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

December 2016 / January 2017: Issue 120


Chronic kidney disease Pages 16 to 18

Neocate: The UK’s No. 1 Amino Acid-Based Formula References: 1. De Boissieu D, Matarazzo P, Dupont C. J Pediatr 1997; 131(5):744-747. 2. Vanderhoof JA, Murray MD, Kaufman S et al. J Pediatr 1997; 131 (5):741-744. 3. Koletzko S, Niggemann B, Arato A, et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221-229. 4. Venter C, Brown T, Shah N, et al. Clinical and Translational Allergy 2013; 3(1):23. 5. Ludman S, Shah N, Fox A. BMJ 2013; 347-355. 6. Fiocchi A, Brozek J, Schßnemann H, et al. WAO J 2010; 3:57-161. 7. Hill DJ, Murch SH, Rafferty K et al. Clin Exp Allergy 2007; 37(6):808-822. Neocate is a Food for Special Medical Purposes for use under medical supervision, after consideration of all feeding options including breastfeeding. eHF=Extensively Hydrolysed Formula; AAF=Amino Acid-Based Formula; GI= Gastro Intestinal


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. Merry Christmas and a Happy New Year to you all. Emma December 2016 / January 2017 - Issue 120



11 COVER STORY Fussy eating in toddlers and young children



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 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 Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email


Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES December 2016 / January 2017 - Issue 120

ISSN 2398-8754

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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. @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 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.

6 December 2016 / January 2017 - Issue 120



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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Clinical Nutrition Vol 104, no 4. pg 1083-92.

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. December 2016 / January 2017 - Issue 120



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

The term ‘Mediterranean Diet’ 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

8 December 2016 / January 2017 - Issue 120

Figure 1: The Med Diet Pyramid (from

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 4 December 2016 / January 2017 - Issue 120



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