Smart Bites December 2022 Issue

Food Chemical Sensitivity

Mercy Hospital menu review Plant and Food Research

Creating I S S U E 1 9 | D E C 2 0 2 2

and environmentally sustainable

Click where you see this link to learn more.

Smart Bites is the quarterly magazine of Dietitians New Zealand. We exist to build a strong and sustainable profession that empowers New Zealanders to make informed food and nutrition choices and inspire change that enhances the health and wellbeing of Aotearoa, New Zealand.

Smart Bites has taken the baton of informing and updating our members from "News and Views", which for 56 years was the voice of the New Zealand Dietetic Association and then Dietitians New Zealand. Ka mua, ka muri.

Discover us online: www.dietitians.org.nz IG: dietitiansnz

Contact us: General Manager: Kath Eastwood admin@dietitians.org.nz

Editorial team: Julie Carter, Anna Greenan, Lizz Whittred, Deepti Shivandhana editorsmartbites@gmail.com

As I write this, we’re rapidly approaching Christmas, summer holidays and hopefully an opportunity for us all to take some much needed time out. 2022 has flown by, that’s for sure!

Anna F R O M T H E E D I T O R I A L T E A M

At Smart Bites we love reading our contributors articles about the roles they’re working in and new knowledge they’re acquiring. As dietitians, our career opportunities are diverse. The upskilling, growth and learnings we undertake, so often can support us in other areas of our lives as well.

Leading into summer, where diet culture is rife, it feels fitting to use the book ‘Reclaiming Body Trust’ (by Hilary Kinavey and Dana Sturtevant) as an example of this; as dietitians, we can support our patients to move towards a place of body trust. And, how valuable to do the same thing for ourselves personally; to get out of our heads and check in with our body more regularly over the day; noticing how we are feeling and what we might need in that moment.

Greenan

Something to ponder if you have the time and capacity over the holiday season.

The team at Smart Bites hope you enjoy our final edition for the year. A huge thank you to all our contributors over the year(s) – the magazine doesn’t work without you. We are always looking to add to our fantastic team, so please reach out if you are interested to join in the New Year and let’s chat: editorsmartbites@gmail.com

Wishing you all a very Meri Kirihimete me te Hape Nū la.

Eastwood

Meri Kirihimete!

As we near the end of the calendar year, it seems timely to reflect on the last 12 months and re-assess our goals and plans for 2023.

Of i ifi thi h b th

We are looking forward to continuing our mahi with Te Kāhui Manukura o Kai Ora and providing all members greater support in this area throughout 2023 as we move towards creating a culturally safe environment where all dietitians, especially Māori can thrive, a critical step to increasing the diversity of our profession.

The health and disability system reform has

Kath

We have continued to improve the value from Dietitians NZ for members. The pandemic provided us with the opportunity to reduce some of the barriers to professional development by creating more virtual events and this year offered both inperson and virtual options for our annual conference. It was great to be back on the South Island (for the first time in over a decade!) and conference continued to be a highlight on our PD calendar. We would once again like to acknowledge and thank the many members, particularly SIG convenors, who contributed to making the event so successful!

Finally, I would like to take this opportunity to thank all those members who continue to give so much of their time, energy & expertise to Dietitians NZ & enhancing our profession. Many of you go above & beyond and we thank you for your ongoing support & significant contribution. Teamwork makes the dream work!

Wishing you all a happy and safe Christmas and New Year!

Kath

Ngā manaakitanga

F R O M D I E T I T I

From the Registrar's desk

Kia ora, Mālō e leilei, Talofa, kia orāna, nǐ hǎo, Bula Vinaka;

As we head into the summer holiday period registration staff are gearing up for APC renewals and registration of new graduate Dietitians. If you haven’t already updated your MYCCP we encourage you to do so now. Complete the compulsory sections and upload evidence of signed off supervision, peer review and cultural competence. Set aside an hour to complete Moodle to maintain your prescribing endorsement.

Congratulations to all graduands as you start out on your professional career as Registered Dietitians.

For reference, new graduates can view the registration process here: https://www.dietitiansboard.org.nz/registr ation/new-zealand-graduates/ https://www.dietitiansboard.org.nz/wpcontent/uploads/2020/12/2020-New-NZGraduate-Information.pdf

The Board’s role is essentially one of public safety. It ensures the profession of dietetics is regulated and that standards of competence and ethics are set, monitored and maintained as prescribed under the HPCA Act 2003.

Philippa Bascand

The Board also works with its counterparts in Australia, the UK, South Africa, and Canada to ensure dietitians who seek to work here are fit to practise, and meet cultural safety requirements, while not imposing unnecessary regulatory entry barriers to practice. The Board has had a voluntary Mutual Recognition Charter in place with Dietitians Australia since 2007. Most other health professions in NZ and Australia are covered by the TransTasman-Mutual Recognition Act 1997 but dietitians are not legally regulated under the Australian Health Practitioner Regulation Agency in Australia. Like any such voluntary arrangement, regulatory and professional changes mean it is timely to review and refresh our Agreement to ensure it supports current regulatory practice and is fit for purpose on both side of the Tasman.

From the Registrar's desk

Both Boards are early into an engagement process to refresh our mutual co-operation arrangements to ensure accreditation standards, assessment of overseas qualifications and workforces can cooperate and move easily between the two health systems. The Board and DA will outline more on this work later in 2023. Excitingly, however, we have had seven Australian dietitians apply for NZ registration this year compared with two in 2021. NZ is seeing renewed interest from our Australian colleagues seeking career opportunities here post COVID-19 and the travel and immigration restrictions it caused.

The Board has recently received advice from the Prescribing Expert Advisory Group about the prescribing practice of dietitians and whether it would be useful to expand the list of available medicines on the Medicines Schedule approved for prescribing by dietitians as designated prescribers. The Board will update the profession before the end of the year on its approach, and any recommendations it may make to the Ministry of Health.

A friendly reminder for all dietitian prescribers to work within your scope of practice, to complete annual Moodle quiz, and have prescriptions counter signed if the medicines you seek to prescribe are not listed on the approved schedule – see here: https://www.dietitiansboard.org.nz/wpcontent/uploads/2022/08/MasterProduct-List-for-Dietitan-Prescribersupdated-August-2022.pdf

Our office will be closing from midday 23 December 2022 and reopening a at 9.00 am Tuesday 10 January 2023.

Meri Kirihimete me te Hape Nū Ia!

Philippa Bascand, Sherin de Souza and Board

Future-focussed dietetics training: supporting our next generation of dietitians to embrace emerging roles

The Dietetics team at Massey University strive for diversified student curriculum and work-integrated learning (placement) experiences, with continuing development underway for teaching practices to equip our graduates to best meet future needs. In this feature, we spotlight two recent Massey graduates who have embraced emerging roles and are making an impact within the food and nutrition space, building literacy, and improving the health of communities in Aotearoa

I was born in Nelson but was quickly moved to Auckland where I grew up on the (sometimes) sunny Hibiscus Coast. I am a Foodie through and through. If I’m not cooking food, I’m thinking about food, or planning a trip to a new restaurant. I’m also really interested in the sciences, and the black and white yet extremely grey nature of nutrition science drew me in!

My role at My Food Bag is incredibly varied, which is one of the things I love about it. I work with our talented chefs to make the weeks balanced but also commercially viable – which unfortunately due to our food environment, can be more challenging than it sounds. I have to keep on the pulse of nutrition trends, and how the evidence does or doesn’t stack up against it to make sure what we put to market is evidenced based. I spend time training my colleagues, nutrition team and wider business about nutrition – they’re so receptive to learning at every opportunity, which is really rewarding. I also work with our Food Quality teams on food labelling, allergen control and nutrition claims management, which is the more “food tech-y” aspect of my role.

Catherine Bell Nutrition Manager My Food Bag

I also keep busy with the people management and leadership element of my job, seeing young people grow their career in food as I do the same is so exciting to me.

My Dietetics training at Massey has helped me to be confident in my evidenced based approach, and I draw on the research and evidence gathering skills I learnt from my training every day. Being able to form a clear concise nutrition opinion, based on the facts at hand, that you can communicate confidently to the layman, is so valued in the food industry. These skills I only gained by becoming a Dietitian.

Highlights of the role so far include some of the projects in the nutrition communication and public health space. My Food Bag often partners with universities on research projects and has an ongoing partnership with the Heart Foundation that I’m really proud to be a part of. Recently presenting alongside Lily Henderson from the Heart Foundation at the Dietitians NZ conference on our partnership and the Heart Healthy meals we include in our range each week was a fantastic experience. And, of course, the food… Sometimes I am trying up to 15 new recipes a day and our whole team is food obsessed, both inside and outside of work. Working with a team of people that has made their passion their job makes for such a fun and energetic workday. It’s very fast paced, and there is truly never a dull day at My Food Bag.

Finding ways for more Dietitians to infiltrate the food industry is incredibly important. There is always a healthy tension between marketing claims, and nutrition science, and dietitians need to be at the table and part of those conversations within industry settings. I encourage any new Dietitian to get some volunteer or work experience within the food industry to see how collaborative and rewarding it can be. Though you don’t see clients or patients one on one, I feel like industry work is also an incredible opportunity to make a difference to the health of individuals and communities. From a public health lens, tens of thousands of Kiwis eat My Food Bag every week. If you quantify the impact of a nutritious swap we’ve made, the numbers can be mindboggling.

F R O M M A S S E Y U N I V E R S I T

Catherine Bell with Nadia Lim at My Food Bag

I was born in Cape Town, South Africa, and moved to NZ with my family in 2000. I've grown up in a Pasifika Church, and consider myself a Pasifika, Kiwiana, South African, incredibly blessed to have been immersed in vibrant, colourful cultures and traditions!

My experiences through the Pasifika church, time spent volunteering in Samoa, and my public health placements, all reinforced to me that the public health space was where I wanted to be, where I truly belonged. My current role as the Healthy Schools Programme Coordinator and a Lifestyle team member at the Diabetes Foundation Aotearoa sees me donning all sorts of hats! In my Schools role, I do my best to support schools within the nutrition and wellbeing space. This includes organising and facilitating workshops, events and expos for staff, students and families, running interactive healthy eating on a budget and cooking classes, support with policy development and implementation, creating tailored resources and more. In my Lifestyle team member role, I support our Cook'n Kiwi programme by co-facilitating workshops and events, designing workshops and resources, connecting community groups to appropriate support services, and networking/collaborating with relevant stakeholders. I absolutely love my role! It's so diverse, and no two days are ever the same!

One of my highlights happened last week, where we liaised with the Health and PE department of high school in South Auckland and developed a Healthy Eating on a Budget and Masterchef Cook-Off workshop for their Year 10 cohort. We ran back-to-back workshops for classes ranging from 12 - 25, and it was incredibly rewarding and fulfilling, to see the lightbulb moment happen for so many of the teens during the workshop, and the delicious vegetable-bulked dishes that they whipped up in 20 minutes (with the majority having never cooked before!). I knew that I was where I was meant to be, when the teens asked if we could please come back next week.

Esau Healthy Schools Coordinator Diabetes Foundation Aotearoa

F R O M M A S S E Y U N I V E R S I T Y

Kim

I learnt so much from my Dietetics training at Massey and I draw on this every day in my role - communicating in lay terms, critical thinking, motivational interviewing, empathy, the thirst to keep learning and improving, and thus continue to improve the service and supports that I provide to our communities, as well as the confidence to know and remember that I am the nutrition expert and that I do have a voice and a place at the table. Most importantly, my cultural awareness and respect for others, their beliefs, their food practices and way of life.

Being a public health dietitian is incredibly humbling. You are often going into the life and environment of another soul, invited into the sacred and vulnerable space of another human, family, community. I don't take this for granted. For me, being a public health dietitian is an honour and I consider myself incredibly blessed to be in this space. The ripple effects are immeasurable.

F

Kim Esau, second on the left, celebrating the things most important to herfamily, faith and food

Exploring Inflammatory Bowel Disease Dietetic Services in Aotearoa New Zealand

I work as a rural generalist dietitian in the beautiful Central Otago and Queenstown Lakes areas. In recent years I have developed a particular interest in gastrointestinal conditions, and I was encouraged to do some research by some inspiring colleagues. My research topic arose after discussions with Prof Michael Schultz and Dr Cath Wall (NZRD). We developed a research proposal exploring the topic of dietetic services for patients with Inflammatory Bowel Disease (IBD) in NZ.

IBD is a chronic disease affecting increasing numbers of New Zealanders. Diet therapy plays an important role in disease treatment and management. International IBD management guidelines recommend that all patients with IBD should have access to dietetic support and nutrition therapies 1-3. Our research aimed to investigate NZ IBD patients’ experiences of dietetic services; evaluate the capacity of the NZ gastroenterology dietitian workforce and assess gastroenterologists’ experience of NZ IBD dietetic services.

Online surveys of patients, dietitians and gastroenterologists were conducted in early mid 2020. Responses were received from 407 IBD patients, 79 dietitians and 40 gastroenterologists. Half the patients had seen a dietitian for IBD nutrition advice.

Patients more likely to have seen a dietitian were/had: Crohn’s disease, previous IBD surgery, were younger, or receiving biologic therapy. Younger patients were seen faster by a dietitian than older patients.

Two-thirds of patients found the dietitian advice at least moderately useful while nearly 20% did not. Patients who saw a dietitian in a private clinic were more likely to find the advice useful, as were those who had received written advice. A common theme from patients was the need for dietitians to have specialist knowledge of IBD and patients wished to have ongoing dietitian access to address nutrition needs that may vary over time.

Nicky McCarthy

Not surprisingly, nearly all (97%) gastroenterologists reported that their IBD patients ask about nutrition; 57% reported that there were not enough dietitians to meet patient needs. Nearly 80% of dietitians said they would require changes to their dietetic service to see higher numbers of IBD patients Over half of dietitians saw IBD patients infrequently and many were not confident that they are up to date with the nutritional management of IBD. Many dietitians expressed a wish to have greater links to the IBD multidisciplinary team (MDT)

The results of our research showed that NZ patients do not have adequate or equitable access to dietetic services. Dietitians acknowledged the need for additional upskilling in the nutritional management of IBD. While some dietetic services already provide excellent IBD care, further work is needed to guarantee that access to quality and timely dietetic care is available for all patients with IBD in NZ. Increased resourcing of dietetic services and stronger links to the IBD MDT will help to ensure this.

I really enjoyed the challenge of completing research and having the opportunity to look at a topic in depth, which is not a luxury I usually have working as a generalist dietitian. I hope this research helps to raise the profile of diet in IBD treatment and management and highlight the benefits of a greater role for dietitians in the IBD MDT

References:

1 Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, et al British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68(Supplement 3):s1-s106.

2. Kapasi R, Glatter J, Lamb CA, Acheson AG, Andrews C, Arnott ID, et al. Consensus standards of healthcare for adults and children with inflammatory bowel disease in the UK. Frontline Gastroenterology. 2019.

3. Crohns and Colitis Australia. Australian IBD Standards: Standards of healthcare for people with inflammatory bowel disease in Australia. Crohns and Colitis Australia; 2016.

For dietitians who are interested in looking at some opportunities to increase their knowledge in IBD here are some places to start:

European Crohns and Colitis Organisation

https://ecco-ibd eu/education html

Has some audio recordings on specific IBD topics plus information about IBD education workshops (can sometimes be attended online)

Gut Smart – Crohns and Colitis Australia

Nutrition and IBD for Dietitians – Gut Smart

Nutritional Therapy for IBD website

Nutritional Therapy for IBD - Home (ntforibd.org)

A website which collates information, research and resources related to nutrition and IBD. Maintained by health professionals and patients/family members with IBD.

Education in Nutrition

https://educationinnutrition.com.au/ Webinars on Inflammatory Bowel Disease

Nestle Modulife Website

https://mymodulife.com/experts/ Training programme that trains providers in the Crohn’s Disease Exclusion Diet and provides resources to support its use. The CDED is designed to treat Crohn’s disease as an alternative to exclusive enteral nutrition Research on its effectiveness is ongoing

Food Chemical Sensitivity: The evidence for use in clinical practice

Food chemicals occur naturally in the foods we eat or may be synthetic, added to foods for a variety of reasons. This article will look at naturally occurring food chemicals (and intolerances to these)

The European Academy for Allergy and Clinical Immunology (EAACI) requirement for an adverse food reaction, termed a ‘food intolerance’, is to have; 'objectively reproducible symptoms, not to involve an immunological mechanism, nor on account of food toxicity'.

Types of Adverse Food Reactions

‘Adverse food reaction’ is a broad term encompassing all mechanisms of food reactions. Timing is a key tool in differentiating between them:

Food allergy is immune driven, and, with only a handful of uncommon exceptions, an adverse reaction occurs within 2 hours of allergen consumption.

Food intolerances are non immunemediated, with poorly understood mechanisms, postulated to irritate nerve endings with increased leukotriene production by food additives (in patients with atopic dermatitis and proven food intolerance), or other undefined mechanisms such as enzyme deficiency Symptoms include hives, headache, gastrointestinal symptoms among others.

F e d e ( s

contribute to an eliciting ‘threshold’, at which an adverse reaction occurs. Focus tends to lie on the food last eaten, forgetting the many other contributory foods over the past 72 hours. Glutamate, Salicylates and Amines are naturally occurring food chemicals.

Salicylates, Amines and Glutamates

Salicylates are a family of naturally occurring food chemicals (2hydroxybenzoates) found in many plant foods. They are associated with colourful, flavoursome, fragrant fruit and vegetables, natural flavourings and fragrances. Salicylate is concentrated in the skin of produce, providing anti-bacterial and preservative properties, protecting plants from insects and pests until the produce is ripe. Salicylate content is highest in unripe produce, decreasing with ripening. Concentrated products such as juices or tomato puree have higher salicylate load per serve. Well ripened seasonal produce in whole form are lower in salicylate.

Aspirin (acetyl salicylic acid) is a member of this chemical family. Natural salicylates are active ingredients in many herbal medications because of their pain killing and anti-inflammatory properties.

Amines (Vaso-active tyramines or Biogenic amines) contribute to the richness of flavour in food. They occur naturally (in fruit and vegetables) or form with the breakdown of proteins with aging, in maturity or fermentation, increasing with ripening and browning. Foods such as cheese, smoked meats, canned or pickled fish, long life milk, chocolate or fermented products such as beer and wine are high in amine. Histamine, phenylethylamine, dopamine, tyramine and serotonin are found in food. There is a lack of consensus on the exact levels of amine in individual foods. The Dietitian is best guided by the broad principles of amine occurrence and a focus on freshness, in patient education. (San Mauro Martin et al, 2016)

Glutamate occurs naturally in food and is associated with umami flavours. Lglutamate is an essential amino acid. Added glutamate adds ‘BIG” flavours and may be added to foods in the form of flavour enhancers such as Monosodium Glutamate (MSG) – (621-625) or Ribonucleotides (627-635). Naturally occurring glutamate increases in foods with ripening and maturity. Foods such as cheese, tomato, mushroom, stock cubes, soy sauce, yeast extracts are high in glutamate. Pure MSG is added to snack foods, soups, sauces and Asian foods to give a big savoury flavour.

A History Summarised

Historically, synthetic or added food chemicals bore the brunt of the blame for food chemical intolerances, until the role of natural food chemicals came into question.

Benjamin Feingold, a Californian allergist and paediatrician published the Feingold diet (1973), excluding salicylates and synthetic food additives in the management of hives, asthma and eczema in his patients. Noting a correlation between diet and behaviour, he extended this to children with ADHD and Autism. He postulated those sensitive to aspirin may be intolerant to dietary salicylate.

Dr Clancey, an Immunologist at the Royal Prince Alfred Hospital (RPAH) (1973) became interested in the role of diet in the pathogenesis of recurrent idiopathic urticaria and angioedema. The literature suggesting the role of naturally occurring salicylates, and artificially added preservatives and colourings in eliciting adverse food reactions

Anne Swain (Gibson), an RPAH Dietitian working with Dr Clancy included a cohort of 76 patients with idiopathic urticaria and angioedema, responding to low food chemical diets in her PhD, published 1980. Subsequently other conditions were noted to respond to dietary restriction including abdominal pain, diarrhoea, headaches and respiratory symptoms. Clinical observations suggested milk, wheat, natural amines, MSG and several other food additives could also trigger symptoms, which led to the strict version of the Royal Prince Alfred Elimination Diet being developed. There are now strict and simplified versions in RPAH resources.

It is postulated that inadvertent exclusion of lactose and fructan along with a simple, whole food diet improved symptoms and that possibly the earlier interventions gave the right answers for the wrong reasons.

However, there have been no peer reviewed published studies since the 1980s.

A 2015 systematic review of the current literature with regard to sensitivity to food additives, vasoactive amines and salicylates (excluding food colourings) concluded that there was a lack of well-designed placebocontrolled studies investigating the role of many of these substances to provide evidence-based advice for the removal of food additives, histamine and salicylates from the diet. There was no convincing data on the impact of food chemicals on atopic disorders in children, and concern raised about the impact (of food exclusion) on growth and development in children, and the nutritional status in adults with significant dietary restrictions

The reviewers concluded that until there was better evidence and more current food composition data was available, clinicians would be ill-advised to prescribe a low food chemical diet in the management of IBS. There was concern the diet is highly restrictive and nutritionally deplete with a long and cumbersome protocol leading to poor compliance and ambiguous results.

They noted the use of low food chemical diets in the management of various conditions is poorly described and reviewed in the literature and not widely used internationally. (Skypala et al, 2015)

So where is there evidence for the use of low food chemical diets in clinical practice and where is a low food chemical diet appropriate?

The challenge is in the absence of current data and the perpetuated use of historical data in clinical practice.

Monash University researcher, Sreepurna Malakar investigated the Role of naturally occurring dietary salicylates in irritable bowel syndrome (IBS) in her thesis, 2017, finding significant discrepancies between the 1980’s data and current analysis of the salicylate content of many foods. There are many reasons the Monash data differs from the 1980’s data giving rise to conflicting figures for the salicylate content of foods, with differences in analytical methods and in our food supply.

If salicylate exclusion is being applied clinicians need to be mindful that the new analysis by Malakar (2017) is the current ‘gold standard’ for salicylate analysis. There are similar issues with the measurement of amine in foods between studies.

The widely used nutritional analysis program, Foodworks has adopted the 1980’s RPAH data and is not useful in clinical practice.

Some authors claim dietary salicylate to be precipitant in gastrointestinal symptoms in 70% of those with IBS, however the role of low salicylate diets in IBS is hampered by a lack of randomized controlled trials and controversial data on the salicylate content of foods.

Monash data indicates 85% of patients with IBS respond to a reduction in fermentable carbohydrates, however, more recently naturally-occurring bioactive food chemicals such as salicylates have also been implicated in IBS.

Initial work identified a low prevalence of dietary salicylate-sensitivity, suggesting a non-targeted low-salicylate dietary approach for IBS patients will have little clinical impact, however, a more recent Monash pilot study (2021) evaluated the role of naturally-occurring dietary salicylates in the genesis of functional gastrointestinal symptoms in patients with IBS. While the 10 patient cohort was small, there was clear symptom provocation in one aspirin sensitive patient, developing abdominal symptoms and fatigue with the high salicylate diet, with the study concluding there is some evidence for dietary salicylates influencing the genesis of symptoms in a subset of patients with IBS, with a larger cohort needed to assess therapeutic benefit. (Tuck et al, 2021)

In the gastroenterology clinical setting, a patient whose symptoms increase on the low FODMAP diet may be food chemical sensitive as the FODMAP diet has a naturally food chemical load.

A 2015 systematic review concluded food chemical sensitivity may be considered in:

Paediatrics:

Chronic urticaria and angioedema Idiopathic anaphylaxis

Severe Eczema ( after dermatologist and allergist workup) Adverse behavioural reactions

Orofacial granulomatosis (low cinnamate, low benzoate, low flavour enhancers)

Adults:

Chronic urticaria and angioedema Migraine

Eczema (after dermatology workup) Idiopathic anaphylaxis Asthma

Oro-facial granulomatosis (low cinnamate low benzoate, low flavour enhancers)

Given the poor evidence for low food chemical diets and unreliable data on which to establish low food chemical ‘lists’. Dietitians should use the guiding principles of:

Allergy focussed diet history

Timing and reproducibility of symptoms

Misattribution (? concurrent FODMAPs)

Dietary load of big colourful flavours, ripeness (salicylates decrease, amines increase with ripeness) and concentration (slice of tomato v canned tomato v tomato paste)

Often it is enough just to exclude or reduce the dose and frequency of the most concentrated dietary sources

In conclusion, any decision to exclude a food, food compound or food chemical should have a finite time frame and be supported by re-producible challenge. For more information on synthetic food chemicals ‘The New Additive Code Breaker’ is a must have bench book, an oldie but a goodie, breaking the number code and identifying most likely sources.

References: Skypala, I. J., Williams, M., Reeves, L., Meyer, R., & Venter, C. (2015). Sensitivity to food additives, vaso-active amines and salicylates: a review of the evidence. Clinical and Translational Allergy, 5, 34

San Mauro Martin I, Brachero S, Garicano Vilar E. Histamine intolerance and dietary management: A complete review. Allergol Immunopathol (Madr). 2016 SepOct;44(5):475-83.

Malakar, S, Gibson, PR, Barrett JS, Muir, JG. Naturally occurring dietary salicylates: A closer look at common Australian foods Journal of Food Composition and Analysis 57 (2017) 31–39

Tuck CJ, Malakar S, Barrett JS, Muir JG, Gibson PR. Naturally-occurring dietary salicylates in the genesis of functional gastrointestinal symptoms in patients with irritable bowel syndrome: Pilot study. JGH Open. 2021;5(8):871-878

Hansen M et al. The New Addditive Code Breaker. ISBN 0-85091-477-9

Mercy Hospital Room Service Menu Review

In January 2021, I started work as sole Dietitian at Mercy Hospital Dunedin. Part of this role involves the development and review of the Room Service menu; a model of foodservice which allows patients to order from a single menu from 7am till 7pm. This provides flexibility and autonomy with regards to what they order and when.

-By Angie Lucas, NZRD

Mercy Hospital implemented Room Service in 2018 and to ensure the menu meets recommended standards and specifications it is reviewed every two years. In 2021/22 the review was carried out by myself (Dietitian) and Rachel Bond (Head Chef). After consulting with Wendy Dodunski (Dietitian and Manager of Nutrition and Food Services at Te Whatu Ora Waikato), we decided to use the Queensland Health Nutrition Standards for Meals and Menus (NSMM), 2018 as our assessment tool (1). This tool was chosen for a number of reasons including the fact that there are currently no New Zealand specific nutrition standards for hospital foodservices and the Queensland NSMM included standards that best reflect the type of menu offered and the type of facility that Mercy Hospital is i.e. Short Stay Patients.

The process for reviewing the menu included collecting information on our patient profile as well as diet and allergy code usage at Mercy Hospital Information regarding recipes and menu items was gathered from the Mercy Hospital CBORD database, written menus, recipes, review of product labels and tests in the kitchen e.g. weighing portion sizes.

Some adaptations were made to the assessment tool e.g. Mercy Hospital is accredited by Coeliac NZ Dining Out Programme, therefore an additional standard for gluten free diets was added.

Reviewing the menu did take a lot of time, however a spreadsheet was created to improve efficiency and keep all the data in one place. It was useful to get an insight into what we are doing well and if our menu is catering for our patient profile It was also useful to develop recommendations for improvements.

Main findings and summary from the menu review:

Overall: Mercy Hospital's Room Service Menu 2022 meets the majority of the Queensland Health NSMM, 2018.

Main areas for improvement included: increasing the portion size of meat/meat alternatives for some dishes; reducing the amount of sodium in some dishes; increasing the fortification of some menu items and adding some additional items onto the Puree Menu.

Patient Profile: The age group most frequently admitted to Mercy Hospital are patients aged 51-70 years (39%). A quarter of patients admitted are aged 19-50 (27%) and a quarter are aged 70+ (27%). The current menu, including the improvements outlined below does cater for this large age range. It does this by meeting the majority of the Queensland Health NSMM as well as the Ministry of Health, Eating and Activity Guidelines for New Zealand Adults (2) i.e. patients can self-select off the Room Service menu to enable them to meet the recommended number of servings per day from each of the food groups for adults as well as the eating statements that are applicable to them.

Even though Mercy only admits a small percentage of paediatric patients (4.2%), the menu meets the majority of the Paediatric Nutrition Standards and the Minimum Menu Choice (MMC) Standards for Paediatrics within the Queensland Health NSMM.

Length of stay: In terms of length of stay, 92.2% of patients are staying for 1, 2 or 3 nights. These patients do not require extensive choice on the menu and it is therefore appropriate for Mercy Hospital to be reviewed against the Adult Acute Short Stay Standards within the Queensland Health NSMM. Patients who stay longer are at a greater risk of not eating well and may require greater variety. However, only a small percentage of patients are staying longer i.e. 4 nights (4.2%), 5 nights (1.5%), 6 nights (0.4%), 7 nights (0.3%) and >7 nights (1.4%). There are a number of tools in place to help support these longer stays e.g. malnutrition screening; a variety of High Energy and High Protein options (including snacks and nutritional supplements); input from the Dietitian; ‘build your own’ menu categories which provide the opportunity for increased variety.

Diet code usage: The top four diet and allergy codes most frequently assigned in 2021 were: Standard Diet (49.6%), Nil by Mouth (NBM) (26%), Soup and Sandwiches (3.2%), and Vegetarian (2.0%). The current menu provides adequate choices within these diet codes as reflected in the menu review i.e. meets Nutrition Standard 8.1 for Vegetarian and Vegan options; meets the majority of the MMC Standards for Adult Acute Short Stay ; Meal Component Specifications are met for Sandwiches and Soups except pumpkin soup (and this is reflected in the improvements made below).

Salmon, chicken and falafel have all been increased to 100g serving sizes for the Main Garden and Caesar Salads. This has increased the amount of protein by 33% (falafel and chicken) and 66% (salmon). All Chefs have been trained how to test pureed foods so that they meet the International Dysphagia Diet Standardisation Initiative (IDDSI).

High sodium sauces in the Pork Belly Dish have been reduced by 20%.

Vegetarian Burger: Falafel has been increased to 100g per burger. This has increased the amount of protein by 33%.

Black Bean Burger: The Black Bean pattie has been replaced with a new Bean Protein pattie. This has increased the amount of protein by 50%.

Grilled Mushroom and Kumara Rosti Dish: Changed to ‘Grilled Mushroom and Vegetable Rosti’. The Kumara Rosti has been replaced with a new Bean Protein pattie. This has increased the amount of protein by 140%.

Pumpkin Soup: Skim milk powder has been added to increase calories and protein. This has increased the amount of protein by 186% and calories by 44%.

Improvements made as a result of the menu review: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Puree menu to be reviewed and updated in 2022. Dietitian and Head Chef will review and update all written recipes and information on CBORD so that they align.

Mushroom and Rosti dish

Pork Belly dish

References:

Nutrition and Menu Work Group, Statewide Foodservices. (2018). Queensland Health Nutrition Standards for Meals and Menus. Queensland: Department of Health. Available from: https://www.health.qld.gov.au/ data/assets/pdf file/0030/156288/qh-nutritionstandards.pdf

Ministry of Health. Eating and Activity Guidelines for New Zealand Adults. (2020). Wellington: Ministry of Health. Available from: https://www.health.govt.nz/system/files/documents/publications/eating-activityguidelines-new-zealand-adults-updated-2020-jul21.pdf

Please note: There is now a revised 2022 version of the Queensland Health NSMM. Available from: https://www.health.qld.gov.au/ data/assets/pdf file/0030/156288/qhnutrition-standards.pdf

Mercy chefs and Dietitian Angie Lucas

The Friendly Food Co

Our aim at The Friendly Food Co is to provide IBS sufferers with a trustworthy product that will help them enjoy tasty and exciting meals without having to put up with the symptoms that often follow flavourful meals.

By Kelsey Paterson & Bianca Berton-Scarlet

In March this year we launched our exciting new business venture, The Friendly Food Co. Creating low FODMAP and gluten free spice mixes and seasonings for all our IBS and coeliac friends out there!

We both trained as dietitians at the University of Otago, before starting our first jobs together in private practice, where we supported clients with IBS.

We came up with the idea at the end of 2020. It then took us about 15 months of product and brand development before launching in March 2022. The launch was a huge success, and we were overwhelmed with support Within the first month we stocked our first wholesaler and within the first three months we were distributing to Fodshopper in Australia. We’ve recently signed on a nationwide distributor and are hoping to soon make a presence into small health food stores On top of all of this, we have recently launched an online IBS low FODMAP course to help make IBS and low FODMAP education more accessible to those in need.

Currently all our products are handmade, however, moving forward we want to progress into contract manufacturing to free up time to spend on other parts of the business. We are working on being stocked in smaller supermarkets such as Farro, with the dream of eventually making it into bigger supermarkets. We also hope to make it into more stores across Australia. We have a lot of exciting ideas for new product development on the horizon, however the biggest challenges we are currently facing are time and capital. Our goal is to eventually work full time in the business, mixed between the clinical work and the business/product.

Although neither of us have business degrees, our dietetic studies have given us a solid foundation for starting up a food company. In fact, the food service lectures that we never thought we’d use, became the most helpful! They came into use when creating our jar labels, our food control plan and understanding the health and safety procedures during production.

There is so much potential for dietitians in the evolving food industry. So often, we see nutritionists or nutrition “enthusiasts” promoting all sorts of products, and we think that potentially dietitians get scared of crossing the line with the Board when it comes to launching businesses in this area. The thing is though, we are the EXPERTS and we are more than qualified! It would be great to see more dietitians moving into this space.

Bianca; “I’ve always had a passion for IBS and gut health. In working with clients on the low FODMAP diet, I realized that low FODMAP convenience food products were severely limited in the retail market I’d learned a lot from my experience with a previous start-up business, which made going into business again, a lot less daunting.”

Kelsey; “the desire to create a low FODMAP product came from my own struggles with IBS and multiple food allergies. Once I started working with clients in the same space, the need for a low FODMAP convenience product was a no-brainer.”

Policy, Influence and Working Outside the Box

One of my favourite things about being a dietitian is how varied our careers can be. I knew from early in my studies at McGill University in Canada that I was not drawn to be a clinical dietitian, but the breadth of options wasn’t always clear Initially I thought I would be a high performing sport dietitian or diabetes specialist

By Edith Bennett

My first job was in a regulatory role with the Canadian Government, regulating nutrition labelling. Although I loved sports nutrition, public health and policy work just made a lot of sense to me and I couldn’t believe that as a dietitian I could influence policy changes. In some respects, my career path has been deliberate, but mostly it has been a willingness to try new things and having the confidence that my wide-ranging dietetic skills would support me to be successful in the role. In the last 10 years, I have gone from wanting to be a sport dietitian to working in what some might say is a less traditional dietitian role with the Ministry of Health in health systems leadership.

Edith Bennet

Understanding the wider health system

Public health professionals are by and large system thinkers. As I was deciding what to research as part of my Master of Public Health thesis with the University of Auckland, I became curious about whether hospital resources were equitably distributed for one of the biggest public health challenges New Zealand was facing. This curiosity led to me completing my research portfolio looking at the epidemiology of who received publicly funded bariatric surgery, as well as an analysis into some of the reasons why some hospitals funded more surgeries than others. As someone who first and foremost champions preventative medicine, I have had to challenge my own thinking to focus on a surgical intervention, and I’ve learned that a strong focus on an equitable health system lies at the core of my interest.

Two-years ago, this opened another door in my career when I joined the System Flow team at the Ministry of Health. This team was responsible for monitoring the performance of hospitals planned care delivery. I am proud of the discussions I led in this space, advocating for the valuable skills that dietitians (amongst other allied health professionals) can contribute to improving planned care delivery.

Being able to challenge and influence thinking in a space that historically focuses on surgical interventions is credit to the cross-disciplinary mindset dietitians have. Working on health service delivery at a national level is a unique spot for a dietitian, but I hope others will see how our professional scope enables us to work in system and clinical leadership roles, and to seek these rewarding opportunities.

Health System Leadership

Fast forward to the present, and I am working as a Principal Advisor in the Ministry of Health Office of Chief Clinical Officers, which includes the Chief Allied Health Officer. My role cuts across medical, nursing and allied health issues and supports our Chief Officers to provide strategic clinical leadership. Dietitians have a wealth of skills; we have a strong clinical foundation, are analytical, and can communicate complex topics easily. I have drawn upon all these skills to be successful in this role - from providing Ministers with crucial information, to developing a model of care.

I love to see the growth of our profession and I am optimistic that more dietitians will be confident to seek out and own leadership positions in the broader health sector. We have a lot to offer, from public health, through to our research and clinical expertise. I think a challenge for us over the next few years is to articulate the value we contribute to rising health and health system challenges.

Creating Positive Foods: Good for people and good for the planet

At Plant & Food Research we believe that science can create a better, more sustainable, future. We have expertise across the food value chain – from breeding to consumer and market insights – and we are enhancing our capabilities in circularity and total bioresource utilisation Our approach is to support our partners to produce great tasting and nutritious foods that are also environmentally sustainable.

We call them “Positive Foods” ™ .

-By Christian Pena, Market Team Lead (Food, Seafood, and Bioengineering) at Plant & Food Research, Auckland

The last three years have demonstrated that, in addition to climate change, unexpected global uncertainties might be the new normal. It is also difficult to predict what consumers will want to eat in future. While there are identifiable mega trends, including sustainability and plant-based foods, consumers are also investing in individualized diets and chasing specific bioactives that offer desired health attributes.

Delivering to future consumers could be quite a challenge and might require specialized expertise, sophisticated systems, and technologies. Our Digital Diets project at Plant & Food Research is exploring the use of artificial intelligence to predict novel bioactives, their physiological targets, and health functionalities.

By 2050, almost two-thirds of people will live in cities Dr Denise Conroy and her Stakeholder and Consumer Intelligence team at Plant & Food Research are future casting consumer perceptions and trends, including attitudes to new production technologies, like vertical farming. Similarly, to better understand consumer perceptions, Science Group Leader Dr Farhana Pinu is developing flavoromics approaches to deepen the understanding of the relationship between food composition and sensory properties.

With the climate changing, it is of course critical to account for future growing conditions. Breeding apples for a warming climate is an example of Plant & Food Research’s contribution to increasing resilience and helping future-proof Aotearoa New Zealand’s industries. By creating ‘digital twins’ of production systems and supply chains we aim to speed up critical decision-making and responses to the major challenges of the future.

In our Growing Futures ™ programme we invest in risky blue skies research to tackle future challenges, such as the growing global population and its urbanisation. We want to safeguard the production of nutritious and tasty food beyond just the next decade and achieve this whilst having less impact on the natural environment.

In addition to new systems and technologies, total utilisation is part of our strategy to minimize environmental impact. Using every part of what we produce makes sense financially as well. Our vision is to transform products previously viewed as waste streams and process them into new nutritious foods or use them to extract nutrients and food ingredients.

Despite the future challenges we all can foresee, and the uncertainties we all can feel, at Plant & Food Research we are optimistic about the future of food production in New Zealand. Working together, we can make sure that we have the necessary knowledge and solutions to adapt to change and create Positive Foods™ desired by global consumers.

New and perhaps unexpected partnerships are likely to have an important role in generating innovations in food products, technologies, and production systems. It is also critical to look beyond these innovations to understand what the sophisticated future consumers will value. We need to understand how to generate a value proposition with a broad appeal, and still offer foods that are individualized for health and lifestyle requirements. Dietitians are important partners and experts with early insights into what the future might look like, and we are keen to share our science and explore collaborations.

Farmer Time –Connecting Tamariki to Kai

“Once in your life you may need a doctor, a lawyer, a policeman .... but every day, three times a day, you need a farmer.” Nadia Lim quoted* in an interview recently. But are our tamariki aware of where the food they eat at each meal originates from, who grows it and the journey of kai from paddock to plate? Farmer Time is an exciting educational programme connecting students directly with their own farmer or grower to learn more about food production.

With 65% of New Zealanders now living in major or urban centres many of our young people can be disconnected from where their food comes from, many may have never experienced a working farm. One research project by Rabobank showed 81% of the urbanbased New Zealand teenagers surveyed, know only a little or nothing about farming and food production. Farmer Time bridges this urban-rural knowledge gap by bringing food producers directly into a primary or intermediate school classroom via video technology.

Farmer Time was developed in the UK and piloted and launched this year in Aotearoa by Beef + Lamb New Zealand. Regina Wypych, Head of Nutrition, at Beef + Lamb New Zealand facilitated the programme roll out, says “the programme has been a huge hit with farmers, kaiako and tamariki alike.”

“It’s the simplicity, autonomy, and fun of the programme that is so appealing. Once the food producer has been matched with their teacher they collectively decide on the content of each fortnightly, 15–20-minute session” says Regina. “There’s such a huge range of topics covered, and teachers can very easily match this to their class curriculum subjects. Sessions are also child-centred and based on questions students ask. “

Farmer Time is open to all food producers, with many growing a range of food, along with being kaitiaki of the land, so the session topics can be quite diverse. The programme has the support of Ministry of Primary Industries, Horticulture and Agriculture Teachers Association, 5 + A Day, Federated Farmers, United Fresh and Beef + Lamb New Zealand.

If a school already has existing nutrition-related programme such as 5+ A Day Fruit & Vegetables in Schools, Garden to Table, Enviroschool, Food for Thought, or Ka Ora, Ka Ako (Healthy School Lunches), Farmer Time can complement these, so that tamariki develop a greater understanding of the food that sustains Aotearoa.

The programme has grown amazingly fast and what started with 8 teachers matched with farmers for the pilot has grown to 45 teachers reaching over 860+ students. The programme is currently taking sign-ups for Term One 2023 from teacher of classes Years 1-8 and food producers.

You can find out more about Farmer Time at www.farmertime.co.nz . To hear a recent Radio New Zealand interview, with Teacher Brigid Ladley and her students sharing their first hand their experience of the programme click here.

A Summary Report of the Farmer Time Pilot can be found here.

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