP/outpatient clinics in West Hertfordshire and to provide domiciliary visits. Applicant must have previous experience in a UK hospital and have access to transport. Start ASAP for a minimum of three months. To be considered for this role please email Hayley@eliterec.com or call 01277 849 649. www. elitedietitians.com. Not available for this position? Why not recommend a friend or colleague and earn a £250 referral bonus on successful placement (terms and qualifying period apply). Contact us now!

dieteticJOBS.co.uk The UK’s largest dietetic jobsite

events and courses University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals

• Obesity Management Module - 30th September • Gastroenterology Module - 8th October

For further details please email marie.e.coombes@

nottingham.ac.uk, tel: 0115 951 6238 or check out the

University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.

Nutrition and Survivorship: Nutritional Issues Following Cancer Treatment 12th May

The Royal Marsden Education and Conference Centre www.royalmarsden.nhs.uk/education/

Paediatric Nutrition 16th May

University of Nottingham - School of Biosciences

Modules for Dietitians and other Healthcare Professionals www.nottingham.ac.uk/biosciences

Nutricia Paediatric Allergy Symposium 18th May

BALTIC Centre for Contemporary Art

www.nutricia.co.uk/newcastleallergyevent/

Eating & Nutritional Care for Older People with Dementia 19th May

One-Day Conference

www.medicacpd.com

COPOC Tel Aviv 2015

To place a job ad in NHD magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate)

20th to 22nd May

1st International Conference on Controversies in Primary and Outpatient Care, Tel Aviv, Israel

www.comtecmed.com/copoc/2015/

Obesity, Diabetes and the Metabolic Syndrome 21st May

The 15th Plymouth Symposium

‘New ideas and controversies in obesity’

Plymouth Postgraduate Medical Centre,Derriford Hospital estore.plymouth.ac.uk/

NHDmag.com May 2015 - Issue 104

the final helping

Neil Donnelly

Regular readers of this column will be aware that it is nothing more than the reflections and recollections of the previous Editor of NHD, usually relating to weight management issues. This issue, as a result of an almost spectacular increase in recent years in the demand for gluten-free products from consumers worried about gluten and bona fide individuals with a diagnosis of coeliac disease, I was going to focus on how much this availability has changed. Before I could really focus my thoughts, my mother-in-law rang to invite us to spend Sunday night in York on the final day of her holiday. NHD would have to wait!

‘Teachers must not talk about getting fat or compliment colleagues on losing weight in front of pupils.’

Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders

We were staying close to York Minster and, having toured the Minster, we decided to attend Choral Evensong at 4.00pm. While waiting in the Quire, I read the notice sheet that we were handed. Highlighted boldly in a box was information on Receiving Holy Communion. It read: ‘Gluten-free communion wafers are available at the communion station nearest the pulpit at the front left of the Nave. If you require a gluten-free communion wafer, please inform a Steward and make your way to the front of the Nave. When the time comes to receive communion, please ask the priest for a gluten-free wafer. If you need to receive communion in your seat, please tell a Steward and this will be arranged.’

How very appropriate I thought. I’ll include that. Bread they say is the Staff of Life, to this you can now add glutenfree communion wafers. The following morning, while having a leisurely cup of tea in our room with the TV on, interspersed with all the election politics and promises on Lorraine Kelly, was, you guessed it, a cookery demonstration using gluten-free flour. Obviously a way to make dough! D’oh! Finally, by the time you read this, we should know the result, sort of, of the Election on May 7th. So much political battling has been made over the NHS, all promising to keep it safe, but not one single mention of obesity and what individuals can do to help. We shouldn’t be surprised, as approximately one third of voters are obese. Obesity will of course bankrupt the NHS. The latest government-backed guidance advocates the following: ‘Teachers must not talk about getting fat or compliment colleagues on losing weight in front of pupils.’ It has been developed by the PSHE (Personal, Social, Health and Economic Education) Association funded by the Government Equalities Office whose work is targeted at school children. Good job! That’s the future sorted. On a lighter note, back in York, we then headed off to Bettys to enjoy a legendary Fat Rascal scone with jam and cream which was not on their extensive gluten-free menu. Delicious. As I said, reflections and recollections, nothing more. NHDmag.com May 2015 - Issue 104

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NHD May 2015 issue 104

Articles inside

dieteticJOBS

The final helping

Events and courses

In memory of Pat Judd

News

Web watch

Rethinking dairy

Diabetes

Coeliac disease

Hospital food and nutrition

British Cohort Report

Specialist infant formulas