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NHDmag.com

Issue 101 February 2015

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS BRIGHTON & HOVE

ISSN 1756-9567 (Online)

Lauren McCormack p9

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

Louise Dickie Specialist Stroke Dietitian

adult food allergy lactose intolerance coeliac disease cows’ milk vs goat milk

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from the editor Numerous people will be well into their New Year resolutions by now, many of which would have had a theme around getting fitter or losing weight.

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

Did any of you get involved in the National Obesity Awareness Week, 12-18 January 2015? It aimed to highlight the impact of obesity on the NHS and why we need to take action now to lead healthier lifestyles. The NHS spends between £5 billion and £9 billion treating obese patients and related complications such as Type 2 diabetes. Hospital admissions with a primary diagnosis of obesity among people of all ages rose from 1,019 to 11,763 in a decade. There were some interesting ‘infographics’ given during the Awareness Week. Did you know that the NHS employs approximately 1.35 million people and it seems likely that a quarter of these staff would be classified as obese and a further one third as being overweight! If all NHS staff took steps to be healthier and more physically active, it would have a big impact and show ‘a lead by example approach’ to our patients. However, around 75 percent of NHS Trusts do not have an obesity plan or policy implemented. And so to the articles that we have for you in issue 101. A fascinating project that has dealt with several difficult challenges is a community food strategy across Brighton and Hove. Lauren McCormack tells us how communities, businesses, statutory agencies and individuals worked together to help create a healthy, fair and sustainable food system which led to the implementation of this strategy. There were many chalEditor 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

lenges faced, including obesity, food poverty and malnutrition, so please delve into this report to find out more. In the UK, 15 people every hour suffer a stroke and up to 50 percent of these will have dysphagia. Dysphagia and nutritional interventions in stroke care by Louise Dickie tells us the importance of optimising the nutritional care provided to assist in promoting the best patient outcomes. If you are considering offering dieteticled clinics for people with coeliac disease, may I direct you to Fiona Moor’s article? Fiona shares with us how it is done in Southern Derbyshire and how the dietitian manages these clinics and patients. Last year, Carina Venter told us about paediatric food allergies. This month it’s the turn of adult food allergies. Such allergies have complex symptoms and it is important to diagnose and manage these well. Carina explains how, and reminds us that, from 12 December 2014, all major food allergens need to be clearly identified on food labels. And we have more too, as Jacqui Lowden looks at The nutritional qualities of goat milk as an alternative to cows’ milk in infant formulae. She concludes that ‘Goat milk infant formula, however, is not suitable for infants with a cows’ milk protein allergy, unless directed by a healthcare professional’. I hope you enjoy reading this first of the next 100 issues of NHD!

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@ networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

NHDmag.com February 2015 - Issue 101

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Contents

9

COVER STORY

COMMUNITY FOOD STRATEGY 6

News

43 Infant feeding: dairy

15 Adult food allergy

48 Web watch

23 Lactose intolerance

50 NHD app for easy download

29 Dysphagia in stroke care

52 dieteticJOBS

37 Coeliac disease

53 Events and courses

40 Book review

54 The final helping

41 Subscribe to NHD Magazine

Editorial Panel Chris Rudd Dietetic Advisor

Jacqui Lowden Paediatric Dietitian

Neil Donnelly Fellow of the BDA

Lauren McCormack Health Promotion Dietitian

Ursula Arens Writer, Nutrition & Dietetics

Tak Chin Specialist Registrar

Dr Carrie Ruxton Freelance Dietitian

Carina Venter PhD, RD Senior Lecturer, University of Portsmouth

Dr Emma Derbyshire Nutritionist, Health Writer

Dr Justine Butler, Senior Researcher and Writer

Dr Anita MacDonald Consultant Dietitian in IMD

Louise Dickie Specialist Stroke Dietitian

Kate Harrod-Wild Specialist Paediatric Dietitian

Fiona Moor Head of Dietetic Services, Royal Derby Hospital

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NHDmag.com February 2015 - Issue 101


Cow & Gate Friends are designed to make vegetables an essential part of the weaning journey. This unique range of savoury food pouches helps parents start weaning with single XGIGVCDNGUCPFITCFWCNN[KPVTQFWEGEQODKPCVKQPUQHĆ?CXQWTU a process that helps create a love of vegetables for life. Find out more about then5VCTV8CT[4GRGCVoapproach to weaning at www.in-practice.co.uk/weaning.


news

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

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

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New ‘super’ review What we eat and drink can affect chronic disease risk, although studies are not always consistent in their findings. Now, a new paper has pooled results from a substantial number of meta-analysis and systematic review papers, providing evidence of the highest quality. The review included 304 papers published between 1950 and 2013. Findings showed that plant foods were particularly effective at protecting against diet-related chronic diseases, especially grain products. Tea was also found to help protect against major chronic diseases risk, while soft drinks were found to be least protective. Finally, it should be considered that most of these papers focused on chronic diseases such as overweight/obesity, Type 2 diabetes, heart disease and cancer. Other chronic diseases such as mental, skeletal and digestive health, were slightly under-represented and need to be studied further. For more information, see Fardet A & Boirie Y (2014). Nutrition Review Vol 72 (12), pg 741-62.

Wholegrains, fibre and health There is a growing body of new evidence looking at how wholegrains and fibre may help to support health. Now a new review has collated findings from latest research. The review published in Nutrition & Food Science gathered evidence from 49 scientific studies. Results from observational studies showed that higher wholegrain and dietary fibre intakes were associated with a significantly lower risk of cardiovascular disease, diabetes, abdominal obesity and certain cancers. Equally, intervention studies suggested benefits for appetite control, digestive health, improved blood lipid levels and glycaemic control. Given these findings, Government and industry should work to help the public identify foods rich in wholegrains, e.g. breakfast cereals and dietary fibre (especially insoluble fibre) and communicating the health benefits of these. For more information, see: Ruxton CHS & Derbyshire EJ (2014). Nutrition & Food Science Vol 44 (6), pg 492-519.

Pregnancy, iron and childhood wheeze It is well known that low iron status These are interestin pregnancy can lead to anaemia in ing findings, suggestthe mother and, if uncorrected, in the ing that pregnancy child. Now, a new study has looked at iron status possibly the role that iron has to play in relation has broader roles to play in child to childhood wheeze. Scientists used data from the Avon health. Further Longitudinal Study of Parents and studies, ideally Children (ALSPAC) study; a cohort as randomised of children born in the 90s. Informa- trials, are now tion about iron intake, status and child needed. For more health from 157 mother-child pairs was informaanalysed. Higher serum Transferrin Recep- tion, see tor (TfR) levels (an indicator of re- Nwaru BI duced iron status) were linked to in- et al (2014). creased wheeze while higher ferritin British Journal levels were linked to improved lung of Nutrition Vol 112 function. (12), pg 2018-27.

NHDmag.com February 2015 - Issue 101


news Latest on obesity

Irregular eating is often linked to poor health but this has not been widely studied. A new study has now looked into this. Energy intake data was analysed from five-day estimated food diaries (n=1,768), forming part of the National Survey of Health and Development; one of Britain’s’ oldest cohort studies, collecting birth and health data from people born in 1946 to date. Results showed that energy intakes were highest between meals. Irregular energy intakes at breakfast and between meals were significantly associated with increased risk of metabolic syndrome (a cluster of metabolic and cardiovascular risk factors). Waist circumference was also significantly higher for those having irregular energy intakes at breakfast, at evening meals and on a day-to-day basis. A second study has also now looked into whether high-protein and low glycaemic index diets could be beneficial for weight management. The European DIOGENES study, a randomised controlled trial, recruited 256 overweight or obese adults (BMI >27kg/m2). Once they had taken part in an eight-week low-calorie diet they were allocated to five different ad libitum (eating in an uncontrolled environment) diets, each varying in their protein content and glycaemic index. This took place over 12 months. When on the low-calorie diet, mean weight loss was 11.2kg (about 24.6lbs). Weight regained over the 12 months was significantly lower in the high-protein compared with the low-protein diet group (2.0 versus 2.8kg). High and low glycaemic index diets did not affect levels of weight regained. Overall, irregular eating could have broader effects on metabolic profile and health, while high-protein diets appear to have a role in weight management. Further studies are now needed. For more information, see Pot GK et al (2014). International Journal of Obesity Vol 38, pg 1518-24 and Aller E et al (2014). International Journal of Obesity Vol 38, pg 1511-17.

New Irish water intake data Around 60 percent of an adult’s bodyweight is water, performing key roles such as nutrient transport, waste removal and temperature regulation. Given this, new survey data in Ireland has now estimated daily water intakes. The Irish National Adult Nutrition Survey (NANS) analysed four-day semi-weighed food records from 1,500 free-living adults aged 18 to 90 years. Total water intake (i.e. drinking water plus water from other beverages, along with food moisture) was 2.3 litres per day, with 67 percent of water coming from beverages and 33 percent from foods. Overall, mean intakes and the proportions of water coming from foods and beverages were generally in line with European guidelines. However, intakes were found to be lowest amongst the elderly, those with less education, of lower social class, who were less active, had a higher body mass index or level of body fat. These findings highlight the need to target these particular groups, helping to ensure that they drink enough water to support health. For more information, see: Connor LO et al (2014). Journal of Human Nutrition & Dietetics Vol 27 (6), pg 550-56.

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NHDmag.com NHDmag.com February 2015 - Issue 101

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Cover story

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS BRIGHTON & HOVE The work of the Brighton & Hove Food Partnership in coordinating a community food strategy, which encompasses health, sustainability, cooking and food growing.

Lauren McCormack Health Promotion Dietitian

Brighton & Hove Food Partnership is all about food - bringing together communities, businesses, statutory agencies and individuals, to help create a healthy, fair and sustainable food system across the city. In 2006, Brighton & Hove was one of the first cities in the UK to launch a food strategy, which encompassed sustainability, health, cooking and growing (1). Through working with a range of partners and community groups, over 90 percent of the aims outlined in the food strategy were achieved. Building on the success of this, Brighton & Hove is now delivering on the revised strategy ‘Spade to Spoon: Digging Deeper’ (2). It’s an action plan which sets out how the city intends to address health inequalities, reduce food poverty, support local food businesses

and reduce the environmental impact of the way we produce, consume and dispose of food. Meeting these aims is no mean feat. The challenges of obesity, food poverty, climate change and food waste are vast and the causes are multidimensional. The role of the Food Partnership is to coordinate the delivery of the food strategy. This includes bringing other organisations together, sharing best practice and encouraging partnerships, as well as directly delivering some services. The Food Partnership also holds a seat on a number of strategic boards in the city to help influence other local policies and strategies which have an impact on the food system. Twenty members of staff bring a range of expertise to the organisation,

Vision and aims of the food strategy A healthy, sustainable and fair food system for Brighton & Hove • Residents eat a healthier and more sustainable diet. • Residents have better access to nutritious, affordable sustainable food. • The city has a vibrant sustainable food economy with local businesses, local products and employment opportunities. • Public organisations have healthy, ethical and environmentally responsible food procurement policies and practices. • More food consumed in the city is grown, produced and processed locally using methods that protect bio-diversity and respect environmental limits. • More people engaged in communal activities around food. Lauren specialises in weight management and is interested in the environmental impact of food and how sustainability messages can be incorporated into health promotion guidance.

• Waste generated by the food system is reduced, redistributed, reused and recycled. • Local and sustainable food is promoted and celebrated by residents and visitors. • High quality information, support and training on sustainable food and nutrition issues is readily available and there are networking opportunities to encourage links between sectors. • Local planning and policy decisions take into account food issues and the city is engaged with national campaigns. NHDmag.com February 2015 - Issue 101

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malnutrition

including dietitians; nutritionists; a food waste expert; community gardener; food poverty campaigners and community cooks. Each team deliver specialist services, but cross-organisational working is fundamental. COMMUNITY NUTRITION TEAM

Commissioned by Public Health Brighton & Hove, the community nutrition team deliver a city-wide weight management service; led by registered dietitians and nutritionists. Adults are offered the opportunity to attend a series of oneto-one appointments, or to attend a community group programme ‘Shape Up’, which includes nutritional advice, behaviour change strategies and exercise. Specific groups have been designed for women post pregnancy, as well as a male only group which takes place at Brighton and Hove Albion football stadium. “My body confidence has increased and my cholesterol is going down, so thank you for the support and information.” - Shape Up participant. The Family Shape Up programme is a weight management programme for children aged six to 13 years old. Sessions emphasise practical, handson learning using specially designed games, visual demonstrations and activities. This is delivered in partnership with Albion in the Community - the charity branch of Brighton & Hove Albion Football Club. Combining their exercise expertise alongside The Food Partnership’s nutritional knowledge has proved to be highly effective; average completion rates have been 80 percent since the programme began in 2013. 10

NHDmag.com February 2015 - Issue 101

“I can move faster now and I have more energy and feel happier about myself.” - Family Shape Up participant, aged six. Another programme for children is Zip Zap which is a year-long after school club for fiveto seven-year olds. Children learn the value of healthy eating, alongside games that encourage activity and movement. Once a term, parents and carers are invited to join in and learn new skills together. The topics extend beyond the usual healthy eating messages to include cookery, gardening and reducing food waste. Zip Zap is currently in its first year, but the intention is to roll it out to every primary school in the city. In addition to these programmes, the Food Partnership delivers Baby Buffet, Weaning Well and Eat Well workshops for a range of groups. The Food Partnership also offers training to support workers, early years’ providers and kitchen staff. COOKERY TEAM

The cookery team run a range of courses and workshops across the city. Linking with the community nutrition team, ‘Shape Up in the Kitchen’ has been designed for adults with a BMI over 25kg/m2, who are looking to improve cookery skills and learn how to make healthier recipes. ‘Family Shape Up in the Kitchen’ is a cookery group for children and their parents, which encourages families to cook healthy meals together. Adults with learning disabilities can join the ‘Cooking Together Lunch Club’ which teaches


malnutrition basic cookery skills in a supportive environment; as well as improving confidence in the kitchen, this course also aims to promote independence. In collaboration with MIND, a cookery group for people who suffer with anxiety and depression was also successfully piloted earlier this year. In all cookery courses, healthy eating advice is incorporated with visits from one of the Food Partnership dietitians. Cookery leaders also provide participants with practical tips around cooking on a budget and reducing food waste. Ingredients used at the cookery courses meet the Food Partnership’s buying standards (which consider the environmental and local economic impact of ingredients). “I really enjoyed the ‘First Time Cook’ course. The friendliness of the staff and participants was fantastic and the actual practical side of the cooking was fun! I am looking forward to making these recipes at home to improve my eating habits.” - First time cook participant. The cookery team run ‘Pick and Cook’ sessions which take place at community growing projects. These are open to all members of the public and aim to connect people with where food comes from and how it is produced. They are also designed to inspire people to cook local, seasonal produce and spend more time outdoors. SHARING THE HARVEST PROJECT

The health benefits of gardening and food growing are well documented (3). A growing body of evidence now recognises the impact of gardening on improving both physical and mental wellbeing (4-12). The work carried out by our Harvest team over the past four years has helped triple the number of community gardens from 25 to 75 and there are now over 4,000 residents involved in community gardening across Brighton & Hove. Be it to increase activity levels, spend more time outdoors, learn new skills or meet new people, volunteering at a community garden brings lots of benefits. The Food Partnership has recently been awarded £500,000 from the Big Lottery to support people with learning disabilities, or those with experience of homelessness, mental health issues, abuse and addiction to access gardening to improve their health and wellbeing. Services are evaluated using the ‘five ways to wellbeing’ model, an evidenced based ques-

tionnaire developed by the New Economics Foundation (13). A recent evaluation found that since joining a community garden, 44 percent of volunteers reported wasting less food and 36 percent of volunteers reported buying more local food. Further benefits were acknowledged by those who identified themselves as having a mental health problem or learning difficulty: 48 percent reported improved mental wellbeing, 35 percent reported improved physical health and 38 percent reported improved confidence and social skills since joining a community garden. “You probably don’t realise how much the orchard has changed my life. Just being able to go to a group where people understand your problems and you don’t have to explain anything. Just to have a group of supportive and understanding people around you. I can’t believe that I hadn’t even noticed that my (anxiety and depression) issues had gone away so quickly!” LOVE FOOD HATE WASTE CAMPAIGN

Food waste is a big issue in the UK and in Brighton & Hove food makes up 35 percent of the city’s domestic waste. The Food Partnership coordinates the Love Food Hate Waste programme and speaks to hundreds of people each year through public outreach workshops and community events. An example of successful partnership working between the Food Partnership, Brighton & Hove City Council and members of the community, is the Community Composting scheme, set up to divert domestic food waste from landfill. There are now 1,000 households taking part and a network of 30 neighbourhood compost sites across the city. “Some people might argue that our contribution towards reducing waste is a drop in the ocean, however, I think it is amazing to see how much waste 30 households can turn into a useful resource.” - Community composter. Food waste reduction messages are threaded throughout all of the Food Partnership services - from meal planning tips and advice about healthy portion sizes to practical cookery skills. PROJECTS

Coordinating the food plan involves working with a range of organisations and lobbying for change. This includes working with large caterers to establish healthy and environmentally responsible food procurement policies and practicNHDmag.com February 2015 - Issue 101

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malnutrition es. A real milestone was reached this year when Brighton & Hove City Council agreed to introduce minimum buying standards for all their catering contracts (including primary schools). The standards cover animal welfare, nutritional content and the use of local, seasonal produce. Food Poverty is another growing campaign area for the Food Partnership and it recently submitted evidence to the All Parliamentary report Feeding Britain. There has been a sharp increase in food poverty both locally and nationally (14). One major concern is that people experiencing food poverty are more likely to skip meals and compromise nutritional intake. To support people experiencing financial hardship, the Food Partnership runs ‘Eating well on a budget’ sessions. For workers and volunteers, the Food Partnership offers food poverty awareness training which teaches people how to recognise food poverty, as well as providing advice on signposting individuals to emergency food aid and support with underlying financial issues. The Food Partnership also helps co-ordinate a food bank network, which helps bring together groups across the city working to support people in hunger. “I just wanted to say that I found the training session really insightful and in depth. I went into the session knowing very little about food poverty, its causes and options that are out there, but I left with a breadth of new knowledge.” - Food poverty awareness session attendee.

Having seen an increase in the number of food banks in the city from two to 12, the City Council has just committed to an action plan on food poverty in 2015. CONCLUSION

With increasing populations and finite resources, considering sustainability of the food system is becoming paramount. Looking at how we produce, consume and dispose of food as a community and working together on all aspects of the food chain is an effective way to promote healthier choices for the individual and for the planet. In short, food issues cannot be looked at in isolation. With great challenges ahead, such as rising obesity levels and food poverty, it’s now more important than ever to take a joined-up approach to food. The work in Brighton & Hove shows how useful and important a focus on food can be, in dealing pressing social, economic and environmental challenges. Inspired by Brighton & Hove’s pioneering model, many UK cities have now adopted their own unique food strategies, and the launch of the national Sustainable Food Cities network in 2013 is helping bring this thinking into the mainstream. There is still plenty of work to do, but significant groundwork has been done. If we continue to look for practical solutions, share best practice and keep these messages high on the political and personal agenda, we can help make change happen.

References 1 Spade to Spoon. Brighton & Hove Food Partnership. Available online at: http://bhfood.org.uk/downloads/downloads-publications/19-spade-to-spoon-strategy2003/file 2 Spade to Spoon: Digging Deeper. A food strategy and action plan for Brighton & Hove. Brighton & Hove Food Partnership. Available online at: http://bhfood.org.uk/ downloads/downloads-publications/18-spade-to-spoon-strategy-2012-print/file 3 Garden Organic and Sustain (2014). The benefits of gardening and food growing for health and wellbeing. ISBN: 978-1-903060-60-5. Sustain, UK. Available online at: www.sustainweb.org/publications/?id=293 4 Alaimo K, Packnett E, Miles R, Kruger D (2008). Fruit and vegetable intake among urban community gardeners. Journal of Nutrition Education and Behaviour, 40(2), 94-101 5 Hawkins JA, Thirlaway KJ, Backx K and Clayton DA (2011). Allotment gardening and other leisure activities for stress reduction and healthy aging. HortTechnology, 21(5) 557-585 6 McCormack LA, Laska MN, Larson NI and Story M (2010). Review of the nutritional implications of farmers’ markets and community gardens: a call for evaluation and research efforts. J Am Diet Assoc,110 (3), 399-408 7 Nelson JM, Erens B, Bates B, Church S and Bosher T (2007). Low income diet and nutrition survey. Volume 3 Nutritional status, physical activity, economic, social and other factors. London: Food Standards Agency, The Stationary Office, UK 8 Sempik J and Aldridge J (2005). Health, wellbeing and social inclusion: therapeutic horticulture in the UK. Loughborough University Institutional Repository. CCFR Evidence Papers. Issue 11 9 Sempik J, Aldridge J and Becker S (2003). Social and Therapeutic Horticulture: evidence and messages from research. Thrive, in association with the Centre for Child and Family Research, Loughborough University 10 Stigsdotter UA and Grahn P (2004). A garden at your workplace may reduce stress. In: Dilani, A (ed.), Design and Health III - Health Promotion through Environmental Design, Research Centre for Design and health, Stockholm, Sweden, 147-157. 11 Ratcliffe MM, Merrigan KA, Rogers BL and Goldberg JP (2011). Behaviours associated with vegetable consumption. The effects of school garden experiences on middle school-aged students’ knowledge, attitudes and behaviours associated with vegetable consumption. Health Promotion Practice, 12,1, 36-43 12 Zick CD, Smith KR, Kowaleski-Jones L, Uno C, and Merrill B (2013). Harvesting more than vegetables: The potential weight control benefits of community gardening. American Journal of Public Health, 103(6), 1110-1115 13 New economics foundation (2011). Five ways to wellbeing. New applications, new ways of thinking. Written by Sam Thompson and Jody Aked. Commissioned jointly by the National Mental Health Development Unit (NMHDU) and the NHS Confederation, nef, London, UK 14 Cooper N and Dumpleton S (2014). Walking the breadline: the scandal of food poverty in 21st-century Britain. Oxfam and Church Action on Food Poverty, UK. ISBN 978-1-78077

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NHDmag.com February 2015 - Issue 101


THE MOST COMPLETE PRETERM RANGE At Cow & Gate, we have given our all in the development of the most comprehensive range available for preterm babies. By working closely with neonatal practitioners, Nutriprem is now the only preterm range that complies with the latest ESPGHAN guidance and includes a hydrolysed protein formula.1

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adult food allergy

DIAGNOSIS OF IgE-MEDIATED FOOD ALLERGY IN ADULTS Adult food allergy presents with a range of complex symptoms. A good diagnostic work-up is required, followed by appropriate dietetic advice.

Tak Chin Specialist Registrar in Allergy Medicine, Southampton General Hospital

Carina Venter PhD, RD Senior Lecturer, University of Portsmouth

Dr Tak Chin is a Specialist Registrar in Allergy Medicine at Southampton General Hospital

As well as being a Senior Lecturer at the University of Portsmouth, Carina is an Allergy Specialist Dietitian with The David Hide Asthma and Allergy Research Centre on the Isle of Wight. She is also a Food Allergy Module Leader at the University of Southampton.

In clinical practice, the offending food(s) causing IgE-mediated food allergy can often be identified by taking a careful clinical history. Important elements of the history include the type of food involved, quantity of food ingested, time between ingestion to reaction, symptoms/signs of the reaction, other occasions when similar reactions occurred, time since last reaction and other factors involved (e.g. exercise). In complex cases, a food-symptom diary may be required as an adjunct to the history. The usual first-line diagnostic tests, routinely used in conjunction with the clinical history, to establish the diagnosis of IgE-mediated food allergy, are skin prick tests (SPT) (which can be performed with commercially-prepared standardised solutions of food allergen extracts, or with fresh foods (prick-toprick (PTP) testing) and serum specific IgE (sIgE) to food allergens. SPT is generally preferred as it offers a quick and reproducible method for detecting IgE sensitisation. Although it is a safe procedure, severe and fatal anaphylactic reactions have been reported in those with highly severe allergies (1). It is, therefore, recommended that SPT is performed by experienced personnel in an appropriate setting with access to emergency medications and equipment. sIgE offers an in vitro method for quantifying IgE sensitisation and may be useful when SPT is not possible (e.g. limited skin surface for SPT, dermatographism, suppressed skin reactivity due to antihistamines, needlephobia). Sensitivity and specificity varies depending on the food, as well as other factors (e.g. allergen extract, commercial test system, age of the patient). In general, a negative SPT result has an excellent nega-

tive predictive value, while a positive SPT result only indicates the possibility of symptomatic IgE-mediated food allergy. One exception to this is IgE-mediated food allergy to certain fruits/vegetables (particularly those associated with pollen-food allergy syndromes), which may sometimes not be detected using commercially-prepared extracts/reagents due to the labile nature of the allergenic epitope involved. For some of the common major food allergens (e.g. hen’s egg, cows’ milk, peanut), decision points based on SPT size and also sIgE titre cut-off values have been described which have a >95 percent positive predictive value for IgE-mediated food allergy. However, decision points have not been successfully established for other major food allergens (e.g. soy, wheat) and the less common food allergens. A potential issue with both SPT and sIgE is the possibility of cross-reactivity to common allergenic epitopes in related foods, unrelated foods and pollens which may result in false positives to food allergens that are not clinically relevant. For certain foods - componentresolved diagnostics (CRD) - which involves the measurement of sIgE against purified individual proteins within the food - may be useful in determining the risk of severe allergic reactions. Numerous food proteins have been identified and knowledge of their allergenic significance continues to evolve. In general, sensitisation to seed storage proteins and non-specific lipid transfer proteins (nsLTP) is usually associated with a higher risk of severe allergic reactions. In contrast, sensitisation to Bet v 1-related PR10 proteins is usually associated with mild allergic reactions to fruits and vegetables NHDmag.com February 2015 - Issue 101

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adult food allergy due to cross-reactivity with birch pollen. For example, the seed storage protein Ara h 2 has a very high positive predictive value for severe allergic reactions to peanut (2). The other seed storage proteins Ara h 1 and Ara h 3 have also been associated with severe reactions - severe reactions, however, have been described in patients who are negative to these allergens (3). Exceptions have been reported where Bet v 1-related PR-10 proteins have been associated with severe allergic reactions (e.g. Gly m 4 in soy allergy) (4). Furthermore, sensitisation patterns may be different for populations in different countries a study evaluating CRD in European patients with severe allergy to hazelnuts demonstrated that sensitisation was mainly to the major hazelnut allergen Cor a 1.04 (Bet v 1-related PR-10 protein) in Switzerland and Denmark, whereas it was mainly to Cor a 8 (nsLTP) in Spain (5). More recently, Cor a 9 and Cor a 14 (seed storage proteins) have been shown to be associated with severe allergy to hazelnuts in a Dutch population (6). CRD appears to be useful in the more unusual clinical manifestations of IgE-mediated food allergy - such as when used in selected cases where wheatdependent exercise-induced anaphylaxis (WDEIA) is suspected (e.g. omega-5 gliadin (Tri a 19))(7) and in the evaluation of delayed anaphylaxis to red meat (e.g. galactose-α-1,3-galactose (α-gal)) (8). At the time of writing, a systematic review assessing the diagnostic accuracy of SPT, sIgE and CRD in supporting the clinical diagnosis of IgE-mediated food allergy is under way (9). Oral food challenges (OFCs) may be necessary to establish the diagnosis of IgE-mediated food allergy or to determine the clinical relevance of SPT, sIgE and/or CRD results. The doubleblinded placebo-controlled food challenge (DBPCFC) is considered the ‘gold standard’ diagnostic test. OFCs can also be performed single-blinded or open. However, the potential risk of severe allergic reactions, as well as the time-consuming and resource-intensive nature of the procedure, limits their use. International consensus and standards have been developed to standardise various aspects of DBPCFCs to allow comparison between research studies (10). These variables include pre-challenge assessment, safety measures, type/quantity of the food allergen to be administered, timings between doses, intra-challenge assessment, managing subjective symptoms, objec16

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tive criteria for a positive challenge, observation periods and outcome reporting. Elimination diets are not usually diagnostic of food allergy on their own - while resolution of symptoms during an elimination diet supports a diagnosis of food allergy, this may be accounted for by other factors and so OFC should be performed to confirm the diagnosis. Elimination diets may be performed in several ways: (i) elimination of one or several suspected foods, (ii) elimination of all except a defined group of foods and (iii) elemental diet (e.g. hydrolysed formula, amino acid-based formulas). The basophil activation test (BAT) appears to be a promising area of future development for diagnostic tests in food allergy with one recent study demonstrating that it can significantly reduce the requirement for OFC to peanut (11, 12, 13). However, this test is not yet routinely available in clinical practice. A number of unproven tests are often used by complementary/alternative medicine practitioners (e.g. Vega testing, hair analysis, iridology, kinesiology, specific IgG/IgG4, cytotoxic test) and cannot be recommended for diagnosing food allergy. DIAGNOSIS OF NON-IgE-MEDIATED FOOD ALLERGY IN ADULTS

The principles behind the diagnosis of non-IgEmediated food allergy do not significantly differ from those for IgE-mediated food allergy - the main difference is that clinical history, SPT and sIgE often do not correlate as well in non-IgE-mediated food allergy due to the immune mechanisms involved. As a result, elimination diets and modified OFCs (tailored to the individual and clinical reaction) are required more often in order to demonstrate if a suspected food is clinically relevant. This is particularly the case in atopic eczema/ dermatitis (AE) where multiple IgE sensitisation without proven clinical relevance is commonly seen. Reactions to classical food allergens (e.g. hen’s egg, cows’ milk) in adulthood are not as common as in childhood (17) - adult studies have shown that foods cross-reactive to birch pollen can worsen AE (18, 19). Three different reaction patterns may be seen in food-induced AE: (i) non-eczematous reactions (usually IgE-mediated causing pruritus, urticaria, flushing but also other immediate-type gastrointestinal, respiratory or anaphylactic symptoms); (ii) eczematous delayed reactions (usually after hours to


adult food allergy

The cornerstone in the management of food allergies in adults, requires avoidance of the offending food and prescription of emergency mediation when required. days) and (iii) combination of early non-eczematous and eczematous delayed reactions. It is, therefore, recommended that the skin should be evaluated after 24 hours and later ideally using a validated score (e.g. SCORAD, EASI) following OFC for AE, as otherwise delayed reactions may be missed. It is also recommended that OFC is preceded by a diagnostic elimination diet of suspected food items over a period of up to four to six weeks (rather than the usual two to four weeks for IgE-mediated symptoms). Full details discussing the diagnostic approach in eczematous reactions to foods in AE are available in a position paper (20). Atopy patch testing (APT) may be considered as an additional diagnostic test in suspected foodinduced AE. However, they are not in widespread clinical use since standardised reagents, methods for performing APTs and interpretation of their results have not been established. The use of APT has been evaluated (primarily in children), but did not result in a significant reduction in OFCs required where food-induced AE was suspected (21) - as a result, APT is not generally recommended for the routine diagnosis of food-induced AE. For non-IgE-mediated gastrointestinal food allergies, a consensus diagnostic guideline is available for eosinophilic oesophagitis (EoE), which the most common form of eosinophilic gastrointestinal disease (EGID) (22). The diagnostic criteria for EoE includes: (i) clinical symptoms related to oesophageal dysfunction and exclusion of secondary causes of oesophageal eosinophilia, (ii) eosinophilpredominant inflammation on oesophageal biopsy (≼15 eosinophils per high-power field; two to four biopsies should be obtained from both the proximal and distal oesophagus), (iii) mucosal eosinophilia isolated to the oesophagus which persists after a proton pump inhibitor trial and (iv) a response to treatment such as dietary elimination or topical corticosteroids can further support the diagnosis.

The diagnostic approach to identifying the causative food(s) in patients with EoE is challenging. The usual strategy for this involves two phases: the elimination phase(s) of four to six weeks (rather than the usual two to four weeks for IgE-mediated symptoms) followed by the reintroduction phase(s). The general principle behind this is to initially induce resolution (of symptoms and ideally also oesophageal eosinophilic inflammation on histology) through the elimination phase, so that causative and non-causative food(s) can be identified when they are re-introduced - a food is considered causative if it results in recurrence of the above. The main elimination strategies may be broadly categorised as follows: (i) elemental diet free of food allergens (e.g. complete liquid amino-acid based formula); (ii) empiric food elimination diet which excludes the most common causative foods allergens (e.g. six food elimination diet: dairy, soya, eggs, wheat, peanuts, fish/shellfish) and (iii) targeted elimination which removes food allergens based on history and the results of allergy testing (e.g. SPT, sIgE, APT). Food protein-induced enterocolitis syndrome (FPIES) was previously thought to occur primarily in infants and young children only - however, it has been reported to also occur in adults (with the predominant trigger being shellfish) (23). As with the other non-IgE-mediated food allergies, SPT and sIgE are often negative and so OFC remains the only diagnostic test and is considered the gold standard. There is currently no standardised protocol for OFC for FPIES - however, this is usually done by experienced personnel as an open challenge with a long observation period after the last dose (minimum four to six hours) in a facility that can manage dehydration and allergic reactions. Preand post-challenge (six hours) blood samples for complete full blood count with differential counts can be taken to look for an increase in peripheral blood neutrophil counts - this has been proposed as NHDmag.com February 2015 - Issue 101

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ADULT FOOD ALLERGY

one of the major criteria for a positive challenge in acute FPIES. However, in clinical practice, the diagnosis of FPIES is often made on the basis of a suggestive clinical history and resolution of symptoms on elimination of the causative food. APT in FPIES has been evaluated in children (24, 25) - at present APT is not recommended for routine diagnosis of FPIES. For completeness, coeliac disease (CD) is technically classified as a non-IgE-mediated food allergy - the diagnosis of CD is primarily by serology (e.g. specific endomysial antibodies (EMA/ AEA), IgA anti-tissue transglutaminase antibodies (IgA-TG2/a-TTG/TTA), deamidated antigliadin antibodies (IgA-DGP or IgG-DGP); IgGTG2 is primarily useful in patients with known IgA deficiency) and duodenal biopsy when the patient is on a normal (gluten-containing) diet. It may also involve HLA testing (e.g. HLA-DQ2, HLA-DQ8 haplotype). The diagnostic algorithm for CD in adults is available in a guideline (26). Dermatitis herpetiformis is a related cutaneous condition associated with CD - diagnosis is by skin biopsy and demonstrating the presence of granular IgA deposits in the dermal papillae of uninvolved perilesional skin as shown by direct immunofluorescence (27). MANAGEMENT OF ADULT FOOD ALLERGIES

The cornerstone in the management of food allergies in adults, requires avoidance of the offending food and prescription of emergency mediation when required. Dietary avoidance issues Avoidance of allergenic foods can be complex, leading to nutritional deficiencies and can affect 18

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quality of life. Ideally, all adults presenting with a suspected or proven food allergy, should be referred for a dietetic consultation (28). A dietitian can provide individualised advice regarding the foods that should be avoided, the level of avoidance required and suitable substitute foods (29, 30). In addition, advice on required nutritional supplements can be provided. Advice on a range of lifestyle issues, such as shopping, eating at school or in the workplace, socialising and eating out and going on holiday will also be provided (31, 32). A challenging factor in dealing with patients with FHS is to establish each patient’s tolerance level or degree of avoidance required. This will mainly be determined by the type of food allergy the patient is suffering from and the underlying mechanisms. Some people with food allergies, particularly those which are IgE mediated, need to completely avoid an allergic food - even in trace amounts. Others may be able to include small amounts of the food in their diet with no adverse effects. There are no clear guidelines for avoidance levels, but some patients may be aware of their own tolerance levels by trial and error. It is also known that some individuals become tolerant to baked forms of milk and egg, whilst they may still be allergic to less cooked forms. The level of avoidance required should, therefore, also be reviewed at regular intervals. In terms of fruit of vegetables and nuts, it is also important to understand if the patient is suffering from a primary fruit, vegetable and nut allergy, or if the patient is suffering from a crossreaction to pollens such as birch and grass. For those with primary food allergies, strict avoid-


ADULT FOOD ALLERGY ance may be required, whereas those suffering from aero-allergen cross reactive reactions, often tolerate cooked versions of the food. In terms of avoiding the major food allergens, EU labelling covers all the major food allergens, which, as from 12 December 2014, all need to be clearly identified on food labels in either bold, underlined or italic type. The major food allergens include: • Cereals containing gluten (i.e. wheat, rye, barley, oats, spelt, kamut or their hybridised strains) and products thereof • Crustaceans and products thereof • Eggs and products thereof • Fish and products thereof • Peanuts and products thereof • Soybeans and products thereof • Milk and products thereof (including lactose) • Nuts i.e. Almond (Amygdalus communis L.), Hazelnut (Corylus avellana), Walnut (Juglans regia), Cashew (Anacardium occidentale),Pecan nut (Carya illinoiesis (Wangenh.) K. Koch), Brazil nut (Bertholletia excelsa), Pistachio nut (Pistacia vera), Macadamia nut and Queensland nut (Macadamia ternifolia) and products thereof • Celery and products thereof • Mustard and products thereof • Sesame seeds and products thereof • Sulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10mg/litre expressed as SO2. • lupin and products thereof • Molluscs and products thereof. In the UK, The Food Standards Agency have information available on their website: www. food.gov.uk May contain labelling Manufacturers often use phrases such as ‘may contain nut traces’ or ‘made on a production line using soya and milk’ or ‘produced on a line handling egg’ to show that there could be accidental traces of another food in a manufactured product, from the production process. This labelling is completely voluntary and, therefore, not legally binding, but many manufacturers choose to label their products in this way.

Current advice from the BDA Food Allergy and Intolerance Support group, regarding the management of precautionary labelling in those with more severe food allergies or nut allergies: (taken directly from the FAISG Nut avoidance diet sheet): It is important to take these warnings seriously and consider the following points: • Just because a particular food with a nut warning has been eaten safely in the past, does not mean that it will always be safe; it may contain nut traces next time. Recipes and manufacturing processes can change. • All nut warnings should be treated with the same level of risk regardless of the wording used. • Patients may be more sensitive to nut protein if they are unwell, have been doing strenuous exercise or drinking alcohol, so having a nut trace during these times is more risky. • Chocolate and chocolate covered items pose a higher risk of nut contamination because chocolate dripping off one product may be used on another during manufacturing. Therefore, chocolate with nut warnings should always be avoided (lists of peanut free or all nut free products are available from chocolate manufacturers). The safest approach is to avoid all foods with ‘may contain’ nut warnings. However, if a food with a nut warning is to be eaten, the following advice should always be followed: 1. Always have in-date emergency medication to hand. 2. Be within easy reach of a phone or mobile that has charge and reception. 3. Only eat if someone is with you who can help if a reaction occurs. 4. Avoid if in a remote location, far from emergency services. 5. Avoid if unwell or asthma is not well controlled. 6. Avoid after strenuous exercise or drinking alcohol. 7. Avoid if previously had an anaphylactic reaction to nut traces or ‘may contain’ products. Discuss your approach to managing ‘may contain nut’ products with your dietitian or allergy team, as they can give you specific advice. NHDmag.com February 2015 - Issue 101

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ADULT FOOD ALLERGY SUMMARY

In summary, the manifestations of food allergy in adults in varied diagnosis can be complex and any tests performed should be interpreted by a competent clinician. The management of adult food allergy will necessitate a referral to a dietitian in most cases. Important information can be provided during a dietary consultation such as foods to avoid, suitable foods to eat, supplementation of nutrients, label reading and lifestyle advice.

Sensitivity (‘true positive rate’) = the percentage of sick people who are correctly identified as having the condition Specificity (‘true negative rate’) = the percentage of healthy people who are correctly identified as not having the condition Positive predictive value (PPV) = probability that the disease is present when the test is positive Negative predictive value (NPV) = probability that the disease is not present when the test is negative

References 1 Bernstein DI, Wanner M, Borish L et al. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. JACI 2004; 113: 1129 2 Klemans RJB, Otte D, Knol M et al. The diagnostic value of specific IgE to Ara h 2 to predict peanut allergy in children is comparable to a validated and updated diagnostic prediction model. JACI 2013; 131: 157 3 Nicolaou N, Custovic A. Molecular diagnosis of peanut and legume allergy. Current Opinion in Allergy & Clinical Immunology 2011; 11: 222 4 Berneder M, Bublin M, Hoffmann-Sommergruber K et al. Allergen chip diagnosis for soy-allergic patients: Gly m 4 as a marker for severe food-allergic reactions to soy. International Archives of Allergy & Immunology 2013; 161: 229 5 Hansen KS, Ballmer-Weber BK, Sastre J et al. Component-resolved in vitro diagnosis of hazelnut allergy in Europe. JACI 2009; 123: 1134 6 Masthoff LJN, Mattsson L, Zuidmeer-Jongejan L et al. Sensitisation to Cor a 9 and Cor a 14 is highly specific for a hazelnut allergy with objective symptoms in Dutch children and adults. JACI 2013; 132: 393 7 Morita E, Matsuo H, Chinuki Y et al. Food-dependent exercise-induced anaphylaxis-importance of omega-5 gliadin and HMW-glutenin as causative antigens for wheat-dependent exercise-induced anaphylaxis. Allergology International 2009; 58: 493-8 8 Commins SP, Platts-Mills TA. Anaphylaxis syndromes related to a new mammalian cross-reactive carbohydrate determinant. JACI 2009; 124: 652 9 Soares-Weiser K, Panesar SS, Rader T et al. The diagnosis of food allergy: protocol for a systematic review. Clinical and Translational Allergy 2013; 3: 18 10 Sampson HA, Gerth van Wijk R, Bindslev-Jensen C et al. Standardising double-blind, placebo-controlled oral food challenges: American Academy of Allergy, Asthma & Immunology-European Academy of Allergy and Clinical Immunology PRACTALL consensus report. JACI 2012; 130: 1260 11 Sato S, Tachimoto H, Shukuya A et al. Basophil activation marker CD203c is useful in the diagnosis of hen’s egg and cows’ milk allergies in children. International Archives of Allergy & Immunology 2010; 152: 54 12 Glaumann S, Nopp A, Johansson SG et al. Basophil allergen threshold sensitivity, CD-sens, IgE-sensitisation and DBPCFC in peanut sensitised children. Allergy 2012;67:242–247 13 Santos AF, Douiri A, Bécares N et al. Basophil activation test discriminates between allergy and tolerance in peanut-sensitised children. JACI 2014; 134: 645652 14 Muraro A, Werfel T, Hoffmann-Sommergruber K et al. EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy 2014; 69: 1008 15 Boyce JA, Assa’ad A, Burks AW et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. JACI 2010; 126: S1 16 Chafen JJ, Newberry SJ, Riedl MA et al. Diagnosing and managing common food allergies: a systematic review. JAMA 2010; 303: 1848 17 Werfel T, Ahlers G, Schmidt P et al. Milk-responsive atopic dermatitis is associated with a casein-specific lymphocyte response in adolescent and adult patients. JACI 1997; 99: 124 18 Reekers R, Busche M, Wittmann M et al. Birch pollen related food trigger atopic dermatitis with specific cutaneous T-cell responses to birch pollen antigens. JACI 1999; 104: 466 19 Worm M, Forschner K, Lee H et al. Frequency of Atopic Dermatitis and Relevance of Food Allergy in Adults in Germany. Acta Dermato Venereoligica 2006; 86: 119 20 Werfel T, Ballmer-Weber B, Eigenmann PA et al. Eczematous reactions to food in atopic eczema: position paper of the EAACI and GA2LEN. Allergy 2007; 62: 723 21 Mehl A, Rolinck-Werninghaus C, Staden U et al. The atopy patch test in the diagnostic workup of suspected food-related symptoms in children. JACI 2006; 118: 923 22 Liacouras CA, Furuta GT, Hirano I et al. Eosinophilic esophagitis: updated consensus recommendations for children and adults. JACI 2011; 128: 3 23 Fernandes BN, Boyle RJ, Gore C et al. Food protein-induced enterocolitis syndrome can occur in adults. JACI 2012; 130: 1199 24 Fogg MI, Brown-Whitehorn TA, Pawlowski NA et al. Atopy patch test for the diagnosis of food protein-induced enterocolitis syndrome. Pediatric Allergy & Immunology 2006; 17: 351 25 Jarvinen KM, Caubet JC, Sickles L et al. Poor utility of atopy patch test in predicting tolerance development in food protein-induced enterocolitis syndrome. Annals of Allergy, Asthma & Immunology 2012; 109: 221 26 Ludvigsson JF, Bai JC, Biagi F et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014; 63: 1210 27 Seah PP, Fry L. Immunoglobulins in the skin in dermatitis herpetiformis and their relevance in diagnosis. Br J Dermatol 1975;92:157-66 28 Venter C and Meyer R. Allergic disease: The challenges of managing food hypersensitivity. Proceedings of the Nutrition Society 2010, 69, 11-24 29 Mackenzie H, Grundy J, Glasbey G, Venter C. Information and support from dietary consultation for mothers of children with food allergies. Accepted for publication Annals of Asthma, Allergy and Immunology. 2014 30 Maslin K, Meyer R, Reeves L, Mackenzie H, Swain A, Stuart-Smith W, Loblay R, Groetch M & Venter C. Food allergy competencies of dietitians in the United Kingdom, Australia and United States of America. Clinical and Translational Allergy (Accepted. Awaiting publication) 31 Skypala IJ, Venter C (2009). Food Hypersensitivity. Oxford. Wiley Blackwell 32 Wright T (2006). Food Allergies. Class Publishing

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Fortisip Compact also has the widest range of flavours, from banana to forest fruit, which may aid patient compliance.1 Reference: 1. Hubbard GP et al. Clin Nutr 2012:31;293–312. Nutricia Ltd., White Horse Business Park, Trowbridge, Wilts. BA14 0XQ. Tel: 01225 751098. www.nutriciaONS.co.uk SCC2650-11/14

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Lactose intolerance

RETHINKING COWS’ MILK: IS IT REALLY GOOD FOR US?

Dr Justine Butler, Senior Researcher and Writer

For article references please email: info@ networkhealth group.co.uk

This article looks at the history of milk consumption, evolution and lactose intolerance. The links between dairy and a range of other illnesses are examined along with the role cows’ milk in bone health. Milk is frequently referred to as a fundamental component of a healthy diet. Why is this? Is milk the only source of some essential nutrient, or is milk unique in that it contains all the nutrients that we require? No other animal on the planet continues to drink milk beyond weaning and, not just that, drinking milk taken from another species that is often pregnant. This unusual practise has become a concern for some scientists. The origins of dairy farming

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 many articles for health journals, regional and national press.

Sheep, cattle and goats were domesticated in parts of the Middle East and central Asia over 9,000 years ago, but it is thought that the use of animals for milk was not practiced until between 6,000 to 8,000 years ago in Asia Minor or Turkey (1). Although this sounds like a long time ago, in evolutionary terms it is very recent history. Hominid (modern human) fossils date back to nearly seven million years ago. If this is represented as a 12-hour clock, starting at midday, humans would have started dairy farming less than one minute before midnight! Dairy farming today

Like humans, cows don’t produce milk unless they have recently given birth. However, the modern dairy cow is routinely impregnated whilst she is still producing milk (this ensures that the

milk yield is kept high). At least twothirds of cows’ milk in the UK is taken from pregnant cows (2). This inevitably affects the levels of hormones found in milk. There are 35 hormones and 11 growth factors in milk (3). Some scientists are particularly concerned about the oestrogen content of cows’ milk (4), suggesting that cows’ milk is one of the important routes of human exposure to oestrogens. Milk production is big business, estimated to be worth £3.8 billion in the UK (5). Although the numbers of dairy cows in the UK have fallen year by year, the milk yield has continued to rise. Over the last 10 years, selective breeding and high protein feed has increased the yield per cow from just under 18 litres per day to over 20 litres per day. The increase in milk yield far offsets the fall in the number of dairy cattle (6). There is a clear trend; fewer cows are being forced to produce more milk, what the cost is to human health remains to be seen. What lies beneath…?

The composition of mammalian milk reflects the requirements of the species producing it, be it buffalo, badger, dog or rat - the best milk for them is that of their own species. While whole cows’ milk contains four percent fat, milk from the grey seal contains over 50 percent fat because seals need a lot of body fat to survive in cold water (7). Whole cows’ NHDmag.com February 2015 - Issue 101

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lactose intolerance

Food allergy is increasingly widespread and the most common of these is cows’ milk allergy, affecting around two percent of infants under the age of one. milk contains nearly a third more saturated fat, twice as much protein and four times as much calcium as human milk which makes it ideal fuel for the rapid growth of new born calves. Human babies grow much slower, but brain development is rapid, so breast milk contains five times as much polyunsaturated fat as cows’ milk. Milk also carries important chemical ‘messenger’ molecules that instruct the infant’s immune systems. These features have evolved over thousands of years and are vital in terms of health and disease. Some of the consequences of consuming cows’ milk (and, therefore, signalling hormones) with a nutrient balance not well-suited to human biochemistry are only just becoming apparent.

The most common foods that trigger allergies are cows’ milk and eggs (16). A hypersensitivity reaction to milk proteins can also cause gastrointestinal bleeding in infants (17). This can lead to iron deficiency anaemia in infants and young children. Cows’ milk-induced gastrointestinal bleeding affects about 40 percent of otherwise healthy infants (18). The only reliable treatment for cows’ milk allergy is to avoid all exposure to cows’ milk proteins. This means avoiding all cows’ milk and dairy products, including: milk, milk powder, milk drinks, cheese, butter, margarine, yoghurt, cream and ice cream. Arthritis

Despite the general dismissal of diet as a possible factor underlying the development of acne, a substantial body of evidence demonstrates how certain foods (especially cows’ milk) may adversely influence hormones and cytokines that influence the causes of acne (8). Research suggests that the hormones in milk (or components of milk that increase hormone levels) can indeed cause acne in some people (9, 10, 11). Whey protein supplements, favoured by bodybuilders, have also been found to increase the risk of acne (12, 13). Because of this, when taking history from teenage males suffering with acne, the use of whey protein supplements should be screened for.

The possible effects of diet on the symptoms of arthritis are often overlooked too. While certain foods, such as milk products and food colouring (19), may make the symptoms of rheumatoid arthritis worse for some people, a vegan diet may help, possibly because of the types of polyunsaturated fats included in the diet (20). Indeed, both gluten-free and low-fat vegan diets have been shown to help combat the symptoms of arthritis (21, 22). Chemicals called sulforaphanes (found in cruciferous vegetables such as broccoli, Brussels sprouts or cabbage) have anti-inflammatory properties that could help protect against the cartilage damage that occurs in osteoarthritis (23). These effects are certainly worth investigating, but more research is needed to confirm the preliminary findings.

Allergies

Bone health

Acne

Food allergy is increasingly widespread and the most common of these is cows’ milk allergy, affecting around two percent of infants under the age of one. Symptoms include excessive mucus production resulting in a runny nose and blocked ears. More serious symptoms include asthma, eczema, colic, diarrhoea and vomiting. Food allergies cause around five percent of all asthma cases (14) and 10 percent of eczema cases (15). 24

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In their recommendations for preventing osteoporosis the World Health Organisation (WHO) state that: ‘The paradox (that hip fracture rates are higher in developed countries where calcium intake is higher than in developing countries where calcium intake is lower) clearly calls for an explanation. To date, the accumulated data indicates that the adverse effect of protein, in particular animal (but not vegetable) protein,


lactose intolerance

. . . most studies of fracture risk provide little or no evidence that milk and dairy products benefit bone health. Some evidence suggests that dairy products can actually increase the risk of bone fracture. might outweigh the positive effect of calcium intake on calcium balance.’ (24). This makes the recommending of milk and especially cheese a somewhat controversial area that some scientists are beginning to challenge. Osteoporotic fracture rates are highest in countries that consume the most dairy, calcium and animal protein (25). In fact, most studies of fracture risk provide little or no evidence that milk and dairy products benefit bone health. Some evidence suggests that dairy products can actually increase the risk of bone fracture (26, 27). So it can be argued that milk is not the best source of calcium and our bone health might benefit if we switch to plant-based sources. Professor Amy Lanou, Chair and Associate Professor of Health and Wellness for the University of North Carolina Asheville, says that bones are better served by attending to calcium balance and focusing efforts on increasing fruit and vegetable intakes, limiting animal protein, exercising regularly, getting adequate sunshine or supplemental vitamin D and getting 500mg of calcium per day from plant sources (25). In a paper in The British Medical Journal, Lanou says that it is time to revise our calcium recommendations for young people and change our assumptions about the role of calcium, milk and other dairy products in the bone health of children and adolescents. Lanou argues that while the policy experts work on revising recommendations, doctors and other health professionals should encourage children to spend time in active play or sports and to consume a nutritious diet made from whole plant-based foods to achieve and maintain a healthy weight and build strong bones (28). Crohn’s disease

It has been proposed that the pathogenic bacterium that causes Johne’s disease in cattle, Mycobacterium avium subspecies paratuberculosis (MAP), may also lead to Crohn’s disease in humans. MAP

infection is widespread among cattle and is also found in retail pasteurised cows’ milk (29). Infection may occur from inhaling MAP in fine water spray from rivers contaminated with infected cow manure. This could explain the clusters of Crohn’s that occur around cities with rivers running through them, like Cardiff in Wales (30) and Winnipeg in Minnesota (31). MAP can be difficult to detect in humans, but when appropriate methods are used, most people with Crohn’s disease are found to be infected (32). Professor John Hermon-Taylor at St George’s Hospital Medical School in London has found MAP in patients with Crohn’s disease from the UK, Ireland, US, Germany and United Arab Emirates (29). Avoiding dairy products alone may not be enough to ensure avoiding exposure to MAP, although if everyone reduced their intake of animal products, there would be fewer cattle and, therefore, less MAP present in the environment. Lactose intolerance

In 1836, after returning from the Beagle, Charles Darwin wrote: ‘I have had a bad spell. Vomiting every day for eleven days, and some days after every meal.’ Darwin suffered for over 40 years from long bouts of vomiting, stomach cramps, headaches, severe tiredness, skin problems and depression. A number of researchers now think that he may have suffered from lactose intolerance (32). This condition is often overlooked or mistaken for something else. Professor William H Durham, Professor in Human Biology at Stanford University describes how most North Americans (and indeed most Europeans) are surprised to learn that the majority of the world’s population is unable to digest cows’ milk (33). Durham describes how we live in a culture strongly committed to the concept that cows’ milk is an ideal food; we tend to think of adult milk consumption as normal and healthy. The dairy industry invests much time and money reinforcing this view. In the 1970s this ‘nutritional NHDmag.com February 2015 - Issue 101

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lactose intolerance

The obvious treatment for lactose intolerance is to avoid all cows’ milk and dairy products. ethnocentrism’ resulted in milk powder being sent abroad as food aid to places where the local population could not digest it. The intended beneficiaries were forced to find other uses for the milk powder; so it was used in whitewash for buildings and distributed in small amounts to be used as a laxative (33). Sadly, in those who could not digest the milk, it disrupted normal digestion and actually increased malnutrition. Who has the white stuff?

Overall, around 70 percent of the world’s population is lactose intolerant (34, 35). At around the age of two (around the time of weaning), most people stop producing the enzyme lactase and so lose the ability to digest lactose, the sugar in milk. As stated, lactase persistence only developed around 8,000 years ago. In evolutionary terms, this is very recent history. The ability to digest lactose can be traced back to a minority of pastoral tribes who gained a selective advantage from the genetic mutation that enabled persistent lactase (36). This includes the Tutsi and Hutu of Rwanda; the Fulani of West Africa; the Sindhi of North India; the Tuareg of West Africa and some European tribes (33). Descendants of these people are able to consume dairy milk today without suffering the symptoms of lactose intolerance (bloating, wind, discomfort etc). In Northern Europe, the prevalence of lactose intolerance is relatively low, varying between one to18 percent (37). The highest levels of milk consumption in the world are seen in Finland, Sweden, the Netherlands, Albania, Germany and Norway. Lactose intolerance is most prevalent in Asian and African countries with 80 to 100 percent frequency in some cases. People who have retained the normal intolerance of lactose include the Chinese, Japanese, Inuit, native Americans, Australian Aborigines, Iranians, Lebanese and many African tribes including the Zulus, Xhosas and Swazis. These people, generally, do not have a history of pastoralism and many don’t consume any milk products at all. The lowest rates of milk consump26

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tion in the world are seen in Thailand, Vietnam, the Democratic People’s Republic of Korea, Mozambique, the Congo and Liberia (38). It could be argued that the lower level of consumption seen in some developing countries reflects the fact that people can’t afford to buy milk products. However, in Japan, which is not a developing country, consumption is very low. Whether the reason is cultural, economic, historical or biological (lactose intolerance), the fact remains that most people in the world don’t drink milk. The obvious treatment for lactose intolerance is to avoid all cows’ milk and dairy products. This means checking labels for lactose in bread, chocolate and other processed foods including meats. In addition, lactose is used in some types of medication, so patients should check with their GP or pharmacist (although symptoms of lactose intolerance rarely occur as a result of taking medication containing it). An increasing amount of lactose-free products are appearing to cater for the lactose intolerant and boost sales of dairy foods. Plant-based milks (soya and nut milks) are naturally lactose-free. Although there is no evidence of calcium deficiency in people eating a diet with no lactose (39), patients cutting out dairy foods may need some help and advice on how to ensure that they still get plenty of calcium. This may be important for young children who need calcium for healthy growth and development. In conclusion, it can be argued that cows’ milk is neither normal nor natural. The health implications of being the only mammal to consume milk as adults (and not just that, milk from another species too) are becoming clearer and may soon force the government to reconsider how cows’ milk and dairy products are promoted. This article presents a summary of an extensive fully-referenced scientific report called White Lies. All the facts presented are based on peer-reviewed published research. To find out more or to access the full references, see the full report online at: www.viva.org.uk/resources/ campaign-materials/reports/whitelies


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dysphagia

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE Every fourth minute, someone somewhere in the UK endures a stroke (1). Stroke survival is on the increase and post-stroke care needs are rising, with stroke treatments from acute to recovery phase to managing stroke side effects, showing improvements in patient outcomes. Louise Dickie Specialist Stroke Dietitian in hyperacute/ acute stroke care, Imperial College HealthCare Trust

Dysphagia is a common side effect of strokes, with between 27 percent and 50 percent of stroke patients being diagnosed (2, 3, 4), and requires clinical and nutritional management. Nutritional consequences linked to dysphagia include compromised dietary intake, leading to malnutrition and dehydration, which in turn may lead to reduced scope to rehabilitate, prolonged hospital stay and increased mortality.

Dysphagia is the impairment of the swallow process during transit of solids or liquids from the mouth to the stomach.

Dysphagia

Louise is currently working as a Specialist Dietitian in inpatient stroke care. Previously, Louise worked as a Specialist Nutrition Support Dietitian in gastroenterology, ICU, parenteral nutrition and care of the elderly.

Dysphagia is the impairment of the swallow process during transit of solids or liquids from the mouth to the stomach. Depending on the site and extent of brain injury following stroke, different muscles and nerves used in the swallowing reflex may not be triggered or functioning properly, leading to dysphagia. Strokes that damage the cerebella are more likely to lead to swallow problems. Dysphagia is classified into four categories based on the location of the swallow impairment: Oro-pharangeal, oesophageal, oesophagogastric and paraoesophageal dysphagia. It is oro-pharangeal that affects the stroke population (5). Within four hours following admis-

sion, it is recommended that stroke patients have their swallow screened for a dysphagia diagnosis with a validated screening tool by appropriately skilled professionals (6). Fifty percent of stroke patients will recover full swallow capacity in the first two weeks, although 15 percent will still have swallowing problems after one month (7). As strokes are more common in elderly patients, agerelated swallow deterioration and other stroke symptoms can further complicate managing stroke-related dysphagia. Malnutrition risk

Protein energy malnutrition (PEM) (either pre-existing or during stroke recovery) is an independent indicator of poorer outcome and mortality after stroke (8, 9, 10, 11, 12). Malnutrition risk is increased in elderly patients (65 years and over) due to reduced lean body mass and many other factors that compromise nutrient and fluid intake. Since restoration of lean body mass is more difficult as age increases, preventive nutritional support is important in the elderly (13). Most strokes occur in those over 65 years; with mean ages in the UK being 72.6 years in men and 78.8 years in females (14). Malnutrition figures vary with up to 60 percent of patients being malnourished post stroke (15) and in 25 percent of the post-stroke population weight loss will persist for up to 12 months (16). The odds of stroke patients becoming malnourished increases with the NHDmag.com February 2015 - Issue 101

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dysphagia

The National Stroke Guidelines for England and Wales recommend that every patient with nutritional problems, including dysphagia and requiring food of a modified consistency, should be referred to a dietitian and an ongoing nutritional plan should be in place

presence of dysphagia, and with prolonged periods of inadequate dietary intake during hospitalisation being a possible cause. This suggests more structured monitoring of nutritional status is needed during stoke admission (17). Nutritional screening for the dysphagic stroke patient

The National Stroke Guidelines for England and Wales recommend that every patient with nutritional problems, including dysphagia and requiring food of a modified consistency, should be referred to a dietitian and an ongoing nutritional plan should be in place (6, 14). Screening is recommended to be carried out on admission and then repeated weekly. (RCP, 2014). There are now two validated screening tools for the stroke population: Malnutrition Universal Screening Tool and The Guys and St Thomas Nutrition Screening Tool, although there are currently no stroke-specific validated screening tools. Dysphagia is not a criterion to trigger scoring on many screening tools. Nutritional interventions in dysphagia care

National recommendations for post stroke patients at risk of malnutrition are to provide specialist dietary advice with the consideration of either oral nutrition support or enteral feeding. The research into nutritional interventions in dysphagia stroke care is becoming stronger to provide us with guidance on the best use of these different nutritional interventions. Interventions include dietary counselling, food texture modi30

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fication, oral nutritional supplements and tube feeding, sometimes with various interventions used together to supplement one another. Areas such as palliative care with dysphagia and other common ethical dilemmas are beyond the scope of this article. Oral nutritional interventions

Modified foods The rationale for the use of texture-modified diets (TMDs) within stroke care is to enable the safe transition of food and fluids to the oesophagus, therefore avoiding penetration or aspiration into the trachea and chest, whilst enabling those with a partial dysphagia to safely continue oral diet. Further research is needed to establish the efficacy of TMDs in clinical and nutritional management of dysphagia. The NHS stipulates that nationally recognised terminology is used for food textures by all health and care settings providing TMDs (NHS 2011). These were developed under the auspices of the National Patient Safety Agency (2011) as a result of clinical incidents. They define the types and textures of foods needed by individuals who have oro-pharangeal dysphagia. Specific standards are provided in a guideline document for four food textures that are to be used with checklists to enable measurement against these standards, in terms of texture consistency. All clinical care settings are recommended to provide at least texture C and texture E (NPSA, 2011), and hospital caterers are advised to provide these as an a la carte menu (The Nutrition and Hydration Digest, BDA/NHS 2011).


dysphagia

Assessment of the comparison between thickened fluids, food, enteral and parenteral nutrition on fluid intake in stroke dysphagic patients has suggested that there is a greater contribution of fluid provided from food, than beverages

Use of TMDs is associated with malnutrition; however, causality is difficult to demonstrate due to confounding factors such as the requirement for feeding assistance, particularly in the post-stroke elderly patient. Many patients with dysphagia find eating uncomfortable and an unpleasant experience. This can lead to early satiety and refusal of food and beverages (14) and lower energy and protein intakes when compared to those taking normal diets (18). TMDs are not always nutritionally adequate (19, 20, 21). Some nutritional composition analyses have shown some to provide as little as 45 percent of average daily energy needs (22). There are no separate regulations to assure that the nutritional composition of TMDs are adequate in health and care settings. However, guidance for catering services is getting better on how to optimise the nutritional content and appeal of TMDs. The Hospital Caterers Association provides practical guidance for provision of TMDs, such as how to best thin puree without detriment to the nutritional value and optimising cooking methods and food presentation. Outsourced food services are also improving the provisions available. There is now a recommendation for a dedicated catering liaison dietitian in every hospital department (Nutrition and Hydration Digest, BDA 2012); however, they are not solely focused on TMDs. Stroke specialist dietitians are likely to have the largest proportion of patients requiring the TMDs, so working with the catering liaison dietitian and hospital catering team is invaluable. Each catering service should provide a

nutritional break down of their TMDs and, by using the Nutrition and Hydration Digest as a guide, the nutritional composition can be deduced. Strategies to maximise provisions of appetising nutrient-dense foods (including snacks) and fluids of suitable textures can increase nutrient intakes (19, 23). Targeted feeding assistance with dysphagic patients has also been seen to be beneficial to nutritional intakes (24). Modified fluids As well as TMDs, thickened fluids are also used as a method of safely consuming oral intake during dysphagia. Dysphagic stoke patients who are restricted to thickened fluids are at high risk of dehydration (25, 26). Stroke-associated reduced thirst sensations and cognitive impairments, as well as non-stroke related risk indicators, such as age and physical disabilities, further increase the potential of dehydration risk for this patient group (28). Other risk factors for dehydration include the low acceptance rates of thickened fluids (29). It is currently unclear whether thickened fluids induce early satiety. Although studies agree that increasing the thickness of a liquid reduces the amount consumed when compared to unthickened fluids. Assessment of the comparison between thickened fluids, food, enteral and parenteral nutrition on fluid intake in stroke dysphagic patients has suggested that there is a greater contribution of fluid provided from food, than beverages (31). Therefore, designing menus and promoting fluid dense foods rather than thickened beverages is an important way NHDmag.com February 2015 - Issue 101

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dysphagia

Tube feeding may be a chosen method of nutritional intervention either to wholly supplement nutritional needs or to supplement intake in those with partial dysphagia. of improving fluid intakes in patients with dysphagia. Enteral or parenteral supplementation may be needed. Although costly, some settings use pre-thickened beverages, which may help to improve fluid and nutrient intakes for our dysphagic stroke patients (31, 32). There are also now pre-thickened ONS available which may be of some benefit for our patients requiring nutritional supplements. Initial observational studies using them in in non-stroke patients with dysphagia requiring ONS, demonstrated achievements in nutritional aims being met in ease of use and palatability (14). Additional support for stroke patients on oral interventions/oral diets

Stroke patients should be provided with appropriate equipment and assistance. The use of a plate guard, specialist cutlery and adhesive place mats are examples of such equipment (34). In addition, the red tray system is a simple strategy that alerts healthcare staff that a patient requires assistance and is useful for patients who require a level of physical or cognitive support. Stroke patients can vary in their need for support with eating and drinking due to other stroke side effects. The use of dining areas have been shown to improve energy intake in elderly patients. With much of post stroke dysphagic population being within this bracket, it may have a positive improvement on nutritional intakes (33). Using oral nutritional supplements (ONS)

Oral nutritional supplements may be helpful for dysphagic patients on oral diets and are recommended for malnourished stroke patients regardless of swallow difficulties (13). A recent Co32

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chrane review concluded that, although we need more studies, the present studies suggest that we should be using oral nutrition supplements for our at-risk patients as their use is associated with increased energy and protein intake and reduction in pressure sores for the dysphagic stroke patient (7) compared to diet alone. Tube feeding

Tube feeding may be a chosen method of nutritional intervention either to wholly supplement nutritional needs or to supplement intake in those with partial dysphagia. Currently, ESPEN recommend enteral feeding for elderly neurological patients with severe dysphagia, and the RCP 2014 guidelines advise to start within 24 hours via a nasogastric tube for any patient deemed in need of artificial feeding (13, 14). There have been few evaluation studies made regarding tube feeding to supplement TMDs to see how they impact on outcomes and to guide clinical practice. No significant difference to mortality rates or pneumonia has been found between the use of NGTs or PEGs in the short term (7). However, when longer-term artificial feeding support is required, then PEG feeding is seen as advantageous, with a significantly lower probability of feeding failure (14). Post-pyloric feeding should be considered if upper gastrointestinal dysfunction is suspected, once medical and pharmacological treatment approaches have been tried or considered. Available evidence suggests that neither the gastric nor post-pyloric route is seen to be superior to the other, with no advantage in terms of reduction in aspiration pneumonia, tube displacements or nutritional intake (7).


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dysphagia

As stroke survival is on the increase and the successes of rehabilitation are becoming more evident, we need to strive to optimise the nutritional care that we provide to assist in promoting the best patient outcomes we can

Nasal bridles, mittens or other restraining devices

Research is sparse in guiding us with the use of these devices, with no randomised trials evaluating the effects of mittens or other forms of restraint. One two-week study involving 104 dysphagic stroke patients found that the use of nasal bridles significantly increased the amount of enteral nutrition and fluid delivered, ameliorated electrolyte disturbances and improved incidence of NGT failures (35). No difference in mortality, morbidity, PEG placements, functional outcomes, or length of stay was seen. If patients are not tolerating NGTs, the current RCP guidelines recommend the use of nasal bridles or early gastrostomy placement with locally agreed protocols (14) and recommend that locally agreed protocols and training is in place if mittens are used. Weaning

Very few studies focus on this transition and there are no national recommendations available for guidance. Some papers suggest as a minimum that a patient must be able to consume adequate oral nutrition and demonstrate a safe and effective swallow on a consistent basis (36). Buchholz (37) proposed a two-step process. Firstly, initiating a intermittent feed schedule as step one and only once a patient is able to consume 75 percent or more of their nutritional needs consistently for at least three consecutive days should the tube then be removed. Reliance on food and fluid charts for assessment of calorie, protein and fluid intake is essential, particularly for patients with impaired memory, or communication barriers, while review of anthropometric and blood results can help to guide if your nutritional plans are working. 34

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Summary

As stroke survival is on the increase and the successes of rehabilitation are becoming more evident, we need to strive to optimise the nutritional care that we provide to assist in promoting the best patient outcomes we can. The forms of nutritional intervention used for dysphagic patients are in need of more research to establish their impact on stroke patient outcomes, including nutritional status, and on what the best strategy is for achieving weight gain, nutritional maintenance or improvements and measurable benefits. Each patient should be holistically assessed to ensure that the most suitable nutritional intervention is used at each step of their post stroke care, with the available current evidence and recommendations guiding your current practice, weighing up of the risks and benefits and thinking about the impact between using the intervention or not on the patient’s quality of life. Whilst the medical aims of active dysphagia management are to continue oral feeding whilst reducing the risk of clinical harm, the nutritional aims are to maintain a good nutrition and hydration status with the most suitable nutritional intervention. More research needs to be done to evaluate the benefits and most suitable nutritional intervention available to maintain or improve nutritional status in our growing dysphagic stroke population. Recent updates in guidance of stroke patients and dysphagic patients should contribute to improved care for these patients and research questions have been asked to add to the current evidence and help strengthen our knowledge for clinical practice.


dysphagia References 1 The Stroke Association 2 Gordon C. Hewer RL. Wade DT. Dysphagia in Acute Stroke. BMJ 1987. 3 Wolfe C. Rudd T. Beech R. The Burden of Stroke, Stroke Services and Research. London: The Stroke Association. 1996 4 Odderson IR. Keatin JC. McKenna BS. Swallow management in patients on an acute stroke pathway: quality is cost effective. Arch Phys Med Rehabil 1995 Dec;76(12):1130-3 5 Mann G. Hankey GJ. Caeron D. Swallowing functions after stroke: prognosis and prognostic factors at 6 months. Stroke 1999 30(4): 744-748 6 Stroke Quality Standards. NICE 2010 7 Geeganage C. Beevan J. Ellender S. Bath PMW. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database of Systematic Reviews 2012, Issue 10. 8 Dávalos A1, Ricart W, Gonzalez-Huix F, Soler S, Marrugat J, Molins A, Suñer R, Genís D. Effect of malnutrition after acute stroke on clinical outcome. Stroke. 1996 Jun; 27(6):1028-32. 9 Dennis, M. Nutrition After Stroke. British Medical Bulletin. 2000; 56 (No 2) 10 Davis J Wong A. Schluter P. Henderson R. Philip J. Henderson R. O’Sullivan. Read Stephen. Impact of Premorbid Undernutrition on Outcome in Stroke Patients. Stroke. 2004; 35: 1930-1934 11 Martino, R et al. Dysphagia After Stroke. Incidence, Diagnosis, and Pulmonary Complications. 2005. American Heart Association. 12 Yoo SH. Kim JS. Kwon SU. Yun, SC. Koh JY. Kang DW. Undernutrition as a Predictor of poor Clinical Outcomes in Acute Ischemic Stroke Patients. Arch Neurol. 2008;65(1):39-43 13 ESPEN Guidelines on Enteral Nutrition: Geriatrics. 2006. 14 National Clinical Guideline for Stroke. Intercollegiate Working Party for Stroke. Royal College of Physicians. 2010. 4th Edition. 15 Norine C. Foley, RD, MSc1, Ruth E. Martin, PhD2, Katherine L. Salter, BA3 and Robert W. Teasell, MD1,3. A Review of the Relationship Between Dysphagia and Malnutrition Following Stroke. J Rehabil Med 2009; 41: 707–713 16 Jönsson AC. Lindgren I. Norrving B. Lindgren A. Weight loss after stroke: a population-based study from the Lund Stroke Register. Stroke 2008 Mar;39(3): 17 Gariballa S. Parker S Taub N. Castleden C. Influence of nutritional status on clinical outcome after acute stroke. Am J Clin Nutr 1998;68:275–81. 18 Bath PMW, Bath-Hextall FJ, Smithard DG Interventions for dysphagia in acute stroke. Cochrane 1997 and physiological burden of dysphagia; its impact on diagnosis and treatment. Dysphagia April 2002, Volume 17, Issue 2, 19 Eckberg, O. et al. 2002. Social pp 139-146 20 Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Dietetics. 2005 Jun; 18(3); 213-9. 21 Bannerman E, McDermott K. Dietary and fluid intakes of older adults in care homes requiring a texture modified diet: The Role of Snacks J Am Med Dir Assoc. 2011 Mar;12(3):234-9. 22 Foley N, Finestone H, Woodbury MG, Teasell R, Greene Finestone L. Energy and protein intakes of acute stroke patients. J Nutr Health Aging. 2006 May;10(3):171-5. 23 Moreno, C, Garcia MJ, Martinez C & Grupo GEAM. Analisis de situacion y adecuacuin de dieta para disfagia en un hospital provincial. Nutr Hosp 2006; 21: 26-30 24 Wilkinson TJ. Thomas K. MacGregor S. Tillard G. Wyles C. Sainsbury R. 2002. Tolerance of early diet textures as indicators of recovery from dysphagia after stroke. Dysphagia 17, 227-232. 25 Hotaling DL. Nutritional Considerations for the pureed texture in dysphagic elderly. Dysphagia 1992 (7) 81-85. 26 Wright L. Cotter D. Hickson M. The effectiveness of targeted feeding assistance to improve the nutritional intake of elderly dysphagic patients in hospital. Journal of Nutrition and Dietitics 2008 21; 6. 27 Finestone HM. Foley NC. Woodbury MG. Greene-Finestone L. 2001 Quantifying fluid intake in dysphagia stroke patients: a preliminary comparison of oral and non-oral strategies. Arch. Phys. Med Rehabil. 82, 1744-1746. 28 Vivanti A, Campbell K. Suter M. Hannan-Jones M. Hulcombe J. Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. Journal of Nutrition and Dietitics. 2009. Volume 22, Issue 2, pages 148–155 29 Axelsson K. Asplund K. Norberg A. Alafuzoff I. Nutritional status in patients with acute stroke. 1998 Acta Medica Scandinavica 224 (3) 217-224. 30 Scharver, C. Hammond C. Goldstein L. “Post-stroke malnutrition and dysphagia,” in Handbook of Clinical Nutrition and Aging, C. W. Bales and C. S. Ritchie, Eds., pp. 479–499, Humana Press, New Jersey, NJ, USA, 2nd edition, 2009. 31 Whelan K. Inadequate fluid intakes in dysphagic acute stroke. 2001. Clinical Nutrition. 20. 423-428. 32 McCormick SE. Stafford KM. Saqib G. Chroinin DN. Power D. The efficacy of pre-thickened fluids on total fluid and nutrient consumption among extended care residents requiring thickened fluids due to risk of aspiration. Age Ageing. 2008 Nov;37(6):714-5 33 Macleod M. Blackie L. Humphrey S. An investigation into the nutritional efficacy, tolerance and patient acceptance of pre-thickened nutritional supplements in dysphagic patients. Proceedings of the Nutrition Society 2010. 69 34 Wright L. Hickson M. Frost G. Eating together is important: using a dining room in an acute elderly medical ward increases energy intake. J Hum Nutr Diet. 2006 Feb;19(1):23-6. 35 Beevan J et al. Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke? BioMed Central. Trials 2007, 8: 19 36 Mann G, Hankey GJ, Caeron D. Swallowing functions after stroke: Prognosis and prognostic factors at 6 months. Stroke 30 4 744-748 37 Buchholz AC. Weaning patients with dysphagia from tube feeding to oral nutrition: A proposed algorithm. Can J Diet Pract Res. 1998: 59; 208-214. 38 Corrigan, ML et al. Nutrition in the Stroke Patient. Nutrition in Clinical Practice. 26, No 3, June 2011. 242-252. 39 Gomes F, Hookway C, & Weekes C.E (2014) Royal College of Physicians Intercollegiate Stroke Working Party evidence-based guidelines for the nutritional support of patients who have had a stroke. J Hum Nutr Diet. 27, 107-121. 40 The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals. DofH. August 2014. 41 The Nutrition and Hydration Digest: Improving Outcomes through Food and Beverage Services. July 2012. The British Dietetic Association. 42 Dysphagia Diet Food Texture Descriptors. April 2011. NSPA/Royal College of Speech and Language Therapists/The British Dietetic Association/ National Nurses Nutrition Group/Hospital Caterers Association 43 Withholding and withdrawing Life-prolonging Medical Treatment. Guidance for Decision Making. Second Edition 2001. BMA. 44 FOOD Trial Collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD Trial. Stroke 2003 34. 1450-1456.

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coeliac disease

DIETETIC-LED MANAGEMENT OF COELIAC DISEASE Coeliac disease affects approximately one percent of the Western European population (1) and is one of the most common gastrointestinal conditions seen. The only treatment for this condition is the strict life-long exclusion of gluten from the diet. Fiona Moor Head of Dietetic Services, Royal Derby Hospital

Fiona Moor is Head of Dietetic Services for the Derby Hospitals NHS Foundation Trust. She has a special interest in coeliac disease and runs the coeliac service for patients within Southern Derbyshire.

This however, is extremely challenging for the patient, particularly, for those who have very mild symptoms or are asymptomatic. The follow-up care of patients with coeliac disease (after the diagnosis) varies hugely within the UK, ranging from patients with coeliac disease being seen in specialist clinics, to the other extreme of being discharged back to the community without any provision of a specialist service (either in primary or secondary care). In addition, the individuals providing the follow-up care could be family practitioners, gastroenterology consultants, nurse specialists or dietitians. The British Society of Gastroenterology recommends that patients should receive life-long follow up through an annual review (2) because of potentially serious long-term complications such as lymphoma (3) and osteoporotic fractures (4), although the risk of these is small (5). The dietitian is best placed to provide this, to ensure that even experienced patients with coeliac disease do not inadvertently consume gluten. The Annual review is also essential to promote an overall balanced diet and discuss any nutritional issues or pos-

sible deficiencies which may arise. Evidence suggests that patients seen in a dietetic-led coeliac clinic have improved outcomes (6) and that dietetic follow-up is the method of management preferred by the patient (7). Within Southern Derbyshire, the dietitian takes the lead for the management of patients with coeliac disease across the whole of the patient pathway. New patient pathway

Following discussions with Southern Derbyshire CCG and the gastroenterology consultants at the Royal Derby Hospital, major changes have been made to the local pathway for diagnosis and management of patients with coeliac disease. This has resulted in less hospital appointments, less unnecessary endoscopies and direct referral into dietetic services reducing the time to treatment implementation. There is emerging evidence which indicates that if a coeliac serology blood test is over five times the normal range (above 50u/ml), then an endoscopy is not required. We have used this information to structure our new pathway (Figure 1).

Figure 1:

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coeliac disease

The group sessions not only offer practical advise on how to maintain a gluten-free

diet, but help patients with the social and

psychological elements associated with any long-term condition

Dietetic-led group patient education sessions

We have been offering dietetic-led group patient education sessions, as an alternative to individual outpatient clinic consultations, for our newly diagnosed coeliac patients since 2010. This was initiated to accommodate the increased number of referrals that we were receiving into the department for newly diagnosed patients. Due to capacity problems at that time, we were unable to offer these patients a one-to-one consultation. Group sessions run every three weeks for 90 minutes; they are very informal and designed for patients to share their experiences. During the session, the condition and dietary management is introduced in detail, covering subjects such as hidden sources of gluten, cross contamination, the use of prescribable products and how to maintain a healthy gluten-free diet. Additional guidance is provided on the importance of ensuring adequate intakes of calcium and iron, how and when to introduce pure gluten-free oats and the appropriate use of barley malt extract. Group members are encouraged to ask questions throughout. A pack of written information is provided to each attendee which contains our Gluten Free Diet Sheet, starter pack cards from various manufacturers, up-to-date prescription list and current guidance on units, as well as information regarding calcium and iron intakes. A display, consisting of gluten-free food packages (both prescribable and supermarket free from ranges) is arranged for patients to look at and discuss. Occasionally, a representative from one of the gluten-free manufacturers will attend and samples will be provided for the patients. Individu38

NHDmag.com February 2015 - Issue 101

als are also encouraged to join Coeliac UK - the associated charity for patients with the coeliac condition. Those who were felt not to be appropriate for the group, e.g. requiring interpreter services, or those not wishing to attend a group session, are given an appointment for a one-to-one consultation. At the group session, the dietitian has access to all patients’ biochemistry, so individual discussions regarding coeliac serology levels, along with iron, vitamin B12 and vitamin D can take place and, if necessary, supplementation can be discussed. There is also a check to see if referral for DEXA scan has been made. A patient evaluation rounds the session off at the end of the 90 minutes. Feedback has always been positive (Table 1). Table 1: Patient feedback from patient evaluation of coeliac group education sessions - 2014 “Very well presented.” “I found it more useful than I had expected.” “Very helpful.” “I’ve thoroughly enjoyed the session.” “I found today really helpful, nice to talk to others in the same situation.”

The group sessions not only offer practical advise on how to maintain a gluten-free diet, but help patients with the social and psychological elements associated with any long-term condition. Following on from the group session, as per the pathway above, patients are offered appointments to be followed up at eight weeks, six months and 12 months post diagnosis.


coeliac disease

Following on from the group session,

as per the pathway above, patients are

offered appointments to be followed up at

eight weeks, six months and 12 months

post diagnosis.

Follow-up dietetic-led clinics

We have been operating follow-up dietetic-led coeliac clinics since 2007, with a clinic scheduled every week. Patients attending are those returning for their six-week, six-month, or 12-month follow-up, or annual review, unless more frequent attendance has been identified. All care is managed by the dietitian, including the monitoring and interpretation of biochemistry and the requesting of DEXA scan and analysing of the results. This meets national guidelines for the surveillance of these patients with coeliac disease and is in line with the BSG guidelines for the management of the condition (2). Prior to the appointment, all patients will have had the following blood tests: full blood count, ferritin, vitamin B12, folate, calcium, coeliac serology and vitamin D. Each clinic appointment is a one-to-one consultation lasting 20 minutes. There is a review of adherence to the gluten-free diet, assessment of changes to symptoms, discussion of blood results, along with weight check and thorough dietary assessment, including adequacy of calcium intake in light of DEXA results. At the six-month appointment, consideration will be made to the introduction of pure gluten-free oats and there will be a review of the gluten-free prescription process to ensure there are no outstanding issues or problems. If any red flag symptoms (unintentional weight loss, altered bowel habits, blood in stools) are identified at the clinic appointment, then discussion will take place with a gastroenterologist and referral made as appropriate.

2 Ciclitira PJ, Dewar DH, McLaughlin SD, Sanders BS. British Society of Gastroenterology. The management of adult coeliac disease. 2010 3 Catassi C, Fabiani E, Corrao G et al. Risk of non-Hodgkin lymphoma in celiac disease. JAMA 2002; 287: 1413-9 4 West J, Logan RF, Card TR, Smith C, Hubbard R. Fracture risk in people with celiac disease: a population based cohort study. Gastroenterology 2003; 125: 429-36 5 Catassi C, Bearzi I, Holmes GK. Association of celiac disease and intestinal lymphomas and other cancers. Gastroenterology 2005; 128 (4 Suppl. 1): 57-67 6 Wylie C, Geldart S and Winwood P. Dietitian led coeliac clinic: a successful change in working practice in modern healthcare. Gastroenterology Today 2005; 15: 11-12 7 Bebb JR, Lawson A, Knight T and Long RG. Long-term follow-up of coeliac disease - what do patients want? Aliment Pharmacol Ther 2006; 23: 825-831 8 Hill PG and Holmes GKT. Coeliac disease: Is biopsy still required for diagnosis at all levels of IgA Tissue Transglutaminase Antibody? Gut 2006; 55 Suppl 2: A11

References 1 Dube C, Rostom A, Sy R et al. The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology 2005; 128 (4 Suppl. 1): 57-67

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book review

Infant, Child and Adolescent Nutrition: A Practical Handbook Review by Gemma Ransome, Specialist Dietitian, Paediatric Intensive Care/ Cardiology, The Harley Street Clinic

by Judy More CRC Press; 1 edition (22 Jan. 2013) ISBN- 978-1444111859 - CAT# K18762 Paperback ÂŁ19.99

Judy More is a registered dietitian who has specialised in paediatric nutrition for over 15 years. Here she has written an evidence-based and concise guide to the key principles of paediatric dietetics, in which she explains the theory behind the basics of a balanced and nutritious diet and describes growth and development throughout childhood. The book covers nutrition from preconception to adolescence up to the age of 18. It addresses some of the common nutritional and feeding problems at different stages of a child’s development. The cultural, physical, emotional, social and psychological factors that may play a part in why feeding can be challenging are also considered and discussed. A section devoted to the social and cultural influences on food choices provides information about common food traditions within different religions and geographical regions. This is particularly useful to those working with diverse ethnic populations. Other highlights include the section on breastfeeding which is covered in more detail than most dietetic texts. There is an example of a feeding routine and tips for good positioning and attachment. The obesity section is a useful tool for health professionals seeing overweight and obese children in the community, recommending discussion points to explore with a family. Throughout there is plenty of practical advice, examples and reference information in easy-to-read tables and illustrations. The text includes case studies, key points and activities to help readers learn. 40

NHDmag.com February 2015 - Issue 101

My only criticism is that the topics in the last section covering nutrition for children with chronic diseases and syndromes, are too complex to set out and fully explain in 15 pages. Although this section acts as an introduction to chronic diseases and specific conditions, the content should not be relied on by healthcare professionals to provide nutritional advice to parents. This book would be useful to nutrition and dietetics students requiring an overview of nutrition and development for children aged 0 to 18 years. It may also be interesting reading for other healthcare professionals involved in the nutritional health of children in primary care and community settings. This text would certainly be useful to those working in food provision and meal planning in childcare settings. Although the preface describes this book as helpful to parents, the language used and textbook style of writing makes it less accessible to the general public. Instead, healthcare professionals could use the tips and examples in this book as a base to help parents manage meal time behaviour and to suggest suitable nutritious meals and snacks.


NHD Subscription 6 print and 10 digital issues • Latest dietetic and nutrition news

NHDmag.com

Issue 101 February 2015

• Feature articles on public health and community nutrition

• Nutrition research updates from the world’s leading nutrition institutions

• Clinical articles with practical features, case studies, guidelines and more

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS BRIGHTON & HOVE

ISSN 1756-9567 (Print)

Lauren McCormack p9

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

Louise Dickie Specialist Stroke Dietitian

ADULT FOOD ALLERGY LACTOSE INTOLERANCE COELIAC DISEASE COWS’ MILK VS GOAT MILK

DIETETIC*/"3sWEB WATCH sNEW RESEARCH

• Expert columns and comment from the coal face of UK dietetics • Career section with live jobs, events and courses

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BREASTFEEDING IS BEST FOR BABIES

Why consider a whole goat milk formula? Cow’s milk is commonly used to manufacture infant formula, generally because it is the most widely available source.

NANNYcare is made from whole goat milk which is now fully regulated and approved for use in infant formula

Better digestibility The immaturity of a new-born infant’s digestive tract requires the proteins in formula to be readily digestible. Goat milk proteins are digested more completely than cow’s milk proteins1. NANNYcare First infant milk:

Casein profile Comparison of Casein profile between human, goat and cow’s milk 100%

% of total Casein

K-Casein

 s2-Casein

 s2-Casein

 s1-Casein

75%

K-Casein

50%

Behaves more like breast milk in the infant stomach forming looser, softer and more porous curds than cow’s milk formula

This aids digestion by allowing easier access by stomach enzymes

Nearly 3-fold more beta-lactoblobulin is digested in goat milk compared with cow’s milk2 Pictorial representation of species variation in Casein curd ‘density’ Cow’s milk infant formula 1 - Cow milk infant formula, whey dominant (40% casein, 60% whey) 2 - Cow milk infant formula (80% casein, 20% whey) 3 - Cow hypoallergenic infant formula

Whole goat milk infant formula

Human milk

 s1-Casein

K-Casein

-Casein -Casein

25%

-Casein 0%

Human milk

Goat milk

Cow milk

Goat milk has a smaller proportion of ʸ s1-casein than cow’s milk and a greater proportion of ʹ-casein, similar to the casein profile of human milk.

For more info visit nannycare.co.uk or email us: enquiry@nannycare.co.uk or call our helpline UK: 0800 328 5826

Method: Samples were reconstituted with water and pH was dropped to 4.5 with HCl

These factors contribute to the better digestion of goat milk and suggest why a goat milk formula may be beneficial and may simply suit some babies better than cow’s milk formulas. REFERENCES: 1. PINTADO, M. E. & MALCATA, F. X. (2000). Hydrolysis of ovine, caprine and bovine whey proteins by trypsin and pepsin. Bioprocess Engineering, 23, 275-282. 2. ALMAAS, H et al (2006). In vitro digestion of bovine and caprine milk by human gastric and duodenal enzymes. International Dairy Journal, 16, 961-968

IMPORTANT NOTICE: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breast-fed. The decision to discontinue breast feeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breast feeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional. Goat milk formula is not suitable for a cow milk protein allergy except under the supervision of a suitably qualified health care professional.


INFANT FEEDING: DAIRY

THE NUTRITIONAL QUALITIES OF GOAT MILK AS AN ALTERNATIVE TO COWS’ MILK IN INFANT FORMULAE During infancy, appropriate nutrition is required for normal growth and development. Jacqui Lowden Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH

Presently team leader for Critical Care and Burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

There is now substantial evidence to indicate that early nutrition also has fundamental implications for longterm health, by programming aspects of ensuant cognitive function, thereby preventing obesity and anaemia, as well as reducing the risk of serious diseases such as diabetes, cardiovascular disease, osteoporosis, cancer and atopy (1, 2, 3). To achieve these outcomes, breastfeeding is recommended (4). Where breastfeeding is not possible, or breast milk is insufficient, infant formulas are used. Traditionally, infant formulas made with cows’ milk are the first line choice for formula-fed infants. Until recently, most of the conclusive studies in human infants published in the international literature have been limited to the evaluation of cows’ milk or soy protein-based infant formulae. Proteins from the milk of animals other than cows, or from various plant sources, have also been considered potentially suitable for use in infant formulae (5, 6). However, the suitability and safety of goat milk has only recently been approved, despite the fact that goat milk has a history of use for human nutrition in many cultures (7, 8, 9) and that there has always been

demand for goat milk infant formulas, with reports of home-made goat formula and raw goat milk being used (10, 11, 12, 13). The Dietetic Products, Nutrition and Allergies of European Food Safety Authority (EFSA) panel (14) concluded that protein from goat milk is suitable as a protein source for infants and for follow-on formulae (as long as the final products comply with the compositional criteria as per the EU Directive 2006/141/EC). From March 2014 goat milk infant formula has now become allowable throughout the EU. But is it any different from cows’ milk formula? Table 1 outlines the main differences between cows’ milk and goat milk formulae. COMPOSITIONAL PROPERTIES

Nucleotides In young infants, rapid growth can increase the need for nucleotides, which are important constituents of RNA and DNA. It is well documented that nucleotide supplementation increases weight gain and head growth in formula-fed infants. Therefore, nucleotides may be conditionally essential for optimal infant growth in some formula-fed populations (19).

Table 1: How goat milk differs from cows’ milk Goat milk is secreted by an apocrine process, similar to that of breast milk (15) Goat milk has a lower level of alpha s1-casein and greater proportion of beta-casein compared to cows’ milk and is more similar to human milk (16) Goat milk has more medium chain fatty acids than cows’ milk (17) Goat milk has five times more nucleotides than cows’ milk, similar to human milk (18) NHDmag.com February 2015 - Issue 101

43


Infant feeding: dairy

Cows’ milk infant formulas are now routinely supplemented with nucleotides. However, goat milk formula already contains an array of nucleotides and so requires no supplementation.

Cows’ milk infant formulas are now routinely supplemented with nucleotides. However, goat milk formula already contains an array of nucleotides and so requires no supplementation (20). Protein and amino acids Goat milk infant formula has amino acids in amounts similar to human milk reference values, when expressed on a per-energy basis (21). The protein content of infant formula has, in the past, been set higher than human milk. This was due to concerns regarding protein quality and insufficient amounts of some amino acids. However, there now exists evidence that the protein content has been set too high, resulting in a greater than normal weight gain and stress on a young infants immature kidneys (22, 23). With this ‘growth acceleration hypothesis’, suggesting that early and rapid growth during infancy programs the infant metabolic profile to be susceptible to obesity and the other components of metabolic syndrome, it is essential that any infant formulas are brought in line with human milk reference values. 44

NHDmag.com February 2015 - Issue 101

Whey proteins Infant milk formulas often have whey proteins added to improve the quality of protein available as essential and semi-essential amino acids (24, 25). Goat milk infant formula, however, has been shown to have sufficient quantities of all essential and semi-essential amino acids, without added whey proteins and so has an amino acid profile compatible with international standards for infant formula (21). It has also been demonstrated that this type of goat milk formula has amino acid digestibility and absorption properties similar to those of a cows’ milk infant formula, with added whey, in an animal model (26). NUTRITIONAL ADEQUACY

As well as meeting international compositional standards, it is also essential that the suitability and nutritional adequacy of infant formulas containing new sources of protein are established (27, 28). Until recently, there has only been one previous randomised controlled trial using a goat milk infant formula to feed infants (29), demonstrating that the growth in 30 infants fed


infant feeding: dairy

Government advice at present is . . . ‘Goat milk infant formula and follow-on formula is not suitable for infants with a cows’ milk protein allergy unless directed by a healthcare professional.’ a goat milk formula was similar to that of 32 infants fed a whey-based cows’ milk formula, but the study was criticised for lack of blood biochemical data and numbers (30). Since then, however, a study published in 2014 has demonstrated that in infants, the growth and nutritional outcomes provided by the goat milk formula did not differ from those provided by a standard whey-based cows’ milk formula. The study of 285 infants fed goat or cow formula or breast milk, provided the necessary evidence leading to the recent change allowing goat milk as a base in infant formula (31). An earlier study by Zhou et al 2011 (16) highlighted an interesting aspect, in that they measured how many times an infant was offered an alternative formula or non-formula foods before the age of four months, as a measure of compliance. In the group randomised to receive the cows’ milk formula, almost 40 percent of the infants were offered either another formula or a non-formula food for more than 12 days before the age of four months. The rates in the infants fed the goat milk formula were far less and more similar to the breast milk fed infants. When parents change their baby’s formulas or introduce solids earlier than the recommendation, a common reason given is because they feel that the baby is not satisfied. This does need to be investigated further, but could possibly suggest that they were more satisfied on the goat milk formula. WHAT ABOUT COWS’ MILK PROTEIN ALLERGY?

The World Allergy Organisation estimates that 1.9% to 4.9% of children suffer from cows’

milk protein allergy (32). It has previously been suggested that goat milk could be used as a possible nutritional alternative to cow’s milk for these infants. However, clinical studies have demonstrated a risk of cross-reactivity between the proteins in cows’ milk and in goat milk (33, 34). There have also been reported cases of infants with cows’ milk allergy developing anaphylaxis after the ingestion of goat milk (35). In the 2012 EFSA publication, it was concluded that, ‘There is insufficient data on the allergenicity of goat milk protein, with no convincing data to support the conclusion that the incidence of allergic reactions is lower when feeding goat milk-based infant formula when compared with cows’ milk-based infant formula.’ It also concluded that, ‘Substituting goat milk protein for cows’ milk protein in infant formula intended for cows’ milk allergic infants cannot be considered safe, unless proven to be so in clinical and in vitro studies.’ (36) Government advice at present is, therefore, that, ‘Goat milk infant formula and followon formula is not suitable for infants with a cows’ milk protein allergy unless directed by a healthcare professional.’ SUMMARY

Optimum nutrition during infancy is not only important for normal growth and development, but also for long-term health. Where breast milk is not available, it is essential that infant formulas can provide, as close as possible, the equivalent nutritional and health outcomes for babies as for those infants who are breastfed. NHDmag.com February 2015 - Issue 101

45


infant feeding: dairy Until recently, most of the conclusive studies in human infants published in the international literature have been limited to the evaluation of cows’ milk or soy protein-based infant formulae. However, there is now published evidence that goat milk infant formula is a safe and suitable alternative to cows’ and soy-based formulas and is approved for use.

Goat milk has several features that have greater similarity to human breast milk than cows’ milk. There is no evidence to suggest that there is any advantage to including extra whey proteins in goat infant formula. Goat milk infant formula, however, is not suitable for infants with a cows’ milk protein allergy, unless directed by a healthcare professional.

References 1 Lucas A. Programming by early nutrition: an experimental approach. J Nutr 1998;128 (suppl 2):401-6S 2 WHO Diet, Nutrition, and the Prevention of Chronic Disease. Report of a joint WHO/FAO Expert consultation. 2003 3 SACN (2011 a). The influence of maternal, fetal and child nutrition on the development of chronic disease in later life (online). London SACN. Available at www. sacn.gov.uk/pdfs/sacn_early_nutrition_final_report_20_6_11.pdf (accessed July 2014) 4 aaP (2012). breastfeeding and the use of human milk. Pediatrics 129, e827-e841 5 Global Standard for the composition of Infant Formula: recommendations of an eSPGHaN coordinated International expert Group. Journal of Pediatric Gastroenterology and Nutrition 41:584–599, November 2005. ESPGHAN Committee on Nutrition 6 Codex Alimentarius Commission (2007). Standard for infant formula and formulas for special medical purposes intended for infants CODEX STAN 72-1981 (amended 2007) 7 Silanikove N, Leitner G, Merin U et al (2010). Recent advances in exploiting goat milk: quality, safety and production aspects. Small Rum Res 89, 110-124 8 Haenlein GFW (2004). Goat milk in human nutrition. Small Rum Res 51, 155-163 9 Razafindrakoto O, Ravelomanana N, Rasolofo A et al (1994). Goat milk as a substitute for cows’ milk in undernourished children: a randomised double-blind clinical trial. Pediatrics 94, 65-69 10 Ziegler DS, Russell SJ, Rozenberg G et al (2005). Goat milk quackery. J Pediatr Child Health 41, 569-571 11 Basnet S, Schneider M, Gazit A et al (2010). Fresh goat milk for infants: myths and realities - a review. Pediatrics 125, e973-e977 12 Taitz LS and Armitage BL (1984). Goat milk for infants and children. Br Med J (Clin Res Ed) 288, 428-429 13 Baur LA and Allen JR (2005). Goat milk for infants: yes or no? J Paediatr Child Health 41, 543 14 European Food Safety Authority (2012). Opinion of the Scientific Panel on Dietetic Products, Nutrition and Allergies on a request from the Commission relating to the suitability of goat milk protein as a source of protein in infant formula and in follow-on formula. The EFSA Journal 10 (3):2603 15 Wooding FBP, Peaker M, Linzell JL (1970). Theories of milk secretion: evidence form electron microscopic examination of milk. Nature, 226, 762-4 16 Zhou SJ, Sullivan T, Bibson RA, Makrides M (2011). How does goat milk infant formula compare to cow milk formula? A randomised controlled trial. Journal of Pediatric Gastroenterology and Nutrition, 52, E208 17 Lindquist S and Hernell O (2010). Lipid digestion and absorption in early life: an update. Curr Opin Clin Nutr Metab Care, 13, 314-20 18 Prosser CG, McLaren RD, Frost D, Agnew M, Lowry DJ (2008). Composition of the non-protein nitrogen fraction of goat whole milk powder and goat milkbased infant and follow-on formulae. Int J Food Sci Nutr, 59, 123-33 19 Singhal A et al (2013). Dietary Nucleotides and Early Growth in Formula-Fed Infants: A Randomised Controlled Trial. Published online September 13, 2010 Pediatrics Vol 126 No 4 October 1, 2010 pp e946 -e953 (doi: 10.1542/peds.2009-2609) 20 Prosser CG, McLaren RD, Frost D, Agnew M, Lowry DJ et al (2008). Composition of the non-protein nitrogen fraction of goat whole milk powder and goat milk-based infant and follow-on formulae. Int J Food Sci Nutr, 59, 123-33 21 Rutherfurd S, Moughan P, Lowry D et al (2008). Amino acid composition determined using multiple hydrolysis times for three goat milk formulations. Int J Food ci Nutr 59, 6709-690 22 Koletzko B, von Kries R, Closa R, Escribano J, Scaglioni S, Giovannini M, Beyer J, Demmelmair H, Gruszfeld D, Dobrzanska A et al. Lower protein in infant formula is associated with lower weight up to age two: a randomised clinical trial. Am J Clin Nutr.2009;89:1836-45 23 Escribano J, Luque V, Ferre N, Mendez-Riera G, Koletzko B, Grote V, Demmelmair H, Bluck L, Wright A, Closa-Monasterolo R. Effect of protein intake and weight gain velocity on body fat mass at six months of age: The EU Childhood Obesity Programme. Int J Obes (Lond) 2012; 36:548-53 24 Janas LM, Picciano MF and Hatch TF (1987). Indices of protein metabolism in term infants fed either human milk or formulas with reduced protein concentration and various whey casein ratios. J pediatr 110, 838-848 25 Janas LM, Picciano MF and Hatch TF (1985). Indices of protein metabolism in term infants fed human milk, whey predominant formula or cows’ milk formula. Pediatrics 75, 775-784 26 Rutherford SM, Darragh AJ, Hendriks WH et al (2006). True ileal amino acid digestibility of goat and cows’ milk infant formulas. J Dairy Sci 89, 2408-2413 27 Global Standard for the Composition of Infant Formula: Recommendations of an ESPGHAN Coordinated International Expert Group. Journal of Pediatric Gastroenterology and Nutrition 41:584-599, November 2005. ESPGHAN Committee on Nutrition 28 Koletzko B, Ashwell M, Beck B et al (2002). Characterisation of infant food modifications in the European Union. Ann Nutr Metab 46, 231-242 29 Grant C, Rotherham B, Sharpe S et al (2005). Randomised double blind comparison of growth in infants receiving goat milk formula versus cows’ milk infant formula. J Paediatr Child Health 41, 564-568 30 EFSA Panel on Dietetic Products Nutrition and Allergies (2004). Scientific opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow-on formula. EFSA J 30, 1-15 31 Zhou SJ et al (2014). Nutritional adequacy of goat milk infant formulas for term infants: a double-blind randomised controlled trial. British Journal of Nutrition 111, 1641-1651 32 Fiocchi A, Brozek J, Schunemann H, Bahna SL, von BA, Beyer K et al. World Allergy organisation (WAO) diagnosis and rationale for action against cows’ milk allergy (DRACMA) guidelines. World Allergy Organ J, 2010, 3(4):57-161 33 Ballabio C, Chessa S, Rignanese D, Gigliotti C, Pagnacco G, Terracciano L, Fiocchi A, Restani P and Caroli AM (2011). Goat milk allergenicity as a function of alphas-casein genetic polymorphism. Journal of Dairy Science, 94, 998-1004 34 Infante Pina D, Tormo Carnice R and Conde Zandueta M (2003). Use of goat’s milk in patients with cows’ milk allergy. Anales de Pediatria, 59, 138-142. 35 Pessler F, Nejat M. Anaphylactic reaction to goat’s milk in a cows’ milk-allergic infant. Pediatr Allergy Immuno, 2004,15(2):183-5 36 EFSA Journal (2012) 10(3):2603. Scientific Opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow-on formulae

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Beef & Gravy

with mashed potato and peas

Staying well-nourished can be a challenge for patients who have Blended atdifficulty chewing or swallowing. Thosehome on a puréed for diet are faced with: • Messy and with dissatisfying results people

dysphagia • Reduced nutritional content

• Time-consuming food preparation • The danger of not blending to a safe consistency • Reduced choice – unable to enjoy high risk foods, such as peas Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether. The good news is there is a more appetising alternative.

Made in a blender at home Staying well-nourished can be a challenge for patients who have difficulty chewing or swallowing. Those on a puréed diet are faced with: • The danger of not blending to a safe consistency • Messy and dissatisfying results • Reduced nutritional content • Time-consuming food preparation • Reduced choice – unable to enjoy high-risk foods like peas Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether.

The good news is there is a more appetising alternative…


web watch

web watch Online resources and useful updates.

NICE CG189 NICE has issued new clinical guidance: ‘Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (CG189)’. This guideline updates and replaces section 1.2 of NICE clinical guideline 43 (published December 2006). It offers evidence-based advice on the care and treatment of obesity. New recommendations have been added about low-calorie and verylow-calorie diets, bariatric surgery and follow-up care. www.nice.org. uk/guidance/CG189 Transferring renal dialysis and morbid obesity surgery services to CCGs The Department of Health has launched ‘A consultation on arrangements for the transfer of commissioning responsibility from NHS England to Clinical Commissioning Groups: Renal dialysis services and morbid obesity surgery services’. The Department wants to know what type of support CCGs will need from NHS England to be able to commission these two services safely and effectively. They are also asking whether the transfer should happen from 1 April 2015, if they can put that support in place. The results will be analysed and used to inform decisions on when and how the transfer in commissioning responsibility should be made. www.gov.uk/government/consultations/transferring-services-fromnhs-england-to-ccgs

48

New investment for treating eating disorders The new investment aimed at reforming the treatment of children and young people with eating disorders paving the way for new waiting time standards has been announced by the Deputy Prime Minister. The investment, which will be rolled out over five years, is part of an ongoing campaign by the government to bring mental health services on a par with physical care. It comes just a month after research revealed that an increasing number of young people, from as young as five, are being admitted to hospital for treatment of eating disorders, with those aged 14 to 25 most likely to be affected. www.gov. uk/government/news/deputy-pmannounces-150m-investment-to-transform-treatment-for-eating-disorders START wELL, LIVE BETTER The Faculty of Public Health has published its 12-point action plan for public health. ‘Start well, live better’ is the culmination of an extensive consultation with faculty members about the top public health priorities for this government and the next. It is not a definitive list of what needs to change; instead, it represents what members believe to be those priority areas where specific and urgent action is needed. Action that will improve people’s health and wellbeing, save lives, and give children and young people the best possible chance of achieving a healthy future are included. www.fph.org.uk/start_ well%2c_live_better_-_a_manifesto

NHDmag.com February 2015 - Issue 101

Evidence update: Hyperphosphataemia in chronic kidney disease NICE has published a new evidence update ‘Hyperphosphataemia in chronic kidney disease’ (Evidence update 72). It provides a summary of selected new evidence relevant to NICE clinical guideline 157: ‘Management of hyperphosphataemia in patients with stage 4 or 5 chronic kidney disease’ (2013). www.evidence.nhs.uk/aboutevidence-services/bulletins-andalerts/evidence-updates/evidenceupdates-by-date Vitamin D guidance for professionals and public Public Health England has published guidance, aimed at both health professionals and the public, highlighting awareness of the risks of vitamin D deficiency. ‘Vitamin D information for healthcare professionals’ aims to make health professionals aware of the significant difference they can make to people’s health be ensuring that those people most at risk, are aware of the implications of vitamin D deficiency, and most importantly, what they can do to prevent it. ‘Vitamin D: All you need to know’ is aimed at the general public and explains how vital Vitamin D is in keeping bones and teeth healthy and its importance in helping the body absorb calcium. www.gov.uk/ government/publications/vitamind-for-healthcare-professionals-andthe-public


Beef & Gravy

with mashed potato and peas

Created by our chef for people with dysphagia

…created by Wiltshire Farm Foods’ award-winning chef Our award-winning Puréed, Pre-Mashed & Fork Mashable meals make a genuine difference to the people who use them. We ensure each recipe is: • Made to the specific requirements of Category C, D or E diets • Great-tasting and visually appealing • Nutritionally balanced • Quick and easy to prepare • Increased choice – prepared to safely include high-risk foods like peas Visit www.wiltshirefarmfoods.com/dysphagiadiets or call 0800 066 3169 to request our free dysphagia brochures and help your patients put the meal back into mealtimes.


NHDmag.com

Issue 101 February 2015

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS BRIGHTON & HOVE

ISSN 1756-9567 (Print)

Lauren McCormack p9

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

Louise Dickie Specialist Stroke Dietitian

ADULT FOOD ALLERGY LACTOSE INTOLERANCE COELIAC DISEASE COWS’ MILK VS GOAT MILK

DIETETIC*/"3sWEB WATCH sNEW RESEARCH


new nHD App You can now read NHD on your tablet or smart phone for FREE! Simply search for NHD Magazine on your App Store and download.


career

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

Band 6 Dietitian - home based - South West We are currently looking for a Band 6 Dietitian who would like to move away from clinical work and into a commercial position within a leading service provider. This position is home based with travel once a week to client sites. This specific area of the business provides frozen meals to the healthcare industry and is based within the South West region, so applicants must be able to travel once a week within this area, including NW, Midlands etc. Interviews are to be held as soon as possible, so if you feel you may be interested, or would like to see a full Job spec, then please either call Hayley at Elite on 01277 849 649 or email hayley@eliterec.com Renal Dietitian, Band 6/7 - Cheshire We are looking for a Renal Dietitian Band 6/7 to commence mid-February for a period of three to four months, preferably a car owner/driver as some cover will be needed at a satellite unit. Hours negotiable full time/part time. Please call 01277 849649 or email hayley@eliterec.com www. elitedietitians.com Band 6 Community Dietitian - Berkshire Band 5/6 Community Dietitian required to cover GP clinics, inpatient community wards, nursing homes and local clinics. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com Band 5/6 Paediatric Community Dietitian Hertfordshire Band 5/6 Paediatric Community Dietitian required four days a week covering general clinics. Case load will include: allergies, weight management, faltering growth and fussy eating. Experience in children’s diabetes and paediatric home enteral feeding would be an

advantage. Case load is all outpatient based so ability to travel between bases and places of work is needed. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com Band 5/6 Community Dietitian - NW England North West England Band 5/6 Community Dietitian is required to cover a nutrition support role covering clinics and home visits, applicant must have own transport. Starting as soon as possible, full time until the end of March. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com Band 6 Paediatric Community Dietitian Essex Band 6 Paediatric Community Dietitian required to cover either a full- or part-time role. A car will not necessarily be required as this role could be based at one site doing clinics. To start ASAP until end of March. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com Specialist Dietitian - Eating Disorders Band 6 Specialist Dietitian with experience of eating disorders for an ongoing contract. This is a hospital-based post in the South of England. For this and similar jobs, please contact Patrice at PJ Locums on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums. co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

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) 52

NHDmag.com February 2015 - Issue 101


career

events and courses University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • IBS & the Use of the FODMAPs Diet Study Day 18th March 2015 • Nutrition Support Module - 22nd & 23rd April, 27th May For further details please contact Marie Coombes via e-mail on marie.e.coombes@nottingham.ac.uk or check out the University website at www.nottingham.ac.uk/biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’. Twitter for Clinicians & Healthcare Managers

25th February A Practical Guide to developing your skills in Social Media Hallam Conference Centre, London www.healthcareconferencesuk.co.uk/social-mediatwitter-nhs ASO Conference: Satiety - From Origins to Applications

3rd March Association for the Study of Obesity Institute of Child Health, London www.aso.org.uk/conferences/

The

Number 1 agency for

Dietetic Recruitment Elite Recruitment are a specialist supplier to private hospitals & commercial companies. We are a preferred supplier to NHS trusts nationwide and are the only agency dedicated to dietetic recruitment.

JOB OF THE MONTH

PAEDIATRIC DIETITIANS URGENTY REQUIRED We are urgently looking for experienced paediatric dietitians to cover posts in Hertfordshire, London and Essex. We have Full and Part Time Posts available in both Acute and Community. Excellent rates of pay – up to £30.00ph.

For these and more jobs, call the Dietetic Recruitment experts;

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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 February 2015 - Issue 101

53


The final helping

Neil Donnelly’s Diary

Neil Donnelly

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

54

I have a plan. To be fair, ever since I can remember, I have gathered my thoughts at the very end of one year and put them, together with any plans for the next, in my new diary. This year has been no exception, except that social activities and events now seem to be well catered for in the ‘working’ week. For me, this has always been a very useful and beneficial exercise. This year, it includes the regular birthdays, anniversaries, holiday dates, Preston North End FC home games, Wales Rugby Union matches, music festival (last year it was the Secret Garden Party in Abbots Ripton, Huntingdon, Cambridgeshire; this year we are heading off to Festival Number 6 in Portmeirion, North Wales) etc. Where is this heading I hear you ask? Well, my diary will also include a few tasks, hopes and professional activities that I would wish to consider either undertaking or maintaining. One of these has always been to look after my own health, which includes weight, as much as I can. For someone who has always enjoyed participating in sport and has spent all his professional life working under a weight management umbrella, (my final year University dissertation in 1970 was entitled ‘fitness and fatness’), I understand and appreciate the huge health benefits that this gives which echo through all my activities and also forms the backbone of my diary, if not my life. So, my agenda for the first couple of months of 2015 is to declutter my ‘stuff’. This is going well. I also set myself the small task of addressing the obesity problem, particularly with reference to its demands on the NHS, through the pages of this publication and the possibility of a United Kingdom Obesity Party (UKOP). This hybrid seedling has failed to germinate. Without going into any details, I guess

NHDmag.com February 2015 - Issue 101

2015

it’s no surprise. As I write, I hear that four out of five adults who listed losing weight as their New Year’s resolution have already thrown in the towel. Why should we expect anything other than a half-hearted whim to elicit a change in behaviour that needs to last months if not years? What was I thinking? We are in second place behind Hungary (very apt) of the 26 nations in Europe’s Obesity League. Individuals and institutions are groaning under the weight of ‘feasters, emotional eaters and constant cravers’ who are barricading our hospital beds. It’s a no go political nightmare when you are likely to alienate at least 25 percent of the population. I returned home last Thursday evening and listened to Question Time on the BBC which of course will now have a question about the NHS every week up to the election in May. Obesity is mentioned, but never dare to question that it forms part of an individual’s responsibility to manage their weight and reduce their likelihood for future demands on the service. I take my hat off to the work of the National Obesity Forum and their representatives, usually Tam Fry and David Haslam, who are saying what the politicians daren’t say. “As a country we need to do more. We should be under no illusions. Obesity has the potential of breaking the NHS.” I have just checked my diary and see that we have a weekend in London booked in February. Must make sure I go on the recently renamed Coca-Cola London Eye! “Keep dancing”.


My COPD means my appetite hasn’t been very good... ...so I started taking Fortisip Compact Protein. It’s very easy to take and I feel like I’m getting better. Ron; Camden

• Low 125ml volume and easy to take • The most protein-rich, energy-dense nutritional supplement on the market • Better compliance1*

Why change to anything else?

*Greater compliance (91%) has been shown with more energy dense supplements (™2kcal/ml) ml) such as Fortisip Compact Protein when compared re ed to standard oral nutritional supplements. Reference: 1. Hubbard GP et al. Clin Nutr 2012:31;293–312. Nutricia Ltd., White Horse Business Park, Trowbridge, Wilts. BA14 0XQ. Tel: 01225 751098. www.nutriciaONS.co.uk SCC2646-11/14

Right patient, right product, right outcomes


lift the growth curve with Infatrini

When a child’s growth slows down, support catch-up growth with Infatrini • Higher energy in a smaller volume – 1kcal/ml • Optimal percentage energy from protein (10.3%)1 • Nutritionally Complete (up to 9kg or 18 months) • Supported by evidence2-4 • NOW with increased calcium & vitamin D to support normal bone growth and development5-7 • NOW with improved LCP ratio (0.35% AA & 0.35% DHA) • Nucleotides similar to breast milk levels8

PER 100ml

Kcal Protein

101 2.6g GOS/ Fibre g FOS

0.6

Ready to use 125ml and 200ml bottles and 500ml pack

Infatrini is a Food for Special Medical Purposes for use under medical supervision, after full consideration of all the feeding options, including breastfeeding. Infatrini is a nutritionally complete, energy dense, ready to use feed for the dietary management of infants (from birth up to 18 months or 9kg in body weight) with faltering growth, or who have increased nutritional requirements and/or require fluid restriction.

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

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NHD Magazine February 2015  

Issue 101

NHD Magazine February 2015  

Issue 101