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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

NHDmag.com

December 2016 / January 2017: Issue 120

Children and fussy eating WHOLEGRAINS HEAD & NECK CANCER EATING DISORDERS 5-A-DAY CAMPAIGN

Chronic kidney disease Pages 16 to 18

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FROM THE EDITOR

WELCOME Emma Coates Editor

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.

Welcome to our final issue of 2016. It has been another successful year for NHD. We’ve published over 70 articles during 2016 which have been exceptional in their quality providing a wealth of information and making great reference points for dietitians, nutritionists and students for the future. This has been a year where, it seems, anything can happen: Brexit, Team GB’s Olympic success, British astronaut, Tim Peake in space, Donald Trump for USA President and the unmentionable - the redesign of the Toblerone. The NHD team is already looking ahead to 2017; we aim to bring you more relevant, up-to-date and insightful features. Our combined December/January issue, as always, is no exception. Our Cover Story, Fussy eating, is often a topic of conversation amongst parents and healthcare professionals. Read through any parent/toddler social media forum, or during parental meeting opportunities at play groups, schools and social play dates, and you will hear discussions and concerns about fussy eating and what to do about it. Specialist Paediatric Dietitian, Paula Hallam, has provided an excellent overview of this much deliberated topic, informing us on how to recognise fussy eating and how to advise parents. Based in Italy, Melanie Steinmair is a nutritionist working with chronic kidney disease patients. She takes us through the evidence to support the use of low protein food products in the nutritional management of CKD; a common practice still in Italy, which has been left behind here in the UK. A variety of health benefits have been attached to wholegrains, one benefit of particular interest is their impact in weight management. Maeve Hanan RD discusses the current evidence and advice surrounding their use and efficacy as part of weight management advice.

Rebekah Smith RD explains how dietary and lifestyle choices can contribute to the development of head and neck cancers, incorporating a case study from her current caseload, which demonstrates current advice and recommendations for this patient group. There is a lot in the news and online about vitamin D and the risks of deficiency now we’re well into winter. It’s highly recommended that those at high risk should take a supplement all year round. We have two articles this month on vitamin D; Jacqui Lowden RD explores the current vitamin D recommendations. Our regular feature in association with PENG comes from Linda Cantwell, Community Home Enteral Feeding Dietitian, who takes us through a Watch and Learn resource - a dietitian’s account of nasogastric feeding, which relates to experience shared in a video diary by Sean White, Home Enteral Feeding (HEF) Dietitian in Sheffield. And if that’s not all, Specialist Eating Disorders Dietitian, Emma Hall RD provides us with information on dietetics specifically relating to Eating Disorders on the general medical ward; Ursula Arens contributes with comment and insight into the Mediterranean Diet and food and skin colour; Dr Emma Derbyshire enlightens us on the controversial use of palm oil in foods, and student Bethany Florey reviews the government 5-A-Day campaign. Don’t forget to take a look at the resources on our website too at www. NHDmag.com. Merry Christmas and a Happy New Year to you all. Emma

www.NHDmag.com December 2016 / January 2017 - Issue 120

CONTENTS

11 COVER STORY Fussy eating in toddlers and young children

News

Latest industry and product updates

32 On behalf of PENG A dietitians account of nasogastric

8 MEDITERRANEAN DIET What does it mean?

tube feeding

34 Palm oil Use in the infant food market

38 5-A-DAY CAMPAIGN Is it working?

16 Chronic kidney disease The role of low protein foods 19 Wholegrains Benefitting weight management

41 50 shades of skin How diet affects skin colour

23 HEAD & NECK CANCER Dietary considerations 27 Vitamin D update Guidance and recommendations 30 Eating disorders Management in hospital wards

43 Web watch Online resources and updates 46 Events & courses, dieteticJOBS Dates for your

diary and job opportunities

47 The final helping The last word from Neil Donnelly

Copyright 2016. All rights reserved. NH Publishing Ltd. 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.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst

Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

@NHDmagazine

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com December 2016 / January 2017 - Issue 120

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NEWS

FOOD FOR THOUGHT

Dr Emma Derbyshire PhD RNutr Nutritional Insight Ltd Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk We would love to hear from you.

Future Food-Tech: emerging solutions I went to the Future Food Tech Conference on 3rd and 4th November which focused on current innovations in food and health. Not surprisingly, emerging solutions to future demands for protein was on the agenda, along with a re-emerging interest in GMO foods. To me, ‘clean’ meat, which is cultured meat grown ‘outside’ the animal’s body from animal cells and GMO foods, seems to go against the trend of ‘natural’ which appears to be driving the current food market. Before huge pots of investment are poured into these, I think we need to ask the real question of whether these would really be accepted. I was slightly disappointed not to see innovation in other areas, for example, new oils, rather than the excessive use of palm oil. To me, this is probably having a greater impact on the environment via intensive deforestation of the rainforests, yet rarely gets a mention compared to meat. If you dig deep enough, some supermarkets are subtly making a shift towards using ‘sustainable’ palm oil, but it seems to be a rather taboo subject (see page 34 for more on palm oil). I would have also liked to have seen more in relation to innovative food developments and the testing of these from a health stance. For example, as we see later on, alternative-dairy products are on the rise, but how do these compare to traditional products with regard to nutrient bioavailability? The development and testing of fortified food products aimed at niche populations groups in need of these would have also been interesting to see. In summary, I, (along with the investors) was not convinced by the future of alternative proteins. When we look at the data, protein is not something that we are short of, or that we under consume. When put it into real context, if we eat meat in moderation and better utilise pulses and lentils, then we are probably there. When it comes to supporting the environment, we perhaps need to look at the bigger picture. VITAMIN D: ARE ORAL SPRAYS THE WAY FORWARD? When we consider nutritional supplements, we automatically think of tablets or capsules which can be hard to swallow. New research, published in the British Journal of Nutrition has now compared the bioavailability of vitamin D3 in capsules to oral sprays. A total of 22 healthy adults took part in a randomised crossover trial, taking 75µg vitamin D3 from capsules, or an oral spray for four weeks. Overall, scientists did not detect any statistically significant differences between the two groups. These findings indicate that oral sprays may be an effective alternative, providing that they are used on a daily basis like supplements. These could be of particular benefit to older populations, or those who cannot tolerate swallowing supplements. Larger studies are now needed to reconfirm findings. For more information, see Todd JJ et al (2016) British Journal of Nutrition Vol 116, Issue 8, pg 1402-8.

www.NHDmag.com December 2016 / January 2017 - Issue 120

NEWS

PRODUCT / INDUSTRY NEWS

LOW PROTEIN CONTENT FORMULAS AND INFANT GROWTH Infant nutrition is recognised as an important window in helping to support appropriate weight gain and prevent childhood obesity. Now, new research has looked at whether lowering the protein content of infant formula could help to regulate infant weight gain. The article published in the American Journal of Clinical Nutrition analysed data from 11 randomised controlled trials comprised of 1,882 healthy infants. At age four months weight, length and BMI comparisons were made between those fed a lower protein infant formula, 1.8g/100kcal (lower than most current formulas) and breastfed infants. Findings revealed that infant formula with lower protein content supported healthy growth that was more closely aligned to that of breastfed infants and World Health Organisation (WHO) growth standards. These are important findings and worthy of further exploration, to help diminish the risk of childhood obesity. For more information, see Alexander DD (2016) American Journal of

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USING SOCIAL MEDIA IN NUTRITION RESEARCH Social media sites have revolutionised how we communicate and reach people. Unfortunately, with this, there has also been a surge in ‘unqualified’ food and nutrition bloggers. Now, two new papers have looked at how social media could be used by researchers. The first publication, published in Academic Medicine described how there is a growing demand to use social media, not only to support research itself, but also to better disseminate the findings from research which could then be used in inform health policy. Other work published in the Journal of Medical Internet Research compared whether recruiting pregnant women using Facebook

(paid advertisements) was more effective than traditional approaches. Facebook advertisements generated high rates of interest quickly and were half the cost of traditional approaches. Facebook was also more effective in recruiting women earlier on in their pregnancies, suggesting that is could be a useful tool in helping to access population groups that are typically under-represented. Overall, social media could be a useful tool in helping to combat the challenges of recruitment. It is also important that evidencebased findings are disseminated via socialmedia to help inform evidence-based policy and gain balance against the emergence of unqualified tweeters. For more information, see Meisel ZF et al (2016) Academic

Medicine Vol 91, no 10, pg 1341 and Adam LM et al (2016) Journal of Medical Internet Research Vol 18, no 9 pg e250.

www.NHDmag.com December 2016 / January 2017 - Issue 120

FOOD & DRINK

MEDITERRANEAN DIET: WHAT DOES IT MEAN EXACTLY? Ursula Arens Writer; Nutrition & Dietetics

The term â&#x20AC;&#x2DC;Mediterranean Dietâ&#x20AC;&#x2122; is a popular shorthand for a selection of foods claimed to reduce the risk of cardiovascular disease and several other health conditions. But does the term relate to geography? Or history? Or science?

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years.

The geographer would observe that there are 23 countries that border the Mediterranean Sea. In practice, the Mediterranean Diet refers to food patterns observed in only two and a half of these: Greece, Spain and Southern Italy. The focus on the diets of 10% of Mediterranean countries, must be credited to Ancel Keys, who first measured blood lipids and dietary data from different countries and then developed his equation predicting the association between intakes of fats and blood levels of LDL. He was the first to champion (in the United States), the health benefits of diets low in saturates and can claim ownership of scientific interest in the English-speaking world of the health benefits of olive oil. Of course, the Greeks and Italians and Spaniards have never needed scientific data to confirm their love of this food. There are many descriptions of traditional Greek/Italian/Spanish diets in culinary literature, but the Blue Zones project, developed by American journalist Dan Buettner, provides excellent current dietary descriptions from the very elderly,

in five areas of the world with the longest healthy-life expectancy (see Table 1). Two of the five zones are Ikaria in Greece and the Province of Ogliastra in Sardinia. The others are in Japan, Costa Rica and California. The diets observed in Ikaria are high in fat, from olive oil and fullfat dairy, and contain lots of starch from daily potatoes and white bread. Intakes of green vegetables and legumes are high; intakes of meat are occasional and in small amounts, and fish intakes are low. The diets observed in Sardinia are lower in fat than those in Ikaria, but also high in starchy foods, such as potato, white bread and pasta. Proteins are mainly from beans, chickpeas and nuts, with occasional small intakes of meat. Fish and poultry are rarely consumed. Fresh and dried fruits are small daily additions, as is red wine. These diets are high in vegetables and legumes and olive oil is consumed daily. However, these diets are nearvegetarian, and very high in starchy foods in the form of potatoes and white bread and pasta. Dairy foods are daily items from goat/sheep sources rather

Table 1: Foods consumed by the very elderly in Greece and Sardinia Greece Daily: green veg (wild greens, herbs, cabbage, lettuce,), veg (onions, peppers, tomatoes, courgette, aubergine), potatoes, sourdough bread, pasta, legumes (black-eyed beans, chickpeas), fruit (lemons, apricots/peaches), feta cheese, goat milk, olive oil, herbal teas, coffee, red wine, honey Other: meat 1x week (goat or sheep), fish 1-2x month (fresh or dried) Sardinia Daily: veg (onions, tomatoes, courgette, aubergine, fennel), potatoes, pasta, fruit (cherries, pears, melon), sourdough or flat bread, legumes (fava beans, chickpeas), goat and sheep milk and cheese, olive oil, barley, coffee, red wine Other: meat 1x week (sheep, pigs), fish, poultry <1x month, almonds

www.NHDmag.com December 2016 / January 2017 - Issue 120

Figure 1: The Med Diet Pyramid (from www.medfoodcultures.org/)4

than bovine and always full-fat. Fresh fruits are consumed daily in season and very small amounts of further sweets are consumed as honey and occasional pastries. The largest investigation of the health benefits of the Mediterranean Diet is the PREDIMED study (primary prevention of cardiovascular disease with Mediterranean diets),3 and parentage of the PREDIMED study is directly attributed to the impressive outcomes of the Lyon Diet Heart Study.1 This randomised 600 French adults after a first myocardial infarction, into either a prudent healthy diet or a Med Diet. The latter were advised to consume more bread, fish and fruit and reduce intakes of red meat. Further, they were supplied with rapeseed oilbased margarine. Dietary assessment showed that in the Med Diet group, intakes of saturated fats were slightly lower and that intakes of oleic acid were slightly higher. Most significantly, the complete replacement of butter with margarine resulted in a three-fold increase in dietary alpha-

linolenic acid intakes. The Med Diet group showed impressive protective effects from adverse cardiac outcomes, but there was considerable subsequent debate as to mechanisms, as outcome measures of serum LDL or blood pressure did not vary between the two groups. The offspring PREDIMED study2 randomised 7,000 Spanish adults who were assessed as being at high risk of cardiovascular disease. The control group was given dietary advice on a healthy lower fat diet, while two other groups were given dietary additions of either one litre of olive oil per week per family, or about 200g of nuts (walnuts/ almonds/hazelnuts) per week per person. The results after five years showed a 30% reduction in cardiovascular events and in stroke, compared to the control diet subjects. Confusions occur because 99% of the control group (being Spanish) also stated that olive oil was their main culinary oil, and nearly 60% stated that they consumed more than four tablespoons per day (although this was lower than the 93% in the olive oil group). Bottom line: diets high in some fats, maybe especially olive oil and/or nuts, seem more cardioprotective than advice to reduce total intakes of fats. So, why do Mediterranean Diet guides promote low fat dairy items or wholegrain breads/cereals (see Figure 1). Also not Mediterranean Diet-ish are, for example, quinoa, avocados, bananas, dark chocolate, soya foods, or other foods that can be promoted as healthy. The science meaning and the cultural meaning must hang together or the currency of the term will devalue and misleading marketing claims gain a toehold.

References 1 De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N (1999). Mediterranean Diet, traditional risk factors and the rate of cardiovascular complications after myocardial infarction: final report to the Lyon Diet Heart Study. Circulation 6, 779-85 2 Estruch R, Ros E, Salas-Salvado J et al (2013). Primary prevention of cardiovascular disease with a Mediterranean Diet. New England Journal of Medicine 368, 1279-90 3 www.Predimed.es 4 www.medfoodcultures.org/files/download/phn%20new%20md%20pyramid.pdf

www.NHDmag.com December 2016 / January 2017 - Issue 120

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COVER STORY

FUSSY EATING IN TODDLERS AND YOUNG CHILDREN Paula Hallam Registered Dietitian

Many parents struggle to teach their children healthy eating behaviours because food rejection behaviours, such as fussy eating and neophobia, are so common in preschool children.2

Paula is a Clinical Dietitian at Great Ormond Street Hospital for Children in the Metabolic Team, working predominantly with children with PKU and their families. She is also a Freelance Paediatric Dietitian, director of ‘Tiny Tots Nutrition Ltd’ and mum to two girls.

Fussy eating can cause a huge amount of distress and anxiety in families, but in their attempts to increase healthy food intake, parents may use strategies that actually hinder the development of healthy eating habits.3 Many people may have seen the news recently stating that ‘fussy eating is all in the genes’, but this is only one piece of the very complicated puzzle of food behaviour in young children. The news report is based on a twin study1 from researchers in London and Norway. The study results suggest that there is significant genetic influence on both food fussiness and food neophobia (FN) during early life, but that shared environmental factors (for example, the home environment) influenced the development of food fussiness more so than FN.1 Fussy eating, also known as picky, faddy or choosy eating, is sometimes seen as being on a spectrum of ‘feeding difficulties’, where fussy eating is the most common form on one end with severe eating disorders at the other.4 However, this is not a universally agreed view and other researchers view fussy eating as having characteristics that are completely distinct from feeding disorders.5 Most researchers agree that fussy eating is a normal part of toddler development with a peak occurrence at around two to six years of age. At present, there is no single widely accepted definition of fussy eating and, therefore, little consensus on the appropriate measure of assessment.6 A definition that is favoured by the authors of a recent review6 is the following:

For a list of useful resources and full article references please email info@ networkhealth group.co.uk

“An unwillingness to eat familiar foods or try new foods, severe enough to interfere with daily routines to an extent that it is problematic to the child, parent or childparent relationship.” Other definitions include: ‘Consumption of an inadequate variety of food through rejection of a substantial number of foods that are familiar, as well as unfamiliar; this may include an element of food neophobia and can be extended to include rejection of specific food textures.’ 7 ‘Limited number of food items in the diet, unwillingness to try new foods, limited intake of vegetables and some other food groups, strong food preferences (likes/ dislikes) and special preparation of foods required.’ 8 These definitions all have a common theme of fussy eating, referring to an inadequate or limited variety of foods through rejection of a significant amount of foods that are both familiar and unfamiliar to a child. OVERLAP WITH FUSSY EATING

Food neophobia is generally regarded as the reluctance to eat, or the avoidance of, new foods.6 The term has been derived from earlier work of Rozin and Vollmecke in the 1980s, described as ‘omnivore’s dilemma’.9 It is thought that food neophobia was an evolutionarily beneficial survival mechanism to help children avoid ingesting toxic chemicals in their environment. In order to avoid eating potentially poisonous plants, children will naturally reject bitter tasting foods.6 However, in the modern world,

www.NHDmag.com December 2016 / January 2017 - Issue 120

From about seven to eight months of age, your baby will want to hold

food and attempt to feed themselves. This can be a messy phase, but try to put up with the mess, as your baby needs to learn this process!

these behaviours can provide a barrier to the acceptance of new foods5 and this can result in a limited diet lacking variety, which in turn can lead to concerns about nutrient composition and adequacy of children’s diets. Food neophobia is seen in all omnivores and resolves with repeated exposures.8 PREVALENCE OF PICKY/FUSSY EATING

Worldwide estimates of the prevalence of picky/ fussy eating range widely from 6% to 50% in different studies.6 Tharner et al11 reported a prevalence of 5.6% in four- year-olds in the Netherlands, whilst Carruth et al12 reported a prevalence of 50% in two-year-olds in the USA. The variations in the definition of picky/ fussy eating and the differences in methods of assessment used in studies, leads to this wide range of reported prevalence, which can differ even within the same study.6 UK prevalence Avon Longitudinal Study of Parents and Children (ALSPAC) is a longitudinal populationbased study investigating environmental and genetic influences on health, behaviour and development of children.13 In the ALSPAC study, a single question was used to assess picky/fussy eating and this question was asked at four time 12

points up to five years (24, 38, 54 and 65 months): Q: Does your child have definite likes and dislikes as far as food is concerned? A: i) No ii) Yes, quite choosy iii) Yes, very choosy The overall prevalence of picky/fussy eating was calculated from the number of cases that reported ‘Yes, very choosy’ at >2 time points. In the ALSPAC study the prevalence of picky eating at each age was between 9.7% and 14.7%.6 There was a clear peak age for picky eating, which was 38 months. FACTORS INFLUENCING THE DEVELOPMENT OF FUSSY EATING BEHAVIOURS

Early feeding Some studies have found that fussy eating is associated with reduced duration of breastfeeding and early introduction of complementary foods.14,15 However, this is not a consistent finding and some studies have found no difference in neophobia or pickiness scores between children who were breastfed or formula-fed, or a mixture of both.16 This study also noted that there was no association of weaning age with the scores. From a different perspective, another research group found an association between sucking

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PAEDIATRIC patterns at two to four weeks of age and the later development of picky/fussy eating.17 Food groups Several studies have identified associations with fussy eating with intakes of particular food groups.6 Some researchers have found a strong association between the mother’s food likes and dislikes and those foods that her children will try/eat.18 This illustrates that it is important to encourage parents/carers to set a good example of healthy eating for their children to see and copy. Another common finding is a decreased intake of fruits and vegetables by picky eaters, when compared to non-picky eaters. In particular, an avoidance of vegetables has been found to be very common in several studies of picky eaters.6 Intakes of savoury snacks and confectionery has been reported to be higher in 14-month-old picky eaters,10 although no difference in energy intake was reported between picky and nonpicky eaters, suggesting that the savoury snacks and confectionery items were replacing more healthy food options.10 Could these differences reflect the early signs of picky/fussy eating, or, indeed, could they contribute to the development of picky/fussy eating at a later age? The debate continues… Dietary fibre Constipation has been found to be associated bidirectionally with higher food fussiness at age four years,10 meaning that a lack of dietary fibre in a child’s diet can be both a cause and a result of food fussiness. Most studies looking at dietary fibre intake in children who are fussy eaters, have found a reduced intake of wholegrains and of vegetables.6 Most studies also found that both groups of children (those who were fussy eaters and those not) had a fibre intake below the recommended intake. NUTRIENT INTAKES

Few studies have investigated the effect of picky eating on nutrient intakes,6 but the issue of inadequate nutrient intake remains a major concern for parents of fussy eaters. Most studies have found an overall adequate energy intake in children who are

picky eaters, as well as adequate intakes of protein, carbohydrates and fats, when compared to non-picky eaters. However, a few studies have found slightly lower energy intakes in children who were picky eaters compared to non-picky eaters.18,19 Intakes of calcium, zinc, iron, vitamin D and vitamin E have been found to be below recommended nutrient intakes18 in picky eaters, but another study found that the low micronutrient intakes occurred in both the picky and non-picky eaters.20 WHEN IS FUSSY EATING A CONCERN?

Understandably, parents of fussy eaters are concerned about their children’s nutrient intakes. However, there is no clear evidence that nutrient intake differs very much between fussy and nonfussy eaters.6 However, it is very important to listen carefully to parents/carers and take their concerns seriously. In my opinion, these situations should be investigated further: Poor growth - If a child is falling off the centile charts (dropped by two or more weight centiles), or has not grown in height, a referral to a paediatrician for an assessment would be appropriate. Extremely limited food intake - If a child will eat less than 10 foods, or if a child is extremely specific about the brands or flavours of foods that they will eat, then you should discuss the child with a paediatrician and consider referral to a multidisciplinary feeding team. This extreme form of fussy eating is seen more often, but not exclusively, in children with Asperger’s Syndrome, or autism, or in children who have traits in common within this spectrum of disorders.21 Sensory sensitivity - If a parent reports that their child is extremely over-sensitive to sounds, lights, touch and tastes, you may suspect that a child has a sensory processing disorder. In this case you should discuss the child with their paediatrician and consider a referral to a multidisciplinary feeding team consisting of an occupational therapist, speech and language therapist and a dietitian.

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PAEDIATRIC HELPFUL If you TIPS are worried a child, always TO OFFERabout PARENTS/CARERS discuss withto another healthcaremanage fussy eaters: Here areyour someconcerns of my top tips help parents/carers professional. TOP TIP 1: Develop a routine for mealtimes and snacks

Make sure you offer meals and snacks at the same time each day (more or less) so that your child knows what to expect. This also ensures that your child does not become over hungry or too tired to eat. Offer three meals and two to three ‘well-timed’ snacks per day - not too close to mealtimes. Try not to allow your child to graze on food all day, but offer plenty of opportunities for access to nutritious foods. TOP TIP 2: Try to recognise signals for when your child has had enough to eat You decide WHAT your child eats and let them decide HOW MUCH they eat. Your child is telling you that they have had enough when they do the following: Say no! Keep their mouth shut Turn their head away Push away a spoon or fork Hold food in their mouth Spit food out Gag or retch TOP TIP 3: Check fluid intake from milk and other drinks If a child is full up on juice or milk, they will not have an appetite for their food. Use a drinking cup for water/ diluted juice/milk and try to phase out feeding bottles by about 12 months of age, as this will automatically decrease the amount of milk that your child drinks. Also, do not offer large amounts of juice/milk just before a meal, as this will fill up small tummies! Between the ages of one and three years, a child needs a maximum of 350ml of milk per day (less if taking other dairy products like yoghurt and cheese), to meet their calcium requirements. TOP TIP 4: Encourage self-feeding and offer small portions From about seven to eight months of age, your baby will want to hold food and attempt to feed themselves. This can be a messy phase, but try to put up with the mess, as your baby needs to learn this process! Offer finger foods at each meal and allow your toddler to hold the spoon or fork themselves, even if most of the food does not make it to their mouths…they will get the hang of it eventually! Try to offer small portions so that your child is not overwhelmed by the amount of food in front of them. TOP TIP 5: Try to eat together as a family as often as possible These days, with everybody’s very busy and hectic lifestyles, families often don’t eat together anymore. Try to make this a priority to eat together as often as you can - even if it is only on weekends. Also try to get your child eating together with other children, as some children eat better when with others. Remember…children learn by copying others! TOP TIP 6: Involve children in food preparation Children love to be involved with food preparation - get creative and start cooking with your children. Allow them to choose a recipe (with your guidance!) and choose the ingredients together. Children can help with measuring/weighing foods, cleaning/chopping up vegetables (watch the sharp knives) and stirring foods together. Research shows that children are more likely to try foods that they have helped to prepare. TOP TIP 7: Check for medical causes Constipation and iron deficiency anaemia can decrease a child’s appetite. Previous negative/unpleasant experiences around food and eating, such as pain, vomiting or gastro-oesophageal reflux can also affect a child’s eating behaviour. If you suspect your child may have one of these conditions, speak to your GP or Health Visitor.

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CONDITIONS & DISORDERS

NUTRITIONAL TREATMENT IN CHRONIC KIDNEY DISEASE Melanie Steinmair Company Nutritionist, Dr SchĂ¤r AG/Spa, Italy Melanie has gained experience in healthcare marketing, nutritional counselling and scientific studies through working in industry. She specialises in renal, metabolic and ketogenic nutritional advice and guidance. Her major interests include nutritional therapies and sports nutrition.

This article looks at the dietary management of chronic kidney disease (CKD), describing the dietary approach commonly used in Italy and some other European and Non-European countries. The use of low protein foods in the management of this condition is not routinely used in the UK. Here we look at this approach, along with current findings and evidence to support its use. CKD is a progressive and irreversible loss in kidney function over a period of months or years. The conservative treatment in the early stages (I-III) consists in pharmacological as well as nutritional therapy, with the aim to preserve the kidney function as much as possible over time. Renal replacement therapy, namely dialysis or renal transplantation, is required in the terminal stages of the disease (IV-V) and comes along with a reduced quality of life on one hand and an increased mortality rate on the other. Environmental risk factors for the development of CKD, like obesity, diabetes mellitus and hypertension, have increased significantly all over the world in the last few decades.9,10 Surveys report a wide range of global CKD prevalence in all of its five stages, varying from approximately 5-13% in the general population. Besides methodological issues, both genetic and environmental factors, such as eating habits, may play a major role. Recent observations have shown a variability of CKD trends over time, where prevalence is stable, or even decreasing in some countries.6 RATIONALE AND AIMS OF NUTRITIONAL TREATMENT

In the 1960s, dialysis was not available as a valid treatment option, which is why dietary recommendations in terms of protein reduction and adequate energy supply were the only options to manage CKD 16

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symptoms and to prolong survival.8 After the Modification of Diet in Renal Disease (MDRD) study in the early 1990s, which showed that nutritional treatment is not as effective concerning the retardation of disease progression as initially expected, its application decreased in most countries, especially in those where dialysis techniques became more and more efficient.11 Nevertheless, there is strong evidence to support the efficacy of nutritional treatment in CKD in predialytic patients in order to protect the residual renal function and to slow down disease progression. Consequently, dialysis initiation can be postponed by approximately one to two years, increasing quality of life for the patient and reducing costs for the sanitary system.7,13 Nutritional treatment is efficient for metabolic and fluid control, as well as for the prevention and correction of metabolic complications like aciduria and proteinuria. A primary aim of nutritional recommendations is the prevention of protein-energy malnutrition in advanced CKD, ensuring a balanced protein-energy intake via an appropriate food choice.2 DIETARY RECOMMENDATIONS

Clinical practice guidelines for the conservative treatment of CKD focus predominantly on the quantity of nutrients, recommending an appropriate energy intake (30-35kcal/kg body weight per day) and restrictions of

Nutritional guidelines and clinical practice should always focus on dietary quality and achieving a balance where quality of life is also considered.

protein (0.6-0.8g/kg body weight per day) and minerals (sodium, potassium, phosphorus).4,3,14 Dietary restrictions, together with economic and social factors, may induce a suboptimal quality of the diet. In fact, potassium restriction can result in a reduced consumption of fruits and vegetables, which are also rich in minerals and vitamins and may, therefore, lead to insufficient nutrient intake. In addition, protein restriction may cause a loss of energy intake, especially if dietetic counselling is missing to give important recommendations about appropriate food choice and portion sizes. Protein quality plays an important role when it comes to the risk management of cardiovascular diseases as a frequent CKD complication. In observational studies, the Mediterranean Diet, which is rich in fruits and vegetables, fibre and unsaturated fats (olive oil, fish) with moderate alcohol consumption, is associated with increased survival and slower disease progression in CKD patients.9,12 Consequently, an appropriate consumption of fish and vegetable oils, like olive oil, should be recommended to renal patients for their high content of unsaturated fatty acids. On the other hand, red meat and foods rich in saturated fats (butter, cheese, cold cuts, pastries and cakes) should be reduced because of their negative impact on the development of cardiovascular diseases.4 ROLE OF LOW PROTEIN FOODS

Low protein versions of products, like pasta, bread, bread substitutes, snacks and sweet products, have been developed for renal patients in conservative treatment are mainly based on starch, in order to obtain a very low protein content. Moreover, they are low in sodium, potassium and phosphorus and

represent a good source of energy. Some of them are rich in fibre, which might help in managing blood glucose levels and to increase the feeling of satiety. These products can replace standard staple foods rich in protein of low biological value, allowing the intake of small quantities of animal proteins and providing a good source of energy.1,2,5 Especially in the advanced stages of CKD, these products may be a valid option for the nutritional therapy due to their high quality nutritional profile. They help to reduce disease progression and to control some complications such as protein-energy malnutrition. Furthermore, they are a valid option also in diabetic nephropathy and in elderly patients, where a high energy intake is considered of supreme importance.1,3 There is huge variability in the availability of low protein foods throughout the world and, consequently, in their application in CKD patients. In most Italian regions, low protein foods for CKD patients on conservative treatment are available and will be covered by the health system up to a defined monthly limit, similar to that for prescribed foods here in the

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CONDITIONS & DISORDERS UK for coeliac disease and metabolic conditions such as PKU. Italian healthcare professionals promote the application of the nutritional therapy in CKD patients, facilitating also patient adherence to the dietetic recommendations. In fact, Italian healthcare professionals have a longstanding tradition in implementing nutritional therapy with the use of low protein foods in the conservative treatment of CKD patients.2 CONCLUSION

Nutritional treatment has always been an important pillar in the management of CKD patients. Numerous studies demonstrated its beneficial effects on metabolic control

and reduction of disease progression. Nevertheless, the application of dietary treatment in the conservative therapy of CKD varies widely in different countries and even in different centres. The expertise of healthcare professionals, including specialist dietitians and/or their availability, the generally poor dietary adherence in patients, the varying availability of specialist foods together with economic factors, may all play a role in the variable approaches to treatment. Nutritional guidelines and clinical practice should always focus on dietary quality and achieving a balance where quality of life is also considered. This applies to both primary and secondary CKD preventions.

References 1 Bellizzi V et al. A Delphi consensus panel on nutritional therapy in chronic kidney disease. J Nephrol, 2016; 29 (5): 593-602 2 Bellizzi V et al. Low-protein diets for chronic kidney disease patients: the Italian experience. BMC Nephrology, 2016; 17: 77 3 Brunori G et al. Terapia nutrizionale nell`IRC in fase conservativa: suggerimenti di pratica clinica e di applicazione delle Linee Guida. Giornale italiano di nefrologia, 2013; www.giornaleitalianodinefrologia.it/web/procedure/protocollo.cfm?List=WsIdEvento,WsIdRisposta,WsRelease&c1=00084&c2=2 &c3=1, accessed 1 October 2016 4 Carrero JJ and Campbell KL. Diet for the Management of Patients with Chronic Kidney Disease; It is not the Quantity but the Quality that matters. Journal of Renal Nutrition, 2016; 26(5): 279-281 5 D´Alessandro C et al. Dietary protein restriction for renal patients: don’t forget protein-free foods. J Ren Nutr, 2013; 23: 367-71 6 De Nicola L and Minutolo R. Worldwide growing epidemic of CKD: fact or fiction? Kidney Int. 2016; 90(3): 482-4 7 Foque D et al. Low protein diets delay end stage renal disease in non-diabetic adults with chronic renal failure. Nephrol Dial Transplant, 2000; 15: 1986-1992 8 Giovannetti S and Maggiore Q. A low nitrogen diet with proteins of high biological value for severe chronic uremia. Lancet, 1964; 1:1000-3 9 Huang X et al. Mediterranean diet, kidney function and mortality in men with CKD. Clin J Am Soc Nephrol; 2013; 8: 1548-1555 10 Kalaitzidis RG and Siamopoulos KC. The role of obesity in kidney disease: recent findings and potential mechanisms. Int Urol Nephrol, 2011; 43(3): 771-84 11 Kalantar-Zadeh K et al. North American experience with Low protein diet for Non-dialysis-dependent chronic kidney disease. BMC Nephrology, 2016; 17:90 12 Khatri M, Moon YP, Scarmeas N et al. The association between a Mediterranean-style diet and kidney function in the Northern Manhattan Study cohort. Clin J Am Soc Nephrol; 2014; 9: 1868-1875 13 Mennini FS et al. Economic effects of treatment of chronic kidney disease with low-protein diet. J Ren Nutr, 2014; 24(5): 313-21 14 National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney, 2002; 39 (suppl 1): S145-S163

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WEIGHT MANAGEMENT

THE ROLE OF WHOLEGRAINS IN WEIGHT MANAGEMENT Maeve Hanan Registered Dietitian, City Hospitals Sunderland, NHS

Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

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

Wholegrains offer numerous health benefits as they are full of nutrients and fibre. They are also promoted to aid weight management. This article will explore the mechanisms and evidence related to this. Wholegrains are defined as the intact, ground, flaked or cracked kernels which remain after the removal of inedible parts of the grain (such as the hull and husk), with the starchy endosperm, nutrientdense germ and high fibre-bran present in the same relative amounts as they exist in an intact kernel.1,2 Wholegrains are fantastically nutritious and can contain up to 75% more nutrients than refined grains, specifically providing starchy carbohydrate, fibre (mainly insoluble fibre, but some also contain soluble fibre), protein, B vitamins, folic acid, vitamin E, omega-3 fatty acid, gut friendly short-chain fatty acids and minerals such as iron, manganese, zinc, selenium and copper.2,3 Studies have linked a diet high in wholegrains with numerous health benefits, such as a 20% reduced risk of bowel cancer and a 30% reduction in the risk of Type 2 diabetes, heart disease and stroke.2-5

POTENTIAL MECHANISMS OF WHOLEGRAINS IN WEIGHT MANAGEMENT

Wholegrains are high in starchy carbohydrates and low in fat, therefore, compared to high fat foods, they have a relatively low calorie content (4kcal per gram of carbs versus 9kcal per g of fat),2 so, displacing higher calorie food may be one reason why a diet high in wholegrains may be beneficial for weight management.6 As wholegrains generally have a low glycaemic index (GI), they slowly release carbohydrate into the blood and stabilise blood glucose levels; this, coupled with the high fibre content of wholegrains, is thought to promote satiety, control appetite and reduce urges for snacking.2 Depending on the fibre composition, it has been suggested that the mechanisms for increasing satiety include:6,7 â&#x20AC;˘ increased time and effort of chewing resulting in a slower eating rate;

Figure 1: Wholegrain anatomy

Bran

Endosperm

Protective outer shell. High in fibre and B vitamins.

Contains starch, protein and some vitamins and minerals.

Germ

The seed for a new plant. Contains B vitamins, some protein, minerals and healthy oils. Picture reference: The Whole Grains Council (http://wholegrainscouncil.org/)

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WEIGHT MANAGEMENT Table 1: Types of wholegrains* Whole wheat including spelt wheat, durum wheat, whole wheat flour, wheat flakes, bulgur wheat and buckwheat Brown rice and wild rice Whole barley including hull-less or naked barley, but not pearled Whole rye and rye flour Oats, including: hull-less or naked oats, rolled oats, oatmeal and oat flakes Maize (corn) Millets Quinoa ‘Ancient grains’ e.g. kamut, freekah *Adapted from BDA Food Facts ‘Wholegrains’2 and SACN report on ‘Carbohydrates and Health’5

• • • •

decreased gastric emptying; alteration of gut hormone secretion; slower energy and nutrient absorption; lower postprandial blood glucose and lipid levels.

EVIDENCE FOR WHOLEGRAINS AND WEIGHT MANAGEMENT

There is some observational evidence which suggests that diets high in wholegrains are associated with lower levels of obesity, for example, ‘The Nurses’ Health Study’8 found that women who consumed a high intake of wholegrains consistently weighed less than those with lower wholegrain intakes, and those with the highest fibre intake had a 49% lower risk of extreme weight gain. A recent large cross-sectional study from the US also found that ‘greater wholegrain consumption [was] associated with better intakes of nutrients and healthier body weight in children and adults’.9 Similar findings have also been reported in the UK.10 In terms of interventional trials, an early study11 relating to bread intake found that roughly 83% of subjects consumed more calories when white bread was provided compared to wholemeal bread. Similarly, Howarth et al (2001)12 found that adding 14g of fibre per day to subjects’ diets during a weight loss trial resulted in a 10% decrease in calorie intake and a weight loss of >1.9kg. However, when the current body of research was analysed by the Scientific Advisory Committee on Nutrition (SACN, 2015),5 they reported that there was insufficient evidence 20

to suggest that wholegrains have an effect on BMI, change in body weight, body fatness or fat distribution; and there was no effect identified between dietary fibre intake, GI or GL on energy intake or body weight change. Nevertheless, based on limited evidence, SACN did find that high intakes of wholegrains may decrease total energy intake and an association was also found between high carbohydrate low fat diets and a lower BMI (see Table 2 opposite). SACN acknowledge that the discrepancy between wholegrain classification in different countries presented as a limitation in examining the combined effect of wholegrains; for example, in Sweden and Denmark wholegrain products must contain 50% or more wholegrain ingredients on a dry matter basis and in the UK and US wholegrain products must contain 51% or more wholegrain ingredients on a wet weight basis, whereas in Germany wholegrain bread must contain 90% wholegrain ingredients.5,13 ADVISING ON WHOLEGRAIN INTAKE

Although there are no specific UK guidelines for daily wholegrain intake, the Eatwell Guide and also the NICE guidelines on Obesity Prevention (2006) recommend basing meals on starchy carbohydrates choosing ‘wholegrain versions where possible’.14,15 Furthermore, the recent SACN report on Carbohydrates and Health5 advised that adults should consume at least 30g of fibre per day and in order to reach this a significant daily intake of wholegrains is needed.

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Table 2: Summary of relevant findings from SACN’s report on Carbohydrates and Health5 Topic

Effect Identified?

Wholegrains and energy intake

Yes - biologically relevant effect, higher wholegrain consumption is associated Limited with reducing energy intake

Diets high in carbohydrates and low in fat

Yes - biologically relevant effect, associated with a lower BMI

Limited

Oat fibre, beta-glucan and barley fibre and energy intake

Adequate

Dietary fibre intake and body weight

Moderate

Dietary fibre intake and energy intake

Moderate

Cereal fibre excluding oat fibre and energy intake

Moderate

Higher dietary fibre breakfast cereals and energy intake

Moderate

Glycaemic index (GI) and eating motivation

Moderate

Dietary fibre and body fatness in children/adolescents

Limited

Glycaemic load (GL) and weight change

Limited

GI or GL and body weight change, BMI or body fatness

Insufficient evidence

Wholegrains and change in body weight and BMI

Insufficient evidence

Wholegrains and body fatness and fat distribution

Insufficient evidence

GI and GL and energy intake

Inconsistent evidence

However, some countries have specific daily wholegrain recommendations for adults (see Table 3).16 The most recent National Diet and Nutrition Survey (NDNS) from 2012-201417 found that the average fibre intake for adults in the UK is below recommended levels at 13-14g/day, which includes fibre found in wholegrains and also fruit and vegetables. Data from the previous NDNS (2008-2011)18 has been analysed specifically for wholegrain intake, which reported that the average daily wholegrain intake (dry weight) was low, at 20g per day for adults and 13g per day for children/teenagers. Furthermore, it was found that 18% of adults and 15% of children/ teenagers did not consume any wholegrain foods.

Level of available evidence

It, therefore, appears that ongoing health promotion related to wholegrains is needed in the UK, such as advising the replacement of refined starchy carbohydrates with wholegrain versions (see Table 4). In order to maximise tolerance and minimise potential gut irritation, it is important to increase wholegrain intake gradually, drink plenty of fluid and to be physically active for at least 150 minutes per week.19 When reading food labels, it is useful to highlight that ‘multigrain’ does not indicate wholegrain (rather it means that the product contains more than one different type of grain),2 and fibre intake can be optimised by choosing ‘high fibre’ varieties of wholegrain products which contain >6g of fibre per 100g.20

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WEIGHT MANAGEMENT Table 3: Wholegrain recommendations for adults Australia

Women: 3-6 servings, men: 4.5-6 servings (age dependant). 1 serving = 1 slice of bread, ½ cup cooked rice/ pasta/noodles, ½ cup of porridge, ⅔ cup cereal ﬂakes, ¼ cup of muesli, ¼ cup of flour, 3 crispbreads, 1 crumpet.

Canada

At least 48g of wholegrains daily from age 9 onwards.

Denmark

At least 75g of wholegrains per day (based on a 2,400kcal diet); therefore ~63g per day for a 2,000kcal diet.

Sweden

75g of wholegrain per 2,400kcal diet; i.e. roughly 70g for most women and roughly 90g for most men.

United States

Women: 3-6 servings, men: 3-8 servings (age dependant). 1 serving = ½ cup cooked rice/bulgur/pasta/cooked cereal, 1 ounce dry pasta, rice or other dry grain, 1 slice bread, 1 small muffin (weighing one ounce).

Table 4: Wholegrain foods and ideas for use (adapted form: BDA food factsheet ‘Wholegrains’2)* Type of food Breakfast cereal

Bread and crackers

Flour

Meals

Snacks

Wholegrain version Whole oats including rolled oats and oatmeal Weetabix, Shreddies, Shredded Wheat, bran flakes, puffed wholegrains and wholegrain muesli Wholemeal, granary, wheatgerm, wholegrain with multi-grain, seeded, mixed-grain, soya linseed, rye (pumpernickel) bread Wholemeal tortilla Wholemeal pitta bread Whole wheat crackers or rye crispbread Oatcakes Wholemeal, wheat germ, buckwheat, unrefined rye, barley, oatmeal and oat flour Brown rice, whole barley (not pearl), bulgur (cracked) wheat, quinoa Whole wheat pasta Whole wheat noodles Wholegrain cereal bars Oats cakes Wholegrain rice cakes Popcorn (plain) Wholemeal scone Wholegrain breakfast cereals

Portion size = 1 serving 1 Tbsp 3 Tbsp

Ideas for use With milk or yoghurt and fruit for breakfast or as a snack, as a topping for crumbles, as a snack. Avoid those with added sugar and salt.

1 medium slice bread ½ tortilla ½ pitta

In place of white bread/tortillas/pitta bread, cream crackers and sweet biscuits.

2 crackers 2 oatcakes NA 2 heaped Tbsp (cooked) 3 Tbsp 1 nest 1 cereal bar 2 oatcakes 2 rice cakes 2-3 cups ½ scone 3 Tbsp

In baking or recipes in place of white flour.

In place of refined rice/pasta/noodles, in casseroles, sauces, soups, and salads.

In place of sweets, crisps and savoury snacks, cream crackers and sweet biscuits.

*There is currently no advice on what amount of wholegrains to eat in the UK but many experts in other countries say to aim for 3 servings per day.

CONCLUSION

Wholegrains have numerous health protective qualities and in the UK, we could benefit from increasing our daily intake. Specifically in relation to weight management, a high wholegrain intake may help to reduce total calorie intake and it is 22

interesting that high carbohydrate low fat diets have recently been associated with a lower BMI; however more research is needed to clarify whether wholegrain intake has a direct effect on BMI, change in body weight, body fatness or fat distribution.

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CLINICAL

THE CHANGING FACE OF HEAD AND NECK CANCER Rebekah Smith Senior Dietitian, ENT/ Max Facs

There are currently 62,530 people in the UK living with head and neck cancer and it is currently the seventh most common cancer in the UK, with 11,000 new cases being diagnosed each year.1

Rebekah qualified at Chester University in 2008 and works within the ENT/ maxillofacial setting, specialising in Head and Neck Oncology.

Head and neck cancer is treated with curative intent by surgery and/or chemoradiotherapy, which can leave patients with long-term swallowing problems that can lead to poor dietary intake with some patients requiring a long-term feeding tube. In the past, the most common causes of head and neck cancer were due to smoking and drinking to excess. An example of a typical patient would be a male in his 60s from a lower social economical background with a high smoking and alcohol history. While this cohort of patients still exists, the demographic has reduced due to the decreasing incidence of smoking in the UK. There has been an increasing trend of patients diagnosed that are tending to be younger (40s-50s), welleducated and who look after their health (never smoked and moderate alcohol consumption)2 and, therefore, a diagnosis of head and neck cancer comes as a shock to these patients.3 This centre has treated patients as young as 21. This change is due to human papilloma virus (HPV) becoming one of the main causes of head and neck cancer and has overtaken excess smoking and drinking as the main cause. Young et al2 estimate that between 70%-90% of newly diagnosed oropharyngeal cancers contain HPV. HPV positive squamous cell carcinomas (SCC) have a different molecular profile than HPV negative SCC, with HPV positive tumours sharing similarities with cervical carcinomas, making it a very different

entity altogether. The evidence available suggests that this increase is due to a change in sexual practices. Within our multidisciplinary team (MDT), the patients HPV status is commonly requested when a biopsy is being completed, looking specifically at the p16 strain. One of the reasons that HPV is looked for is that it has a significant effect on patient outcomes when treated by radiotherapy. A patient with a HPV positive diagnosis has a better outcome (i.e. are more likely to be cured) than a patient who is HPV negative due to their different molecular profile. As HPV is mostly associated with oropharyngeal cancers of the head and neck, e.g. base of tongue, pharyngeal wall and tonsils, these structures are particularly important in terms of swallowing and are often treated by radiotherapy as a primary treatment, or given after surgery. During treatment to these areas, Speech and Language Therapy is often needed to assess how safe the patientâ&#x20AC;&#x2122;s swallow is due to swelling and inflammation. Dietetic input pre-, during and post-treatment is, therefore, paramount to maximise oral intake, reassessing the need for enteral feeding and preventing malnutrition, while dealing with treatment toxicity. The identification of HPV positive carcinomas has led to a change in how radiotherapy is given to these patients, with this patient group being given a lower dose of radiotherapy (De-escalate),4 which, in turn, may help to reduce some of the long-term

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CLINICAL

Some studies have shown

that specific foods, such as citrus fruits, green leafy

vegetables, carrots and fresh soya bean, can decrease the risk of NPC.

side effects associated with this treatment, including xerostomia and swallowing dysfunction. However, symptoms such as pain, mucositis, swallowing problems and mouth ulcers are still prevalent while the patient is undergoing treatment. While HPV and head and neck cancer are frequently talked about, other demographic groups that have a prevalence of nasopharyngeal cancer are the populations of southern China, South Asia, the Artic and Middle East.5 I see this demographic of patients frequently during my practice and they are tested by the MDT for the Epstein-Barr virus (EBV). People who have immigrated to western countries including the United Kingdom, United States and Australia, are still more likely to develop nasopharyngeal cancer (NCP) than the native populations of the country that they have immigrated to. The risk of this population developing NCP decreases the longer the person is a resident in the country and in succeeding generations. So, it is likely that this patient group will continue to be seen in clinical practice and again they are usually treated with radiotherapy as a primary treatment. The link between NPC and the populations of these countries have been long established and have a multifactorial aetiology. Two of the main risk factors in this demographic of patients precluding the development of NPC includes the Epstein-Barr virus and diet. Other factors include gender (more prevalent in males), genetic factors and a family history. As with other head and neck cancers, smoking

and an excess of alcohol will increase the risk factor of developing this type of cancer. EBV is normally developed in childhood all over the world; however, it is only when mixed with the other risks factors that this can turn into NPC. The link between EBV and NPC is not fully understood and is very complex, but it may be that the way the body deals with the virus may contribute to the development to NPC. Diet has a contribution to the development of NPC. People in south-east Asia and China commonly preserve food, especially fish, by salting them. These salt-preserved foods are dietary staples and children in these countries are often weaned on these foods. Studies have shown that salt preservation is an inefficient way to preserve food, leading to putridification of the food and the production of nitrosamines which are known to be carcinogenic in animals.6

The link between EBV and

NPC is not fully understood and is very complex, but it

may be that the way the

body deals with the virus

may contribute to the

development to NPC.

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CLINICAL In a pre-treatment clinic, it is worth taking a diet history to see if the patient is still eating a traditional Asian diet and advising to decrease the amount of salt in the diet. Conversely, some studies have shown that eating frequent amounts of fruit and vegetables can decrease the risk of developing NPC.7 Some studies have shown that specific foods, such as

citrus fruits, green leafy vegetables, carrots and fresh soya bean, can decrease the risk of NPC. This may be due to the antioxidant effect of eating a diet high in fresh fruit and vegetables, which may reduce the production of nitrosamines and free radicles. Therefore, there is evidence that a diet high in fruit and vegetables in this patient demographic may be protective against NPC.

CASE STUDY

A patient with nasopharyngeal cancer attended pretreatment clinic for radiotherapy and was already having chemotherapy at the point of initial contact. This patient was born in the UK with Chinese heritage and was 36 years old. The patient reported following a Chinese diet at home, which included plenty of salted fish, rice, soya and vegetables such as pak choi. This patient had an interest in nutrition and Chinese herbal medicine and believed in the healing power of food. We discussed diet at length including a high protein, high energy and altered textured diet to help them maintain their weight and muscle mass during treatment. When taking a diet history, the patient reported having â&#x20AC;&#x2DC;healingâ&#x20AC;&#x2122; soups with plenty of ginger, garlic and Chinese herbs which he was making himself. The patient felt that these soups had antioxidant properties that would help with the cancer treatment. We discussed the fact that the soup was low in protein and energy and we discussed how to fortify this soup to increase the calorie and protein content with cream, or by adding cheese, or by having them with high protein, high energy snacks as a cup of soup, so that it wouldnâ&#x20AC;&#x2122;t fill him up and he would be able to meet his protein and energy requirements. We also discussed with the patient having unsalted fish due to the stinging/ burning sensation that the patient would experience on their soft palate and in their mouth. The patient did well during treatment, with minimal weight loss due to supplements and a high energy, high protein diet. The patient also continued with his soups and Chinese herbs during the treatment. Longer term, the patient was advised to swap the salted fish to fresh or frozen fish on a more regular basis, but that he could have it occasionally and to continue to have a diet high in fruit and vegetables. It was important for this patient to negotiate and compromise and to adjust the dietary advice for a Chinese diet while taking into consideration the patients beliefs around how his diet would nourish and heal his body. Due to discussions that were had at pre-treatment regarding body composition and muscle wasting, the patient was happy to have a high protein diet and to make changes in his diet to reflect this. This resulted in the patient becoming more compliant during treatment and meeting his nutritional goals. References 1 Cancer Research UK, www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/oral-cancer. Accessed April 2016. 2 Young D, Xiao CC, Murphy B, Moore M, Fakhry C and Day T (2015). Increase in head and neck cancer in younger patients due to human papillomavirus (HPV). Oral Oncology Vol 51, 8, pp 727-730 3 National Cancer Intelligence Network (2012). www.ncin.org.uk/home 4 Zaravinos A (2014). An updated overview of HPV- associated head and neck carcinomas. Oncotarget 5, 12 pp 3956-3969 5 Liu Y, Fang Z, Liu L et al (2011). Detection of Epstein- Barr virus DNA in serum or plasma for nasopharyngeal cancer: a meta-analysis. Genetic Testing and Molecular Biomarkers 15: 495-502 6 Chang ET and Hans-Olov A (2006). The Enigmatic Epidemiology of Nasopharyngeal Carcinoma. Cancer Epidemiology, Biomarkers and Prevention 15, 10 1765-1777 7 Chuang SC, Jenab M, Heck JE et al (2012). Diet and the risk of head and neck cancer: a pooled analysis in the INHANCE consortium. Cancer Causes and Controls 23: 69-88

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PUBLIC HEALTH

VITAMIN D: UPDATE ON GUIDELINES AND RECOMMENDATIONS Jacqui Lowdon Paediatric Dietitian, Team Leader Critical Care, Therapy & Dietetics, RMCH Presently team leader for Critical Care and Burns, Jacqui previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.

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

In July this year, Public Health England (PHE) published new recommendations1 for Reference Nutrient Intakes (RNIs) of vitamin D for everyone in the UK. This advice is based on the recommendations of the Scientific Advisory Committee on Nutrition (SACN) following its review of the evidence on vitamin D and health,2 which advises a change to the previous advice. The Committee on Medical Aspects of Food and Nutrition (COMA)3 had previously stated that dietary intake of vitamin D for most of the UK population (four to 64 years of age) was unnecessary due to vitamin D being synthesised in the skin on exposure to sunlight. RNIs only existed for groups considered to be at high risk of deficiency and were based on the amount required to prevent osteomalacia in adults and rickets in children. However, with public health advice now recommending to stay out of sunlight and wear protective sunscreen, it is no longer possible for most of the UK population to meet requirements. Most people receive very little vitamin D from their diet, as there are only a few naturally occurring foods that contain a significant amount of vitamin D and, in the UK, there are only a few foods fortified with small amounts of vitamin D. WHAT ARE THE NEW RECOMMENDATIONS?

It is now recommended that the UK population aged one year and above have a vitamin D supplement throughout the year. This includes population groups at high risk of vitamin D deficiency (see Table 1 overleaf) and pregnant and lactating women.

The new recommendations are 400IU (10ug)/day for adults and 340400IU/day for infants. PHE have advised that the general population should take a daily supplement of 10ug of vitamin D in autumn and winter, as it is difficult for people to meet the 10ug recommendation from consuming foods naturally containing or fortified with vitamin D. Throughout the remainder of the year, the majority of the population obtain enough vitamin D through sunlight on the skin and a healthy, balanced diet. For those who have little or no exposure to sunlight, e.g. in institutions such as care homes, or who always cover their skin when outside, they will require a supplement throughout the year. Ethnic minority groups with dark skin, e.g. African, Afro-Caribbean and South Asian backgrounds, may not get enough vitamin D from sunlight in the summer and, therefore, should also consider taking a supplement all year round. Children aged one to four years should have a daily 10ug vitamin D supplement. PHE recommends that babies are exclusively breastfed until around six months of age and as a precaution, all babies under one year of age should have 8.5 to 10ug vitamin D/day. Children who have more than 500ml of infant formula a day do not need any additional vitamin D as formula is already fortified. These new RNIs have been recommended to ensure that the majority can achieve and maintain an adequate level of vitamin D throughout the year, for musculoskeletal health only. They do

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Most people receive very little vitamin D from their diet, as there are only a few naturally occurring foods that contain a significant amount of vitamin D

Table 1: Groups at high risk of vitamin D deficiency4 Groups with increased requirements Pregnant and breastfeeding women Infants Twin and multiple pregnancies Adolescents Obese individuals Reduced sun exposure Those living in northern latitudes, especially above 50 degrees

not take into account the ever-expanding list of other health claims for vitamin D.5,6 No RNIs have been set for children under four years of age, only safe intakes. However, this advice differs from that of the Department of Health and the Chief Medical Officers7 recommended dose of 7-8.5ug (approx 300IU) for all children from six months to five years of age. This is the dose that the NHS â&#x20AC;&#x2DC;Healthy Startâ&#x20AC;&#x2122; vitamin drops provide. The British Paediatric and Adolescent Bone Group8 recommends that exclusively breastfed infants receive vitamin D supplements from soon after birth. WHAT IS THE OPTIMUM SERUM VITAMIN D LEVEL?

Scientific debate about optimal vitamin D status still continues. The Institute of Medicine (IOM)9 defines vitamin D status by serum 25-hydroxyvitamin D (25(OH) D), with 50nmol/l meeting the requirements of 97.5% of the population. The British Paediatric and Adolescent Bone Group (BPABG)8 defines vitamin D deficiency as a serum level <25nmol/l, insufficiency 25-50nmol/l and sufficiency >50nmol/l. These levels are thought to protect only muscoloskeletal health. The Global Consensus Recommendations on Prevention and Management of Nutritional Rickets10 classifies deficiency as <30nmol/l, insufficiency as 30-50nmol/l and sufficiency as >50nmol/l. Durup et al11 found that serum levels of 50-60nmol/l provided the lowest all-cause mortality risk. This is alarming in view of the fact that around 30-40% of the UK population have been found to have a plasma 25(OH)D concentration of <25nmol/l in winter.12 28

Seasonal - winter and spring Individuals with darker skin, e.g. African, Asian, Afro-Caribbean Immobility, e.g. people with cerebral palsy, institutionalised individuals Wearing concealing clothes Excess use of sun block Limited diet Vegetarians and vegans Prolonged breastfeeding, even if the mother is vitamin D sufficient Malabsorption Exclusion diets, e.g. milk allergy Renal disease Liver disease Effects of certain drugs, e.g. anti-TB, anticonvulsants

SO, HOW MUCH VITAMIN D DO WE ACTUALLY NEED?

Even with the new guidelines in place, the required vitamin D intake for optimal health also still poses scientific debate. There has been some recent new research investigating vitamin D requirements in some of the higher risk groups, which questions the present guidelines and recommendations. A multicentre randomised controlled trial13 has concluded that maternal vitamin D supplementation with 6,400IU/day safely provides the nursing infant with an adequate amount of vitamin D. This makes the amount currently recommended (400IU/day) irrelevant. At the start of the study, the researchers prescribed 2,400IU/day of vitamin D to a group of lactating mothers. However, the ethics committee had to stop the study and increase the amount being given, as many infants in this group had 25(OH)

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PUBLIC HEALTH D levels<20 ng/ml. If the mother takes 6,400IU/ day, the authors recommend that the infants do not need to supplement with vitamin D. Giving 6,400IU to breastfeeding mothers has the same results on the infants 25(OH)D as when the infants take 400IU/day, but with the advantage that if the mothers take it instead of just the infants, both will benefit from maintaining vitamin D sufficiency. Adolescents are another population group at high risk of low vitamin D status, yet the evidence base for establishing vitamin D requirements remains weak. A recent dose-response, doubleblind, randomised placebo-controlled trial14 has demonstrated that vitamin D intakes between 10 and ~30μg/d are required by Caucasian adolescents during winter to maintain serum 25(OH)D concentrations >25-50nmol/L, depending on the serum 25(OH)D threshold chosen. During the study, the response of 25(OH)D reached a plateau at 46nmol/l; therefore, there is uncertainty in estimating the vitamin D intake required to maintain 25(OH)D concentrations >50nmol/l in 97.5% of adolescents, but it did exceed 30μg/d. The results of this study would, therefore, question the adequacy of PHE recommendation of 10ug/day. CONCLUSION

It is well recognised that vitamin D is essential for musculoskeletal health and there is now emerging evidence as to its many other health benefits. In the UK, with up to 30-40% of the population having low plasma levels during winter months, vitamin D deficiency and insufficiency is a common public health issue, but one that is preventable. In view of this, the UK government have recently reviewed their recommendations for RNIs of vitamin D for everyone. For some at risk groups, these guidelines may not arguably be at optimal doses, in view of recent research findings. However, as it is difficult to achieve the recommended nutritional intake from natural dietary sources alone and impossible to recommend the amount of sunlight exposure to achieve and maintain optimal vitamin D levels, healthcare professionals need to be aware of the new guidelines. We need to be advising our client groups of the new recommendations for vitamin D supplementation and safe intakes.

It’s all in the taste TM

FruitiVits is a vitamin, mineral and trace element supplement specifically designed for children aged 3-10 years on restrictive therapeutic diets.

A great tasting orange flavour Soluble - dissolves easily Low volume - 1 sachet made up in a minimum of 60ml water All in one - A single 6g sachet meets micronutrient* Reference Nutrient Intakes (RNIs).1 Contains 15ug of Vitamin D and 804mg of Calcium per sachet. Only 0.5g of carbohydrate per sachet (suitable for the Ketogenic diet) For further product information or samples, please contact Nutritional Services Helpline on: +44 (0) 151 702 4937 or e-mail

A Nestlé Health Science Company ® Reg. Trademarks of Société des Produits Nestlé S.A.

Fruitivits is a Food for Special Medical Purposes * excludes sodium, potassium and chloride. REFERENCE: 1 Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. HMSO, London. NHD1216

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CLINICAL

MANAGEMENT OF EATING DISORDERS FOR NON-SPECIALIST DIETITIANS Emma Hall Registered Dietitian, Eating Disorders

Emma works with the Nottinghamshire Eating Disorders Service, providing outpatient support to adults with eating disorders. She delivers one-to-one dietetic sessions, joint sessions, provides psycho education sessions and runs a nutrition group with the service.

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

Specialist multidisciplinary teams offer patients appropriate and effective care to support them with what can be complex conditions. But what happens when a patient presents outside of the specialist team? How do we ensure best practice? This article aims to discuss dietetic practice in eating disorders, focusing on the management of patients admitted onto general medical wards. Dietitians have training in a huge variety of mental and physical health conditions and a wide range of skills and knowledge to support patients with these conditions. This places us in a position to have a significantly important role in the Multidisciplinary Team (MDT) and to start to branch into specialist areas of physical and mental health. Specialist teams offer patients appropriate and effective care and, within these teams, there is a variety of skilled professionals allowing MDT-working and discussion to ensure safe practice. I work with the Nottinghamshire eating disorders service and, from speaking with dietitians in the community and hospital setting, alongside my own experiences, I am aware that eating disorders can often be seen as unknown territory for dietitians not working in this area day to day. It can be very daunting to be asked to see a patient with an eating disorder if you have had little experience in this area. GPs may refer a patient, perhaps undiagnosed, to community dietetics, or patients with eating disorders may end up on a general medical ward. We must be careful to work within our areas of knowledge and expertise and, as the Health and Care Professions Council (HCPC) guidelines clearly states in Standards of Proficiency, (dietitians should) ‘know the limits of their practice and when to seek advice or refer’.1 This is not to say that we are not capable of doing our job, but it is a great skill to know at what point to seek support to maintain safe practice.

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CURRENT GUIDELINES

The reasons for admission onto a medical ward can be due to the need for treatments that are not available on psychiatric wards, A&E admissions. It may be a planned admission, usually in conjunction with the specialist eating disorder service, or it may be an unplanned admission, of which the specialised eating disorder service may not initially be aware of. The National Institute for Health and Care Excellence Eating Disorders guidelines (2004)2 can be a useful starting point for understanding the care pathways involved in managing eating disorders. However, more specifically relevant to the medical wards, which are specifically related to the management of patients with anorexia nervosa on the medical wards are the MARSIPAN guidelines: Management of really sick patients with Anorexia Nervosa and Management of Really Sick Patients under 18 with Anorexia Nervosa.3,4 These guidelines came about following concerns nationally that a number of patients with severe anorexia nervosa were being admitted to general medical units and sometimes deteriorating and dying owing to refeeding syndrome, underfeeding syndrome and other complications of anorexia nervosa. Here is an example of a patient with an eating disorder taken from the MARSIPAN guidelines: ‘A female patient of 20 years with a BMI of 13 was transferred from the eating disorders ward to a local accident and emergency because of chest pain. In accident and emergency cardiac

causes were excluded, but she was admitted to a medical ward where she was given a very low calorie intake, around 200 calories per day. She remained in the ward while mild liver abnormalities were investigated and died after five days in hospital.â&#x20AC;&#x2122; (Eating disorders psychiatrist). This shows that inappropriate investigation of mildly abnormal test results can lead to inappropriate prolonged general hospitalisation and that very low calorie regimen without early and frequent monitoring and review may contribute to a fatal outcome in patients with anorexia nervosa (underfeeding syndrome).â&#x20AC;&#x2122; MARSIPAN (2014) These guidelines stress the importance of working as an MDT team and supporting each other to effectively identify the roles and duties of the medical team, in conjunction with support from the specialist services. THE DIETITIANâ&#x20AC;&#x2122;S ROLE

The key question is, as dietitians working in specialist services and on medical wards, how do we play our part in the team to implement these guidelines and support other presentations of eating disorders? The answer is to remember what your skills and limitations are and to make contact with the dietitian in the nearest specialist eating disorder unit (SEDU) or outpatient service. By working in conjunction with a specialist dietitian, you can consult together when a patient is admitted. The benefits of the specialist dietitian is that they work with this patient group on a day-to-day and will have more specific knowledge towards the treatment of this patient group. They will also have direct access to their specialist team members. Consultants working closely together are also significantly important and our co-working provides a good example for other professions. Discussion about refeeding risk vs underfeeding can be considered, alongside potential behaviours to be aware of, such as tampering with feed, water loading, pacing up and down on the ward, patient wanting laxatives etc, to enable the ward dietitian to raise these concerns with the MDT team if required. It may

not be that the dietitian alone is able to resolve these issues, but between the knowledge of the specialist team and the medical team we can put actions into place to keep the patient safe. The dietitian will also play a key role in advising an appropriate diet and/ or nasogastric feeding, again, using the knowledge of the specialist dietitian to ensure safe practice. It is also important to raise the profile of the dietitian on the medical wards, as the role of the dietitian in caring for patients with eating disorders is essential. By being clear on our role and the support we can offer to the MDT it reinforces the importance of a dietitian within an MDT service. Dietitians specialising in eating disorders need to work closely with dietitians on medical wards to enable safe and effective practice. If you do not have a specialist service in your area it is important to seek out your closest specialist eating disorder service and SEDU (this can work both ways, as the specialist dietitian may also need support regarding other conditions in their practice) and consider setting up a MARSIPAN group, which is a group of healthcare professionals from both the medical and specialist eating disorder services, working in collaboration to put together pathways for care on medical wards (www.marsipan.org.uk/). Training sessions can offer a good opportunity to provide support. For example, I provide training sessions at service meetings for dietetic teams working in both the hospital and community setting, to provide relevant information, advice and resources for the dietitians to use. Looking at the wider picture, we can also start to think about the possibility of increasing training for students, ensuring the MARSIPAN principles are taught to frontline undergraduates in dietetics and that placements include an insight into eating disorders. Communication with our commissioners, partner organisations and each other is also essential. Through this and by maximising our skills with joint working, alongside relevant training and resources, we can continue to provide a safe and effective service for our patients.

Comment from the Editor The management of eating disorders is a highly specialised area of dietetics requiring extensive time and patience, working as part of a specialist ED MDT in order to bring about positive outcomes for this at risk patient group. However, nonspecialist ED dietitians will encounter and possibly manage complex patients from this group. In outpatient clinics and on general hospital wards, dietitians may provide a first-line assessment and onward referral to other services for patients with a suspected ED. But, the best practice in this situation may not be well known or officially laid out. In her article, Emma Hall offers her experience and recommendations for dietitians working with ED patients on the general medical ward. www.NHDmag.com December 2016 / January 2017 - Issue 120

ON BEHALF OF PENG

WATCH AND LEARN: A DIETITIAN’S ACCOUNT OF NASOGASTRIC TUBE FEEDING Linda Cantwell, Community Home Enteral Feeding Dietitian

Linda is a Registered HCPC Dietitian working for 5 Borough Partnership NHS Foundation trust. She has recently completed an MSc in Advanced Practice and is a PENG Committee Member.

On January 18th 2016, Sean White, Home Enteral Feeding (HEF) Dietitian in Sheffield, spent a week without any oral diet and fluids, receiving his complete nutrition via a nasogastric (NG) tube. He did this out of professional curiosity and to raise money for the South Yorkshire branch of the Motor Neurone Disease Association (MNDA). During the week Sean kept a video diary reflecting on his experience.

Sean is HEF Clinical Lead of the Parenteral and Enteral Nutrition Group (PENG), a Specialist Group of the BDA. He applied for a PENG research and audit grant to enable him to have his footage edited into a short educational film. The grant is open to all members of PENG and is a great way to complete projects which not only lead to improvements in patient care, but also support the researchers’ professional development. (www. p e n g . o rg . u k / e d u c a t i o n - re s e a rc h /peng-grants.php). Sean’s film is now available online to everyone (not just PENG members) at www.peng.org.uk/education-research/ feeding-tube-challenge.php. It provides an insight into some of the practical considerations and challenges associated with home enteral feeding, covering both bolus feeding, where feed is given at regular intervals during the day through a syringe, and pump feeding, where feed is continuously infused at a set rate via an electronic pump. Sean even gets his daughter Eve involved with setting up his pump feed. This, and many other elements of the video, not only demonstrate how the family can be involved, but also recognises how those of all ages can be supported to use enteral feeding equipment. Sean clearly recognises the organisation, planning and time required to meet his nutritional needs (and those of his patients), using both methods of feeding and this allows viewers to

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consider the pros and cons of each option in order to provide information to a patient, someone in their care, or for themselves. Sean covers the side effects that he experiences and gives an insight into the management of some troubleshooting issues. One of the most commonly experienced problems with NG feeding is getting a gastric aspirate, a vital component, to confirm that the tip of the tube is in the stomach. This is a definite part to watch for any professional or patient who has ever struggled to get an aspirate. On the last day of feeding, Sean also explored what it would be like to eat a variety of different textures with a nasogastric tube in place. This is important, as many people may have a feeding tube placed to provide supplementary nutrition, or may be transitioning from tube-feeding to oral intake. In addition, Sean attempts a blended diet, which is the process of blending homemade foods (his chicken dinner) to a liquid consistency to allow it to be given through his feeding tube. Although this method of feeding isn’t typically recommended by dietitians, there appears to be a growing interest for this within the UK, therefore, giving an important insight into the processing of blending and administration. The week, however, would not be complete without Sean sharing his

Sean has already received positive comments about the impact that his video is having on influencing healthcare professional practice and its potential for use as a teaching aid.

Above: Sean White living with a nasogastric tube for a week. Below: Sean’s daughter Eve helping him with bolus feeding.

“This is worth a watch - walking in the patients’ shoes - for a week! It’s fabulous and a great teaching aid. It highlights some of those things that we never get to see, but that would be real issues for our patients.” Hilary (Chief Nurse) “‘Fascinating work and thank you for making this available. If able, I hope to incorporate this into the stroke unit local induction.” Keiran (Stroke nurse) “Thank you for a really interesting, informative and inspiring film - it really highlighted some of the challenges that our patients have to face every day. Well done for persevering through the week and doing so much to raise awareness!” Eleanor (SALT)

experiences with a patient who requires longterm home enteral feeding, a very poignant ending. Watch this space though, as this is unlikely to be the last you see of Sean. He has received a great number of responses from dietitians who have said that they would also like to try NG feeding and, so, he has a vision in the future to recruit several dietitians and different health professionals to feed via a nasogastric tube for the same week. Undoubtedly a great PR exercise for the profession, a valuable learning experience for those involved and could also provide huge potential to raise the profile and awareness of home enteral feeding.

Although this is a vision, Sean can confirm that he is working on another video-based patient resource: “I am involved in another project with our local MND centre, developing a website containing film footage of patient experience of making the decision to have a feeding tube placed and life on HEF. It is intended to support decision making prior to gastrostomy placement.” If Sean’s video has inspired you to think of how undertaking service development, research or audit could influence your practice and/or patient care why not consider the PENG grant (www.peng.org.uk/education-research/penggrants.php).

www.NHDmag.com December 2016 / January 2017 - Issue 120

PUBLIC HEALTH

PALM OIL: FEEDING THE NEXT GENERATION ON UNETHICAL OILS? Dr Emma Derbyshire PhD RNutr Independent Consultant

Emma is Director of Nutritional Insight Ltd, an independent consultancy to industry, government, publishers and PR agencies. She is an avid writer for scientific journals and media. Her specialist areas are public health nutrition and functional foods. www.nutritionalinsight.co.uk

The infant and toddler food market is steadily expanding. However, how closely do we look at the ingredients list? For sugar perhaps and to ensure that products are as â&#x20AC;&#x2DC;naturalâ&#x20AC;&#x2122; as possible. Nevertheless, other ingredients appear to be finding their way into these products, with Palm Oil (PO) being one. Given the devastating environmental effects linked to PO production, is it ethical to feed the next generation on foods containing these? This article undertakes a cross-sectional analysis of supermarket products and discusses. Palm Oil (PO) comes from the palm tree known as Elaeis Guineensis which is native to many West African countries.1 From the palm fruit itself, two different types of oils can be extracted: palm kernel oil from the seeds and PO from the mesocarp (middle fleshy layer) itself.1 Due to its versatility, PO has found its way into liquid detergents, lipsticks, waxes and polishes and the food market in the form of cooking oils, margarines, ice-cream, ready-to-eat meals and confectionary.2 Unfortunately, the rising popularity of PO has also come at a cost.

PO cultivation requires extensive areas of land. Its production has been linked to deforestation, climate change and socioeconomic instability.3 PO plantations support fewer tree and animal species, resulting in substantial loss of biodiversity.4 In turn, the extensive use of PO has driven up habitat fragmentation, pollution and greenhouse gas emissions.4 It can been predicted that such extensive biodiversity losses will only be avoided if future PO expansion does not involve deforestation.4 From a health stance, PO also contains around 50% saturated fatty acids, mainly in the form of palmitic acid.5 These in turn raise LDL cholesterol, increasing the risk of obesity and cardiovascular disease.4 This is supported by a recent meta-

Figure 1: Percentage of infant and toddler snack foods containing PO PO was present in 60% of infant/ toddler biscuit products.

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Marco Schmidt

PO cultivation requires extensive areas of land. Its production has been linked to deforestation, climate change and socioeconomic instability.3 PO plantations support fewer tree and animal species, resulting in substantial loss of biodiversity.4 analysis of 30 articles, which concluded that PO compared with vegetable oil significantly raised LDL cholesterol.6 Authors went on to conclude that PO use should be reduced and ideally replaced with vegetable oils lower in saturated and trans fat.6 INFANT AND TODDLER FOODS

Whilst it is relatively well known that PO is found in an array of everyday products,2 this article sets out to evaluate the use of PO in infant and toddler snack foods. Supermarket product search engines were used to identify products. The key terms ‘infant’ or ‘toddler’ snack foods were used within these. Product ingredient information was used to extract information related to PO use. In instances where this was unavailable through supermarket websites, individual company searches were undertaken.

A total of 108 products were identified. After the exclusion of breakfast cereals and smoothies, data from 100 products was included in the main analysis. Results showed that PO was present in one in five (21%) of products reviewed. When analysing biscuit-based products, PO was found in three out of five (60%) of these. It was also evident in just under one-third (31%) of snack bars. Other products tended to use sunflower oil, or vegetable oils such as rapeseed or canola. A minority used orange oil for flavour. No products had labels for certified sustainable PO use. Overall, these results show that PO is being used widely in specialist foods targeted at infants and young children. The use of PO did not need to be declared up until December 2014. From the 13th of December 2014, labelling regulations in the European Union declared that food products needed to identify the origin of fats, including PO, along with a description of whether these are

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PUBLIC HEALTH Figure 2: Labels indicating that products are made with certified sustainable PO

partially or fully hydrogenated.7 Subsequently, due to improved labelling procedures, the presence of PO can now be better identified. WAYS FORWARD

One obvious way forward would be to replace PO with blended liquid oils such as rapeseed oil, sunflower oil or soy bean oil.8 Whilst these may cause some technological challenges, these are not regarded as insurmountable.8 Due to their liquid aggregate state, these may not be able to replace PO fractions in every application. Nevertheless, they could be used in applications where only small volumes are used.8 Environmentally, one approach is to use PO from sustainable producers. Some stores are now actively seeking and using products that use sustainable PO. Marks and Spencer appears to be one provider doing this, as specified in their Plan A strategy,9 but greater actions are needed from other stores. In cases where sustainable PO is used, the Roundtable on Sustainable Palm Oil (RSPO) label or Green Palm label may be shown, indicating that products are made with Certified Sustainable Palm Oil, also referred to as CSPO.10 These are shown in Figure 2 above.

For a health stance, substituting PO with vegetable oils may have benefits for LDL cholesterol, as identified by meta-analytical evidence.6 From a broader perspective, for example, with regard to blood glucose regulation or cancer risk, the jury is still out, namely due to the poor quality of research currently available.5 Animal studies have found PO ingestion to be associated with impaired platelet aggregability and venous thrombosis, indicating an increased risk of thromboembolic diseases.11 Most recently, the European Food Safety Authority (EFSA) warned of monochloropropanediol (MCPD) risks, particularly for children;12 3- and 2- MCPD along with their fatty acid esters are found at the highest levels in PO, although these are also present in vegetable oils. These substances are formed during food processing when refined oils are heated at high temperatures.13 Nephrotoxicity symptoms have been observed in animal studies.12 This has raised recent concerns for the EFSA who calculated that the tolerable daily intake of 0.8μg/kg body weight per day was exceeded by infants and toddlers.12 CONCLUSION

It is disappointing to see that infant and toddler foods are not using PO from certified sustainable sources. Equally, given the technological innovations of today, we should be heading towards the use of alternative oils, especially within children’s products. For me, the inclusion of unsustainable palm oil in foods targeted at the next generation just doesn’t sit well. In theory, we are feeding them potentially harmful foods whilst harming their environment in the process.

References: 1 Mba OI et al (2015). Palm Oil: Processing, characterisation and utilisation in the food industry. A review. Food Biosci 10: 26-41 2 World Wildlife Fund (2016). Palm oil: productive and versatile. Available at: http://wwf.panda.org/what_we_do/footprint/agriculture/palm_oil/about/ 3 Ntsomboh-Ntsefong G et al (2016). Brief review on the controversies around palm oil (Elaeis Guineensis Jacq.) Production and Palm Oil Consumption. International Journal of Regional Development 3(2): 2373-9851 4 Fitzherbert EB et al (2008). How will palm oil expansion affect biodiversity? Trends in Ecology and Evolution 23(10): 538-45 5 Mancini A et al (2015). Biological and nutritional properties of palm oil and palmitic acid: effects on health. Molecules 20: 17339-17361 6 Sun Y et al (2015). Palm oil consumption increases LDL cholesterol compared with vegetable oils low in saturated fat in a meta-analysis of clinical trials. J Nutr 145(7):1549-58 7 European Commission (2014). New EU labelling rules. Available at: https://ec.europa.eu/food/sites/food/files/safety/docs/ labelling_legislation_infographic_food_labelling_rules_2014_en.pdf 8 Hinrichsen N (2016). Commercially available alternatives to palm oil. Lipid Technol. 28(3-4):65-67 9 M & S (2016). Plan A. Raw Materials, Commodities and Ingredients. Available at: https://corporate.marksandspencer.com/plan-a/our-approach/ food-and-household/product-standards/raw-materials-commodities-and-ingredients/palm-oil 10 WWF (2016). Which everyday products contain palm oil? Available at: www.worldwildlife.org/pages/which-everyday-products-contain-palm-oil 11 Mizurini DM et al (2011). Venous thrombosis risk: effects of palm oil and hydrogenated fat diet in rats. Nutrition 27(2):233-8 12 EFSA (2016). Risks for human health related to the presence of 3- and 2-monochloropropanediol (MCPD), and their fatty acid esters, and glycidyl fatty acid esters in food. EFSA Journal 14(5):4426, pp.159 13 Lewis S (2016). EFSA warns of MCPD health risks, particularly for children. Available at: www.eurofoodlaw.com/food-safety-and-standards/efsawarns-of-mcpd-health-risks-particularly-for-children-116683.htm?origin=internalSearch

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NETWORK HEALTH DIGEST

Coming in the next issue February 2017

• • • • • •

Paediatric food allergy Obesity surgery Fasting diets Diabetes care in the community Goat milk Cognitive behavioural therapy _______

Check whether you are eligible for a FREE subscription to Network Health Digest at wwwNHDmag.com . . . Don’t miss a single issue!

STUDENT ZONE

THE GOVERNMENT 5-A-DAY CAMPAIGN Bethany Florey Student of PGdip in Nutrition and Dietetics

Upon completing her first year studying PGdip in Nutrition and Dietetics, Bethany has a particular interest in working in paediatrics. However, she is looking forward to future placements to gain more experience in other clinical settings.

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

The UK government officially adopted the ‘5-a-day’ campaign in 2003. The World Health Organisation specifically defined the campaign as a recommendation of five portions of fruit and vegetables to be consumed every day, with one portion consisting of approximately 80g, amounting to 400g in total per day. For children, portion sizes vary, but are often described as the amount which would fit into the palm of their hand; despite this, there is currently no specific guidance on the exact amount one child’s portion should be.2 The ‘5-a-day’ campaign and the associated recommendations were based on evidence was first observed in 1990. This evidence proved that fruit and vegetables provide protective properties, in particular against cardiovascular disease and different cancers even from a young age.6 Evidence also supports that consuming the recommended amount of fruit and vegetables is associated with decreased risk of obesity and the comorbidities associated with this.3 With the rates of obesity steadily increasing, and even more so amongst children, healthy eating campaigns are of upmost importance.3 EVIDENCE OF HEALTH BENEFITS

There is continuous research on this area to determine the associations between consuming fruit and vegetables and the positive impact on health. A large prospective cohort study carried out in Europe observed that amongst the participants consuming a minimum of eight portions of fruit and vegetables per day, they had a 22% reduced risk of developing ischaemic heart disease (IHD) in comparison with those participants consuming less than three portions a day [relative risk (RR)=0.78, 95% confidence interval (CI): 0.65-0.95].4 38

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It was also identified that for every extra portion of fruit and vegetable consumed in a day, there was a 4% reduction in risk of IHD (RR=0.96, 95% CI: 0.92-1.00, P for trend = 0.033)4 Analysis of the health survey for England revealed that there is a significant association with those people who consume seven portions of fruit and vegetables per day and a decrease in all-cause cancer (HR=0.75, 95% CI 0.59-0.96) and cardiovascular (HR=0.69, 95% CI 0.53-0.88) mortality.10 It is important to note a limitation of such data in that it involved people who were perhaps more likely to be conscious of their health based on where they were recruited (i.e. health screening, vegetarian societies etc). Increased amounts of fruit and vegetable consumption is also associated with effective weight management due to the fact that fruit and veg are high in both fibre and water and, therefore, can reduce overall energy intake in the diet and increase satiety.12 Based on these studies, it is evident that fruit and vegetables play a key role in reducing serious conditions such as heart disease and different cancers. However, the key improvements are seen in those individuals consuming more than seven portions of fruit and vegetables per day. SUCCESS OF CAMPAIGN

Despite the fact that there is a great deal of evidence supporting the health benefits of fruit and vegetables, the important question is whether or not people are achieving their recommended daily

For children, portion sizes vary, but are often described as the amount which would fit into the palm of their hand.

amounts. Over the past years, the government has spent approximately ÂŁ3.3 million on the 5-a-day campaign and ÂŁ75 million on the NHS Change 4 Life campaign, which also supports 5-a-day, showing that huge efforts are being spent on supporting the health campaign.10 Despite this, the UK currently has the lowest average intake of fruit and vegetables in Europe,1 with only 30% meeting the recommendation of five portions everyday.6 Amongst children, these figures are even lower: in some areas, as few as 10% are achieving the recommendation, especially in those areas of a lower socioeconomic class.11 A study in Liverpool found that approximately 26% of the children aged 5-11 and 23% of the children aged 12-18 had not consumed any fruit or vegetables the day prior to being questioned.5 Based on these statistics, it is evident that although the government is focusing attention on the 5-a-day campaign, a change needs to be introduced in order to increase the amount consumed on a daily basis, perhaps with a specific focus on children in order to improve the consumption of fruit and vegetables in the general population in the long term. 5-A-DAY AND CHILDREN

Evidence suggests that emphasis on teaching children and families about healthy eating is believed to be the way forward for the future

and to observe the long-term health benefits in the population. Poor eating and drinking habits are often developed during childhood and are continued into adulthood, leading to overweight and related morbidities.9 Pathogenic data has revealed that conditions such as atherosclerosis begin as early as childhood, but by something as simple as increasing fruit and vegetables intake, it can reduce the risk of this condition developing as adults.13 A large study in London, involving 2,383 children from 52 primary schools, focused on fruit and vegetable consumption amongst primary school children.3 The results showed that, on average, these children consumed 293g (approximately 3.6 portions) of fruit and vegetables a day (95% CI 287 to 303). An interesting observation revealed that those children who ate their dinner with their family at the dinner table consumed, on average, 125g more fruit and vegetables per day than those who didnâ&#x20AC;&#x2122;t eat a meal together ((95% CI 92 to 157; p=<0.001).3 One main limitation of this study was that it was only carried out in London, so not necessarily representative of the wider nation. Nevertheless, this still shows important patterns on healthy eating being reliant on the home environment.

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STUDENT ZONE

Current statistics reveal that the general population in the UK, in particular amongst children, are not meeting the recommended five portions of fruit and vegetables per day. CONCLUSION

The School Fruit and Vegetable Scheme (SFVS) is a programme providing one free piece of fruit or veg to children in government-run schools in England for the first three years. A study carried out in 2012 analysing the effectiveness of this programme, collected data from 128 different schools participating in the SFVS.7 The results showed that those children participating in the scheme on average consumed more fruit and vegetables (5.4 portions - 95% CI 5·3, 5·5) than those who didn’t (4.7 portions - 95 % CI 4·6, 4·8). The results also showed that the uptake to the scheme increased as the economic class decreased (r 0·855; P=0.002), but, despite being on the scheme, those in deprived areas still consumed on average fewer portions of fruit than those living in more affluent areas (r 0.860, P=0.001).7 The limitations in this study include the possibility of food recalls being misreported by the parents. Nevertheless, the study shows first hand that in order to teach children effectively and successfully about the benefits of eating healthily and consuming fruit and vegetables on a daily basis, the environment in which they are brought up in is the main contributing factor as to whether or not children achieve this.9

Overall, results and evidence from the literature shows that with each extra portion of fruit and vegetables eaten every day, there can be a 4% reduction in risk of developing certain conditions and diseases.4 Current statistics reveal that the general population in the UK, in particular amongst children, are not meeting the recommended five portions of fruit and vegetables per day.11 Therefore, it is unlikely that the majority of the population is consuming enough fruit and vegetables to see noticeable improvements in health. The main area of focus, in order to see improvements in the national average of fruit and vegetable consumption, should be on children living in more deprived areas as these areas have the lowest consumption rates. Past studies have shown strong associations between the child’s environ-ment and a healthy diet, with this including both home and school environment.9 Therefore, more government efforts and interventions should be seen in both schools and communities to improve both the awareness and access to healthy food in these areas. By introducing healthy eating into the curriculum and encouraging both children and parents to eat healthier in general, noticeable improvements in overall wellbeing may be seen in the future generations.

If you are a student of Nutrition and Dietetics and would like to write an article for the NHD Student Zone on our website, please get in touch by emailing us: info@networkhealthgroup.co.uk. Students are also eligible for a free subscription to NHD. See www.NHDmag.co.uk for more details on how to subscribe. 40

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PUBLIC HEALTH

50 SHADES OF SKIN Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years.

Skin is our biggest organ and all of it visible. But can your skin affect your nutrition? And can your nutrition affect your skin? There is much earnest discussion about skin and possible beneficial nutrients by companies selling expensive moisturising lotions and anti-aging creams. However, there is a dearth of data showing that putting any specific nutrient onto the surface of our bodies affects any measure of skin quality. Skin (colour) is known to be the major factor linked to the production of vitamin D from exposure to sunlight. Vitamin D production is perfectly proportionate to pigmentation: the lighter the skin, the higher the level of vitamin D production per unit of UV light exposure. There has been an explosion in research interest in vitamin D, especially in novel areas beyond bone health and calcium metabolism, and the recent Scientific Advisory Committee on Nutrition (SACN) report on vitamin D launched in July 2016,5 provides important updates, including that everyone in the UK should be taking a daily 10ug supplement of vitamin D, especially in the periods of winter and spring. Turn to page 27 for more on vitamin D guidelines. Chalé and Chalé investigated the topic of vitamin D and skin in the August issue of Journal of the Academy of Nutrition and Dietetics.3 They considered especially the delicate suggestions that racial sensitivities may muddle communication of vitamin D status and risk in different population groups. Chalé and Chalé report that American health surveys often group people into cultural and social categories. Identities of being Hispanic or Latino may say a lot about language and food culture,

but also include a wide splay of skin pigmentation being clumped together, and are not helpful in identifying those at greatest risk of poor vitamin D status. Rather than aggregating heterogeneous traits into homogenous groupings, researchers investigating and reporting on vitamin D status in populations should use measures from skin reflectance spectrophotometry. This scores skin colour/tone on a scale of 0 to 100 and accurately predicts vitamin D status in individuals of different ancestry. In this way, people of different ethnic backgrounds, but similar skin tones, can be better assessed in relation to vitamin D risk. However, more sophisticated measurement does not change conclusions that the highest risk groups for poor vitamin D status are people with darkest skins living in most northerly latitudes. SKIN YELLOWING

The appearance of (pale) skin can be influenced by diet resulting in various shades of yellowness. Eating lots of carrots does result in carotenemia, and is especially visible in the thin and delicate skins of infants and young children. Skin yellowing could be an amazing assessment tool for dietary intakes of fruits and vegetables, and general antioxidant status (so say makers of skin scanner technology

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PUBLIC HEALTH equipment Biozoom®). So what do we know about diet-induced skin yellowing? There are many excellent studies demonstrating this association. Aguilar and colleagues (2014)1 looked at whether measurements of serum carotenoids in children and teens correlated with skin spectroscopy measures, and whether these could also be valid biomarkers for intakes of fruits and vegetables (F&V). They concluded, “yes and yes”. Skin and serum carotenoids were highly correlated and total carotenoids, alpha carotene and beta carotene assessed from 24-hour diet recalls correlated to skin colour measures in children and teens. Aguilar and different colleagues later examined intervention effects of dietary carotenes in a randomised clinical trial (2015).2 Children were asked to maintain normal diets but to additionally consume a small or a larger amount (30ml or 120ml) of a carotenoid rich juice daily for eight weeks. These doses matched beta carotene intakes of just over 20g or just over 90g of cooked carrots per day. Skin scores measured by spectroscopy increased in both groups compared to baseline, and showed significant change by week two (although differences between the lower and higher dose groups were not significant). Conclusions are that including higher amounts of carotenoids in the diets of children results in rapid changes to skin yellow tones and that smaller intake amounts also appear to result in measurable effects. What about measures in the thicker and older skins of adults? Kristine Pezdirk and colleagues investigated Australian young women in a single-blind randomised crossover trial (2016).4 Thirty women of Caucasian or Chinese background, were randomised to consume at least seven daily servings of F&V. For four weeks they were supplied with F&V

boxes that provided items high in carotenoids, such as carrots, sweet potatoes, pumpkin and canned tomatoes. The high-carotene weeks were calculated to provide about 176mg beta-carotene. Then, after a two-week washout period, the young women with given weekly F&V boxes that provided items low in carotenoids, such as aubergines, mushrooms, cauliflower and pears, calculated to provide only about 2.0mg beta carotene per week. Serum and skin tones were assessed in both sun-exposed and protected skin areas and, of course, all women were required to avoid sun bathing and the application of tanning agents during the trial period. Women in both four-week periods successfully recorded heroic intakes of F&V of about seven servings per day, but serum and skin measures demonstrated that not all F&V are the same. In the periods of high carotene F&V intakes, there were significantly higher plasma levels of alpha and beta-carotene and lutein, and there were also significant increases in measures of skin yellowness in different body areas, but no changes to measures of skin lightness or redness. While many intervention trials investigating possible cancer protective effects of high dose (>20mg/d) beta carotene supplements demonstrated disappointing results in the 1990s, and possible adverse outcomes in smokers specifically, the data supporting possible health beneficial effects of diets high in food-sourced carotenes and other antioxidants remains really impressive. The fast and reliable skin measures of carotenoid intakes may become a useful research measure, and may also become a useful motivational measure in those that like to have daily and numeric scores of all their healthy life habits. Counting steps is so yesterday: tomorrows health discussions will be all about your skin tone score.

Information sources 1 Aguilar S, Wengreen HJ, Lefevre M (2014) Skin Carotenoids: A Biomarker of Fruit and Vegetable Intake in Children. Journal of the Academy of Nutrition and Dietetics 114, 8, 1174-1180 2 Aguilar S, Wengreen HJ, Dew J (2015) Skin Carotenoid Response to a High-Carotenoid Juice in Children: A Randomized Clinical Trial. 3 Journal of the Academy of Nutrition and Dietetics 115, 11, 1771-1778 3 Chalé A, Chalé C (2016) Color by Numbers: When Population Skin Pigmentation is not Political but a Polytypical Evaluation Exercise to Measure Vitamin D, Diseases , and Skin Pigmentation. Journal of the Academy of Nutrition and Dietetics, 116, 8, 1251-1256 4 Pezdirc K, Hutchesson MJ, Williams RL, Rollo ME, Burrows TL, Wood LG, Oldmeadow C, Collins CE (2016) Consuming High-Carotenoid Fruit and Vegetables Influences Skin Yellowness and Plasma Carotenoids in Young Women: A Single-Blind Randomized Crossover Trial. Journal of the Academy of Nutrition and Dietetics, 116, 8, 1257-1265 5 SACN (2016) Vitamin D and Health. Public Health England, London

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ONLINE RESOURCES

WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. ROYAL COLLEGE OF PHYSICIANS HEALTH SELECT COMMITTEE - BREXIT AND HEALTH AND SOCIAL CARE INQUIRY: RCP’S CONSULTATION RESPONSE The full impact of the EU referendum result is yet to be known, but it is likely to influence health and social care in many ways. In September, the Health Select Committee requested written submissions on the priorities for health and social care as part of the negotiations on the UK’s withdrawal from the European Union. Find more information about the inquiry here - www.parliament.uk/business/committees/ committees-a-z/commons-select/health-committee/news-parliament-20151/brexit-and-health-and-socialcare-inquiry-launch-16-17/ At the end of October the RCP responded to the HSC’s inquiry on the priorities for health and social care in the negotiations on the UK’s withdrawal from the EU. The RCP have submitted the following recommendations: • Patients should be the first priority. The government must guarantee that EU nationals working in the NHS will be able to stay in the UK and continue to deliver excellent care for patients. • Ensure that the current workforce crisis facing the NHS is not exacerbated through restricting non-UK doctors from working in the NHS. • The UK’s withdrawal from the EU must not affect patients’ ability to participate in high quality research and clinical trials. Patients must continue to have access to innovative new technologies. • Ensure the UK’s position as a world leader in research through accessing Framework 9 (FP9) funding, in addition to regional development funds and bursaries. • Retain the UK’s ability to influence legislation that affects research. • It is crucial that the UK maintains its involvement in frameworks that underpin the protection of public health, or that they are replaced by equivalent or even stronger safeguards. • Engage with the Cavendish Coalition of health and social care employers, professional bodies and trade unions. Full details can be found at www.rcplondon.ac.uk/guidelines-policy/consultation-response-brexit-andhealth-and-social-care

NICE GUIDELINES/STANDARDS UPDATES CLINICAL GUIDELINE [CG127] HYPERTENSION IN ADULTS: DIAGNOSIS AND MANAGEMENT First published August 2011. Updated November 2016. This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively. It also aims to reduce

unnecessary treatment by improving the way blood pressure is measured. Lifestyle interventions, which tie in with the prevention of obesity and cardiovascular disease are discussed, including healthy eating advice, consumption of alcohol and sodium, as well as promoting physical activity. Full details are available at www.nice.org.uk/guidance/cg127.

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ONLINE RESOURCES KING’S COLLEGE, LONDON RESEARCH UPDATE: VICTIMS OF CHILDHOOD BULLYING MORE LIKELY TO BE OVERWEIGHT AS YOUNG ADULTS A new study conducted by researchers at KCL has revealed that, ‘bullied children are more likely to be overweight as young adults, and they become overweight independent of their genetic liability and after experiencing victimisation’. The researchers referred to data from a previous study, the Environment Risk (E-Risk) Longitudinal Twin Study (2015), which included more than 2,000 children from England and Wales, who were followed from 1994-1995, and included children from birth to age 18. This study assessed bullying victimisation in primary school and early secondary school through interviews with mothers and children at repeated assessments at the ages of 7, 10 and 12. The data from this study were analysed. The main findings were: • 28% of children in the study had been bullied in either primary school or secondary school (defined as transitory bullying); • 13% had been bullied at both primary and secondary school (defined as chronic bullying); • children who were chronically bullied in school were 1.7 times more likely to be

overweight as young adults than non-bullied children (29% prevalence compared to 20%). • bullied children also had a higher BMI and waist-hip ratio at the age of 18*. *When the children were aged 18, the researchers measured their body mass index (BMI) and waisthip ratio, an indicator of abdominal fat. The researchers state that associations between bullying and increased risk of becoming an overweight young adult were independent of other environmental risk factors (including socioeconomic status, food insecurity in the home, child maltreatment, low IQ, and poor mental health). Other findings • Analyses showed that children who were chronically bullied became overweight independent of their genetic risk of being overweight. • At the time of victimisation, bullied children were not more likely to be overweight than non-bullied children, indicating that overweight children were not simply more likely to fall victim to bullying.

References Baldwin, J et al (2016) Childhood bullying victimization and overweight in young adulthood. Psychosomatic Medicine DOI: 10.1097/ PSY.0000000000000388 www.kcl.ac.uk/ioppn/depts/mrc/research/environmentalrisk(e-risk).aspx Fisher H, Caspi A, Moffitt TE, Wertz J, Gray R, Newbury J, Ambler A, Zavos H, Danese A, Mill J, Odgers CL, Pariente C, Wong CCY and Arseneault L (2015). Measuring adolescents’ exposure to victimization: The Environmental Risk (E-Risk) Longitudinal Study. Development & Psychopathology, 27, 1399-1416 Further information regarding the research can be found at www.kcl.ac.uk/ioppn/news/records/2016/November/Victims-of-childhood-bullyingmore-likely-to-be-overweight-as-young-adults.aspx

DEPARTMENT OF HEALTH FRONT OF PACK NUTRITION LABELLING GUIDANCE - UPDATE First published June 2013. Updated November 2016. The Front of Pack (FoP) nutrition labelling scheme combines colour coding and percentage reference intakes in line with UK health ministers’ recommendations and the requirements of Article 35 of EU Regulation 1169/2011 on the provision of food information to consumers (EU FIC). Manufacturers and retailers are encouraged to provide FoP labelling on as many of their products as possible where the information is

meaningful for consumers. The guidance covers advice on healthy eating, consistency of messages on packaging, nutrition and health claims. It provides worked examples of products and correct the FoP labelling for their nutritional content. Full information can be found at www.gov. uk/government/uploads/system/uploads/ attachment_data/file/566251/FoP_Nutrition_ labelling_UK_guidance.pdf

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SKILLS & LEARNING

BDA AWARDS Every year the British Dietetic Association (BDA) recognises the achievements of dietitians through their Awards. The BDA General Education Trust offers three annual awards: Rose Simmonds, Dame Barbara Clayton and Elizabeth Washington. The winner of the Elizabeth Washington Award will receive £1,500, and will be invited to present their work at a National BDA Event. This is a great opportunity for all BDA dietitian members to present published, or recently available, educational work. For this award the work can be an article, journal paper, department resource, e-learning material, text book chapter, booklet or website content. The submitted work does not have to be research published in a journal. It must be educational, addressing an audience of dietitians, professional colleagues, students, patients or the general public. The criteria is very broad. The award is open to all dietitian members. This is a chance to achieve national recognition from your professional body for your every-day practice. It also provides an excellent CPD opportunity in terms of the award

and presenting the piece at the BDA national event and other relevant events. Please consider discussing this opportunity at departmental meetings and amongst your colleagues and friends. The Rose Simmonds Award is for an original research publication in the last two years. This should be a scientific piece of work and must be published in print in a peer reviewed journal. Members who are first time published are particularly encouraged to apply. Open to all full members, the winner will receive £2,000. The Dame Barbara Clayton Award encourages applications from projects which have encouraged new ways of working in an innovative way. It must be BDA member led and the focus should be a dietetic intervention, which demonstrates positive outcomes for the profession and the service user. The winner of this award receives £1,500. The application must be submitted by at least one BDA member involved in the work. The deadline for submission for all three awards is 6th January 2017.

You can find more information on the application process and criteria for all three awards on the BDA website:

www.bda.uk.com/about/corporate/bdaawards

Good luck to everyone who enters! www.NHDmag.com December 2016 / January 2017 - Issue 120

DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES

Modules for Dietitians and other Healthcare Professionals • Diabetes I (D24D01) 26th January 2017

University of Nottingham Gastroenterology (D24GE1) 14th & 15th December www.nottingham.ac.uk/biosciences Contact: Katherine.lawson@nottingham.ac.uk National Obesity Awareness Week 12th-19th January www.nationalobesityforum.org.uk/

• Diabetes 2 (D24D02) 12th & 13th January & 15th, 16th, & 17th March 2017

• Understanding Behaviour Change (D24UCB) 8th, 9th & 10th February & 23rd March 2017 For further details, please email Katherine. lawson@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’.

Introduction to Mental Health, Learning Disabilities & Eating Disorders 16th January - Derby www.ncore.org.uk Contact: dhft.ncore@nhs.net Behaviour Change Training Part 1 Dympna Pearson & Associates 24th January - Royal Derby Hospital, Derby www.ncore.org.uk Contact: dhft.ncore@nhs.net

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

BARIATRIC DIETITIAN - SUITABLE FOR EXPERIENCED OR NEWLY QUALIFIED DIETITIANS £22,000-£28,000pa Permanent. Up to 37.5hrs/week The Hospital Group is the UK’s leading private provider of bariatric (obesity) surgery, providing gastric balloon, gastric band, sleeve gastrectomy and gastric bypass surgery. We have a fantastic opportunity for a Registered Dietitian to join our professional and enthusiastic team of clinical and non-clinical staff at either our Bristol, Cardiff, Cambridge or Newcastle clinic. We are looking for a Bariatric Dietitian with a Dietetics degree and registration with the Health & Care Professions Council. We will accept applications from newly or recently qualified dietitians – you do not need to have any experience in bariatrics, although this is

welcomed. The role will mainly involve conducting telephone and face to face consultations with preand post-op bariatric patients. There will also be opportunity to: • Update existing and create new patient literature • Train in performing gastric band adjustments after 18 months in post (full training will be provided), resulting in a salary increase • Be involved in clinical audit • Be involved in training initiatives for colleagues in the Obesity Service in order to provide a consistent approach to the delivery of evidence based nutritional information Please call the HR Department on 0121 445 0241 or email HRdepartment@thehospitalgroup.org for an application form.

dieteticJOBS.co.uk To place an ad or discuss your requirements please call

01342 824 073 (local rate) 46

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THE FINAL HELPING 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.

It’s that time of year again when some of you will be thinking about what Christmas presents to buy and others may be wondering how best to get away from it all! Well, I’m going to try to offer advice on both. Firstly, to Christmas presents. You might wish them to be a little different this year. In so doing, let me take you back in time to Enid Blyton and her ‘Famous Five’ who starred in 21 books published between 1942 and 1963. Fast forward 50plus years and the child-friendly Enid Blyton Ladybird books have now been revamped for an adult audience by bestselling humour writer Bruno Vincent. Let me draw your attention to the title Five Go Gluten Free. For me, the fact that gluten-free has been selected as a ‘storyline’ says everything about how we have been ‘hoodwinked’ into believing that we should now all follow the glutenfree path to some nutritional utopia. In the book, Anne encourages the group to adopt an entirely gluten-free diet and the gang is dependent on nut and seed power balls for their energetic escapades, while secretly longing for a pint of real ale and a bag of pork scratchings. I could go on, but it would spoil the fun! Published by Quercus and priced at £7.99. Getting away this Xmas may be easier than wrapping presents, but if you are considering flying, then watch your weight. By this I do not necessarily mean your own, but what else you are bringing with you. My most recent experience involved summer clothing in one suitcase (20kg maximum weight) and hand luggage. We were allowed 10kg of walk-on hand luggage each in a maximum of three bags each. Excellent. These were not weighed on departure, but were within the 10kg. We also paid for seats together at the front of the plane.

Going out there were no problems except that, as the plane was not full, our seats were relocated and we had to sit at the back in order to ‘balance the plane’. No refund. Coming back was different. We had in total three walk-on bags. All three together weighed less than 20kg. However, on weighing two together, they were over the 10kg limit for one person and I was told that I would have to pay for the excess hand baggage which was considerable. This situation was not helped by the passenger in front of me at the checkout being a rather ‘heavy’ chap and likely to be sitting alongside me on the plane! The customer services checkin lady then said that they were doing an audit and my hand baggage could be placed in the hold free of charge as the plane was full and they would value the space in the overhead lockers! I accepted rather than have to open and repack two cases with a long queue behind me. In a final act of irony, I turned to the onboard magazine and read an article about Hawaiian Airlines winning the right to weigh people before they board their planes. They have stopped pre-booked seating and instead assign seats to passengers when they arrive to ensure weight is evenly spread around the plane! Hawaiian Airlines have been required to redistribute weight in their Boeing 767 cabins to meet manufacturer’s guidelines. This could be a heavy weight topic if more airlines do the same . . .

www.NHDmag.com December 2016 / January 2017 - Issue 120

Getting Nan back to her old tricks again!

is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut function when compared with fasting or supplementary water.1 Helping patients get back to doing the things that they enjoy sooner.

Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision. 1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.

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