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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
June 2017: Issue 125
COPD: NUTRITION AND WEIGHT MANAGEMENT DIET TRENDS SUGAR & SALT UPDATE FORMULA MILKS PKU HISTORY
More information from the BDA page 40
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.
As I write this Welcome, it is the day after the 2017 Eurovision song contest and Portugal’s Salvador Sobral has won with Amar Pelos Dois (meaning ‘Love for two’). Not everyone’s favourite choice, but nonetheless, it came through as the endearing winner. The first contest took place in 1956, as post-war Europe rebuilt itself. Since then, Eurovision has been a beacon of international performance for all to enjoy and has stood the test of time. The British Dietetic Association, another institution that has stood the test of time, is holding their annual Dietitians Week event (12th-16th June 2017) with the theme ‘Evidence and Expertise’. This year, it is ‘an opportunity to encourage a positive discussion about evidence-based nutrition to counter the fads and pseudoscience that unfortunately continue to garner social media shares and column inches.’ You can find more information at www.bda. uk.com/news and www.foodmatterslive. com/news-and-comment/news/ Dietitians-Week-2017. This month we are proud to support Dietitians Week and we bring you plenty of evidence-based articles written by numerous expert dietitians. COPD can be a challenging condition for patients to manage and cope with; maintaining a healthy weight and dietary intake is important for optimum patient outcomes and quality of life. Alice Lunt RD, Health Advisor for the British Lung Foundation takes us through the key points for weight management for patients with COPD. We welcome back Dr Carrie Ruxton with her update on salt and sugar in food, discussing current recommendations and industry changes, while Claire Chaudhry RD returns with an interesting read about the high protein diet trend
Lys Assia, winner of Eurovision, 1956
hitting our social media screens and supermarket shelves at a rate of knots. Whilst diet trends are one thing, the way we perceive our body image can heavily influence our eating behaviours. Nikki Brierley RD shares a thought-provoking article reflecting on the development of body image and the impact this has on our physical and mental health. For our paediatric feature, we are pleased to share a fantastic update on infant and young child formula milk written by Jacqui Lowden RD. As always, Jacqui provides an expert guide through current legislation and recommendations for this specialist topic. We are also very excited to share another IMD Watch article from Suzanne Ford, NSPKU Dietitian with contributions from Christine Clothier, Paediatric and Metabolic Dietitian at Alder Hey Hospital (1965-1992). Suzanne has complied a fascinating journey through the history of PKU management and treatment. We introduce a new Student zone column by Simon Langley-Evans which we hope you enjoy. Don't miss our other regular features including Dr Emma Derbyshire’s Food for thought news roundup, Ursula Arens’s F2F column. I’m off to practice my yodelling for next year’s Eurovision Song Contest! Enjoy the read. Emma
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11 COVER STORY COPD: Nutrition and weight management
Sugar & salt update
Latest industry and product updates
New initiatives to reduce intake
19 INFANT & YOUNG CHILD FORMULA MILKS The current UK market
37 FACE TO FACE With Stefan Gates, Food Writer & Broadcaster 40 BDA update Getting ready for
Dietitians Week 2017
42 Prof Blog A new Student zone
24 Body image
Impact of eating behaviours
column.This month: Early origins of disease
44 Web watch Online resources
28 IMD WATCH
PKU in the UK: the early years
46 Events & courses Dates for your diary
33 Diet trends: High protein diets for weight loss
47 The final helping The last word from Neil Donnelly
Copyright 2017. 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 email@example.com 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 firstname.lastname@example.org Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email email@example.com www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES
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@NHDmagazine ISSN 2398-8754
So, for a range of products that support feeding with breastmilk and contain ingredients that help preterm babies thrive, choose Nutriprem.
From birth to discharge and beyond, the ESPGHAN-Compliant1 Nutriprem range has been designed to aid the development of preterm babies.
EVERY DROP MATTERS Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortifier is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and lowâ€“birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85â€“91.
FOOD FOR THOUGHT
Dr Emma Derbyshire Independent Consultant 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.
New sugar tax approved It has now been announced that a new sugar tax on the soft drinks industry will take place. This was announced as part of the Chancellor’s budget and has been the topic of conversation for a long time, but, nevertheless, came as somewhat of a surprise to the soft drinks industry. Jamie Oliver and his team have played a key role in driving and getting this levy. He was the first to introduce a sugar tax levy in his restaurants and establish an e-petition which was signed by more than 150,000 people backing such a tax. Putting the new tax into practice, sugary drinks are to be graded into two bands. The highest band will contain more than 8g total sugar per 100ml and be levied at 24p per litre. The second band will have a total sugar content of more than 5g per 100ml and cost an extra 18p per litre. So, will this really make a difference? That has been much divided opinion about this approach. One of the criticisms is that there is no evidence that taxing a single food or ingredient can help to reduce obesity levels. Also, foods such as chocolate are not to be taxed as these are regarded as a treats rather than everyday foods and drinks - though it is questionable whether this is really the case. There is potential to extend such a levy to other foods. A simple supermarket online search for ‘children’s/kids cereals’ undertaken by Nutritional Insight, identified more than 100 brands that were chocolate or ‘cookie’ flavoured. For me, starting the day with sugary, chocolate-flavoured breakfasts doesn’t sit well. Equally, there is scope to look at the ‘treat market’ as a whole and fuel investment and marketing into this. So, it seems that this is a step in the right direction. That said, it is also important to establish a data collection scheme alongside the new levy, to evaluate whether such a levy leads to measurable effects or not. This can then lead to future modifications - be it levy adjustments or the application to other products. So, perhaps we should stave of judgements until we find out whether this works or not. For more information, see: www.foodmanufacture.co.uk/Ingredients/Sugar-tax-announcement-praised-andcondemned; www.bbc.co.uk/news/health-35824071
UNHEALTHY TREAT CULTURES HAVE LASTING EFFECTS Imaging studies reveal that obese individuals show greater reward and reduced inhibitory region responsivity to food, which may predict future weight gain. New research published in the American Journal of Clinical Nutrition has examined whether the brainreward response is related to future weight variability. A total of 127 healthy-weight adolescents, aged 14-18 years, were assessed annually for three years. Using functional magnetic resonance imaging, neural responses to cues of impending and actual receipt of high-calorie, palatable foods were measured over the follow-up period. Findings revealed that cognitive reappraisal strategies - particularly those focusing on the benefits of not eating certain highly palatable, calorific foods, could potentially assist in the design of obesityprevention programs for young people. For more information, see: Winter S et al (2017). American Journal of Clinical Nutrition, Vol 105. No 4, pg: 781-789
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NEWS B6 DEFICIENCY MAY DRIVE UP COLORECTAL CANCER RISK Colorectal cancer is the third most common cancer in both men and women worldwide. Identifying modifiable dietary factors is essential to developing primary prevention strategies. Growing evidence indicates that vitamin B-6 may influence colorectal cancer risk in multiple ways, including a reduction of inflammation, cell proliferation and oxidative stress. New research using data from the Northern Sweden Health and Disease Study followed 613 cases from 1985 to 2009, during which time, concentrations of the vitamin B-6 marker, pyridoxal 5’-phosphate (PLP) (the active form of vitamin B-6), were measured along with associated markers of inflammation and oxidative stress. Results revealed a clear association between vitamin B-6 deficiency and colorectal cancer risk, with indications of a role in tumour progression rather than initiation. These are significant findings, highlighting that vitamin B-6 shortfalls may be increasing both the risk and proliferation of the disease. Continued research is worthy of further exploration in this important area of work. For more information, see: Gylling B et al (2017). American Journal
NETWORK HEALTH DIGEST
www.NHDmag.com A wealth of useful dietetic resources for all dietitians and nutritionists
Make the most of your NHD Community!
of Clinical Nutrition, Vol 105. No 4, pg: 897-904
DRINKING SOFT DRINKS IN PREGNANCY LEADS TO BIGGER BABIES The prevalence of overweight and obesity among adults and children has reached alarming proportions over the last few decades. Whilst clear associations have been established between the consumption of sugar-sweetened beverages and risks for obesity, diabetes and heart disease amongst the adult population, the outcome of intakes during pregnancy and the effect upon body mass index and body composition during early years remains unclear. Using data from The Generation R Study, a population-based prospective cohort from foetal life onward examined the data of 3,312 mother-child pairs from pregnancy up to six years of age. Sugar-containing beverage intake was assessed during the first trimester, with a food-frequency questionnaire. Children’s anthropometric data and BMI measurements were collected repeatedly up to six years of age when both fat mass and fat-free mass were measured. Results revealed the mother’s total sugar-containing beverage intake was associated with children’s higher body mass index and final fat mass measurements. These are important findings and, whilst further studies are needed to reconfirm the results, the evidence suggests that strategies focusing upon childhood obesity can track right back to pregnancy. For more information, see: Jen V et al (2017). American Journal of Clinical Nutrition, Vol 105. No 4, pg: 834-841 www.NHDmag.com June 2017 - Issue 125
SUGAR AND SALT UPDATE Carrie Ruxton PhD, Freelance Dietitian, Cupar, Scotland
Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods.
For full article references please email info@ networkhealth group.co.uk
Since dietary guidelines were first published in the UK, there has been a drive to reduce levels of sugar and salt in foods and beverages. Now, a levy will be introduced from April 2018, applying for the first time a direct tax on the sugar content of soft drinks. This article provides an update on recent activities to lower the sugar and salt content of our diet. Until recently, government action has involved direct messaging to consumers, as well as voluntary targets for industry reformulation, mainly directed at salt. Controls on advertising of so-called ‘high fat salt and sugar’ (HFSS) foods to children have also been implemented. In 2015, the Scientific Advisory Committee on Nutrition (SACN)1 set a new target for free sugars of 5% of daily energy; the previous target being 10% energy. Free sugars include all mono- and disaccharides added during processing or cooking, plus those sugars naturally present in honey and fruit juices. Current intakes are far higher than this at around 11% energy in adults and 13-15% energy in children. Maximum recommended salt levels have not changed since 1994 and are 6g per day for adults, with lower amounts advised for children.2 Current intakes in adults are estimated to be around 8g per day,3 but have reduced by 15% in recent years in part due to reformulation. Table 1 presents current recommendations for salt and free sugars. JUSTIFICATION
The 2015 SACN report1 set out the evidence for supporting a sugars reduction, including links between higher intakes of added/free sugars and a greater risk of dental caries in children, as well as higher energy intakes in adults. Consumption of sugar-sweetened soft drinks was associated with dietary energy, body mass index, risk of weight gain and risk 8
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of Type 2 diabetes. SACN estimated that lowering free sugars to 5% energy would reduce daily energy intake by around 100kcal. The main justification for salt reduction is to prevent cardiovascular mortality and morbidity. In 2003, a report by SACN4 highlighted strong associations between high salt intake and high blood pressure, concluding that a reduction in the average salt intake of the population, from 9.5g to 6g daily would lower blood pressure levels and confer significant public health benefits by reducing the risk of cardiovascular disease. HISTORIC ACTION AND PROGRESS
Action to lower sugar consumption has mainly been targeted via dietary advice (e.g. dietary reference values, Eatwell Plate/Guide), a ban on advertising HFSS foods and drinks during children’s TV programming, and a push for manufacturers to adopt front-ofpack (FOP) labelling which displays the macronutrient content in a standardised colour-coded format. Although progress has been slow, there is a trend towards reduced sugar intakes over the past few decades. For example, in the 2000 National Diet and Nutrition Survey (NDNS), the mean percentage energy from non-milk extrinsic sugars was 13.6% in men and 11.9% in women.5 In the most recent NDNS,6 intakes were 12% in men and 11.3% in women. Children’s intakes have also reduced from around 17% in
Table 1: Recommended maximum intakes Free sugars (g/day)
Under 1 year
Should not be given
Should not be added
11 years and over
19987 to 15% in 2014. Indeed, the NDNS showed a statistically significant reduction in sugars from 14% to 13% in children aged 4-10 years.6 However, further action will be needed to move intakes towards the more challenging 5% energy target set recently. Barriers to sugar reductions include consumer taste preferences and the structural role of sugar in certain products, e.g. biscuits, cakes, breakfast cereals. For salt, government action has been mainly targeted at manufacturers via a series of four voluntary salt reduction targets (from 20062014), which set levels for 80 individual product categories. According to the campaigning group CASH, salt reduction in the UK has been a success, with many food products now 20-40% lower in salt.3 This was confirmed by the Institute of Fiscal Studies which reported a reduction in salt intake of 5.1% between 2005 and 2011.8 Interestingly, the reduction was mainly due to the impact of reformulation, since, during this period, households tended to purchase saltier food products. The out-of-home sector remains an issue, as it was not subject to the voluntary reformulation targets. Salt reformulation appears to have impacted on health as suggested by an analysis of blood pressure and heart disease data from 2003-2011 using the Health Survey for England.9 This revealed significant reductions in mortality from stroke and ischaemic heart disease alongside reductions in blood pressure and salt consumption, although there were also positive changes to smoking prevalence and cholesterol levels. Another strand of government action, targeting both sugar and salt, is the Responsibility Deal which encouraged major players in the industry to make voluntary pledges to lower sugar, salt and calories. However, critics of this policy felt that industry did not go far enough, while the voluntary nature of the policy was
believed to create a non-level playing field. A recent evaluation10 of the Responsibility Deal found only modest progress in the fulfilment of pledges and evidence that the more challenging courses of action, particularly sugar reduction and marketing restrictions, were not being chosen by companies. Progress on FOP labelling has also been patchy as many food businesses have either declined to adopt the traffic light system or have introduced their own colour coding. According to a 2009 evaluation,11 most consumers are aware of the concept of FOP labelling, but find the myriad of different systems confusing, potentially creating a barrier to fuller engagement. NEXT STEPS
Work continues to lower the sugar and salt content of the British diet. Public Health England (PHE) is currently meeting with food business leaders to agree sugar reduction targets over the next three years and to set reasonable maximum portion sizes and calorie caps for food product sectors.12 If successful, this will achieve a 20% reduction in sugar from nine food categories by 2020. The duel focus will support obesity prevention which relates more to daily calories consumed rather than to individual macronutrients. Soft drinks industry levy A soft drinks industry levy (SDIL) will be introduced from April 2018 targeting commercial sweetened beverages and applying, for the first time, a direct tax on the sugar content of soft drinks. The policy is directed at manufacturers rather than consumers or distributors and will charge a levy on drinks with an added sugar content of >5%, with a higher charge applying if drinks contain >8% added sugars. Fruit juices and most milk-based drinks will be exempt.13 The threat of fiscal measures has already resulted in www.NHDmag.com June 2017 - Issue 125
an additional round of reformulations amongst key players. For example, Coca-Cola announced in March this year that Fanta Orange had been reformulated to lower the sugar content from 6.9g to 4.6g per 100ml, which now puts it under the SDIL threshold.14 Turning to salt, PHE this year republished the 2014 salt targets which were due to be implemented by the end of 2017.15 Additional salt targets may be set later in the year, but will be part of PHE’s larger reformulation policy, bringing together sugar, salt and calorie reductions.
After several years where progress was minimal, PHE and other bodies, such as Food Standards Scotland, have ramped up activity to encourage food businesses to make meaningful cuts to the sugar, salt and calorie contents of their products. This is expected to impact favourably on consumer health and lower the risk of obesity. The food industry has generally responded favourably to the policies, with a good track record on salt reduction and now has a challenging time ahead to fulfil expectations regarding sugar and calorie reduction.
EXAMPLES OF REFORMULATION • Nestlé announced in March that it would cut the sugar content of its confectionery brands by 10%.16 • 95% of Ferrero products come in portions of less than 150kcal. • In 2015, Cereal Partners launched Less Than 5% Sugar Oat Cheerios with 1.4g of sugar per serving. • In 2015, Quaker launched a Granola range with 30% less sugar and fat than the average product on the market. • Food ingredient manufacturer Macphie reduced the sugar content of its muffin mix by 30% using prebiotic fibre. • Sugar from Coca-Cola drinks products decreased by 18% between 2012 and 2017. • 75% of Pepsi’s estimated retail sales for 2016 were in no-sugar colas. • In 2015, Britvic’s decision to only produce and sell Robinson’s No added Sugar squash removed 6.9 billion calories from the UK soft drinks market. • In 2015, Unilever reformulated the Lipton Ice Tea range using Stevia to reduce sugar levels by 30%.
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COPD: NUTRITION AND WEIGHT MANAGEMENT Alice Lunt, Health Advisor for BLF and Cardiorespiratory Dietitian at Royal Brompton Hospital, London
This article has been put together by British Lung Foundation (BLF), Charity that promotes lung health and supports those affected by lung disease.
For full article references please email info@ networkhealth group.co.uk
One of the many lung conditions that good nutritional management is important for is chronic obstructive pulmonary disease (COPD). COPD can have an effect on the whole body. It is, therefore, vital that people living with the condition maintain a healthy weight and eat a balanced varied diet. This will help with maintaining strength and fitness, as well as supporting the body with fighting infections.1 Food provides the body with energy, including energy to breathe. At rest, COPD patients need to use up to an additional 15% of energy compared with a healthy person, to compensate for the extra physical effort required to breathe. This equates to an estimated additional 430-720 calories per day. Should these additional calories not be consumed, the patient will experience significant weight loss and be at an increased risk of cachexia.2 It has been estimated that around 21% of individuals with COPD (up to 630,000 people) are at risk of malnutrition.3 Conversely, COPD can lead to weight gain due to patients becoming less physically active. Carrying additional body weight increases their risk of cardiovascular disease, high blood pressure, high cholesterol and diabetes. Despite this, most current guidelines and evidence focus on being underweight and malnutrition, rather than general optimal health or being overweight. Facts about COPD in the UK: • It is a group of lung conditions where inflammation and damage cause the airways to be narrowed, making it difficult to empty air out of the lungs. • This includes emphysema and chronic bronchitis. • After asthma, COPD is the second
most common lung disease. • Estimated 1.2 million people, or 2% of the population, are living with diagnosed COPD (2011). • Research from BLF also suggests that prevalence is growing. • There is higher prevalence in the North and Scotland than the South of the UK. • Someone is newly diagnosed with COPD every five minutes.4 MAINTAINING A HEALTHY WEIGHT
Someone with COPD may find their weight increases due to being less physically active and, in those needing steroidal medications, their appetite may increase. If a COPD patient is overweight they will require more effort to breathe and move around. Stored fat compresses the lungs making physical activity harder. Bending also becomes very difficult and leads to breathlessness. A Body Mass Index (BMI) of between 20 and 30kg/m2 is a healthy weight for someone with COPD. Alternatively, waist circumference measurement may be more useful (see Figure 1 overleaf). There are a number of practical tips to help patients make dietary changes. Recommend that they: • check portion sizes and try using a smaller plate; • fill up on vegetables or salad - these should cover about half the plate; www.NHDmag.com June 2017 - Issue 125
FROM HOLDING BACK.. . .TO HOLDING JACK
. .In a shot SOMETIMES PATIENTS CAN’T MEET THE ENERGY REQUIREMENTS THEY NEED THROUGH NORMAL DIET AND ONS ALONE.1
IT’s BEEN SHOWN TO:
Little wonder it helps so much
55% 92% 67%
Increase calorie intake by 55% IN ADDITION TO NORMAL diet 2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4
Pro-Cal shot is a food for special medical purposes and should be used under strict medical supervision. ® Reg. Trademarks of Société des Produits Nestlé S.A.
Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ, UK. Tel: 0151 709 9020 vitaflo.co.uk abbottnutrition.co.uk A Nestlé Health Science Company
References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.
All information correct at the time of print. December 2016
Figure 1: Ideal waist circumference measurement
• avoid frying foods; instead they should try to grill, steam, boil, bake, dry roast or microwave; • choose low-fat options such as skimmed or semi-skimmed milk, low-fat spread and low-fat yoghurts; • choose ‘diet’, or ‘no added sugar’ drinks and puddings; • try sweeteners or gradually reduce the amount of sugar added; • check food labels; • exercise as able, often pulmonary rehabilitation groups are appropriate. In addition, try to get patients to think about why they eat: • Why do they snack between meals? • Are they really hungry? • Is this hunger or actually thirst? • Are they bored and eating out of habit or for comfort? • Have they tried distracting themselves with another activity? SPECIFIC NUTRIENTS
Eating a well-balanced diet, with the right portions of the five key food groups, will not only help patients maintain a healthy weight, but will ensure that they get the right nutrients
to keep them strong and well. The Eatwell Guide is a helpful overview not only for those with COPD, but also friends and family (see Figure 2 overleaf).5 Each of these food groups will contribute to keeping patients healthy: Fruit and vegetables contain vitamins and minerals which boost the immune system and help fight off chest infections.6 Most people can get everything they need by eating a varied well-balanced diet and, therefore, do not need to take a multivitamin. They’re also a great source of fibre, which can help you feel full if trying to lose weight. Starchy carbohydrates give the body energy to perform a range of tasks including breathing. Patients should aim for high fibre or wholegrain versions, which can help them to feel full, keep bowels moving and contain more nutrients including B vitamins and folic acid. Protein helps to keep muscles strong, including the muscles in the chest that help the ribs expand when breathing. It’s also important for the immune system and blood cells.7 Due to the time it takes to digest protein, it helps us to feel full and when taken from a variety of sources, i.e. fish, pulses and lean meats, it can help with balancing intake of fat, fibre and omega-3. www.NHDmag.com June 2017 - Issue 125
MY COPD MEANS MY APPETITE HASNâ€™T BEEN VERY GOOD...
Figure 2: Eatwell Guide
Check the label on packaged foods
Use the Eatwell Guide to help you get a balance of healthier and more sustainable food. It shows how much of what you eat overall should come from each food group.
Each serving (150g) contains Energy 1046kJ 250kcal
3.0g 1.3g LOW
34g 0.9g HIGH
of an adult’s reference intake Typical values (as sold) per 100g: 697kJ/ 167kcal
Eat at leas t5
Chopped t omatoe s
Whole grain cereal
Bagels Whole wheat pasta
Limit fruit juice and/or smoothies to a total of 150ml a day.
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s, p Ea ulse s, fis so t mor h, eg gs, mea red urced e beans t and other proteins and and fish p proc er we pulses, 2 portions of sustainably ek, one esse of which is oily. Eat less d mea t
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s tive rna alte and and t Dairy a f r
we tions se lo Choo ugar op s lower
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Choose unsaturated oils and use in small amounts
2500kcal = ALL FOOD + ALL DRINKS
Source: Public Health England in association with the Welsh Government, Food Standards Scotland and the Food Standards Agency in Northern Ireland
© Crown copyright 2016
Foods that contain protein are also a good source of important minerals, including: selenium (keeps the immune system healthy), iron (helps carry oxygen around the body) and zinc (which helps the body’s ability to heal). Dairy foods are a good source of proteins, vitamins and minerals, including calcium which helps to keep your bones healthy. When taking steroids or becoming less active, the mineral calcium is especially important. This is because steroids can weaken bones and increase the risk of brittle bones or osteoporosis.8 Dairy foods can be high in fat causing patients to put on weight. If overweight, they should be advised to choose lower fat alternatives where possible (i.e. lower-fat and lower-sugar products like 1% fat milk, reduced-fat cheese or plain lowfat yoghurt).
this. Generally, dairy should be included unless diagnosed with a food allergy. If someone reports that dairy makes their mucus stickier or harder to shift, suggest rinsing the mouth or drinking a little water following consumption of milk products. If cows’ milk causes problems, other calcium enriched non-dairy products, such as dairyfree milks, yoghurts, desserts or cheese are recommended to help maintain bone strength.
Crown copyright. Source: Public Health England in association with the Welsh government, Food Standards Scotland and the Food Standards Agency in Northern Ireland.
FACT OR FICTION? MILK AND MUCUS9,10,11
Some people worry that if they eat dairy foods they’ll produce more mucus. However, currently there’s not enough scientific evidence to support
Oils in small amounts in a diet are important to provide certain vitamins: vitamins A and E (for fighting infections), vitamin D (for healthy, strong bones) and vitamin K (for regulating blood clotting and healing wounds). These are found in certain foods, such as nuts, oily fish, avocado and sunflower and olive oils. However, eating too much animal and saturated fat can make it harder to maintain a healthy body weight and can increase the risk of high cholesterol and heart disease. www.NHDmag.com June 2017 - Issue 125
CONDITIONS & DISORDERS
Many people with a lung condition have a dry mouth. This can be caused by breathing through the mouth, taking certain inhaled medications and using oxygen treatment. Food and drinks high in fat, salt and sugar, such as cakes, crisps and sugary soft drinks, which are not needed in a diet, have minimal nutritional value and should be eaten less often in small amounts.
A good aim would be for a patient to drink a minimum of six to eight cups of fluid a day. This can include water, tea, coffee, milk, squash or fruit juice.13
Having a lung condition can have a number of adverse effects on someone’s diet. Patients may experience dry mouth, taste changes, or be too breathless to eat, for example. In these situations, there are a number of steps which can help them maintain a healthy weight and balanced diet. Sometimes people with lung conditions feel too breathless to eat, chew or swallow. Recommend that they: • choose softer, moist foods that are easier to chew and swallow;14 • have nourishing liquids such as milk, smoothies, juice, and soups; • try eating smaller, more frequent meals and snacks; • take time when eating and try to swallow every mouthful before going onto the next.
COPD patients are at risk of being deficient in vitamin D. Vitamin D works with calcium and phosphorous from dairy foods in the body for healthy bones, muscles and teeth. Vitamin D comes from sunshine, not food, therefore, eating a healthy balanced diet is unlikely to provide enough vitamin D. People should consider taking a daily supplement of vitamin D (10 micrograms), especially the following who are at higher risk of becoming vitamin D deficient: • People over 65 years old: this is because their skin is not as good at making vitamin D. • People with darker skin tones: this includes people of Asian, African, Afro-Caribbean and Middle Eastern descent. • People who always cover most of their skin when they’re outside. • People who spend very little time outside during the summer: this includes people who are housebound, shop or office workers and night shift workers. • Pregnant women and breastfeeding mothers. • The further north you live, the more at risk you are of becoming vitamin D deficient and you’re also more at risk if you live somewhere where the air is polluted.12 KEEP DRINKING WATER
It is very important for COPD patients to drink plenty of fluid. This helps to keep them hydrated and keeps mucus moving. If mucus sits in the airways and lungs, they are more likely to get an infection. 16
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HOW CAN FOOD AFFECT SYMPTOMS?
Many people with a lung condition have a dry mouth. This can be caused by breathing through the mouth, taking certain inhaled medications and using oxygen treatment. Recommend the following: • Make sure the patient is drinking enough fluids - at least six to eight cups a day. Ice cold drinks can be refreshing. • Aim for them to eat more soft foods, use more sauces such as gravy and cheese sauce and eat dishes that are moist such as stews. • After using inhalers, they must try to remember to rinse their mouth out and gargle with water. • Make sure they look after their teeth and mouth by brushing regularly and using dental floss. • Let them try sugar-free gum or mints, frozen grapes, pineapple or orange segments to help produce more saliva.
• Smoking and alcohol can irritate a dry mouth. These should be reduced to limit any discomfort. • If a dry mouth is causing soreness or problems with eating then they should speak to a doctor. Products that help produce saliva are available on prescription. A dry mouth can mean that a patient’s sense of taste changes. This is very common. They can try experimenting with different herbs, spices, chutneys and pickles, but should avoid adding extra salt. The feeling of breathlessness can make people gulp air when eating which leads to bloating or trapped wind. Recommend that they: • eat in a relaxed environment and sit in an upright position; • don’t rush and make sure food is chewed well; • limit fizzy drinks; • watch out for some foods which can produce more gas than others, such as cabbage, sprouts, broccoli, cauliflower and beans; • try using peppermint which can help some people with bloating and trapped wind. This can be in the form of tea, a cordial or a capsule. UNINTENTIONAL WEIGHT LOSS
At the opposite end, patients with COPD may lose weight because eating makes them breathless. They may also find it more difficult to shop and prepare meals if they are tired or out of breath.2 This puts patients at risk of malnutrition, which can in turn weaken the breathing muscles and lead to chest infections.13 Patients who find they are losing weight or have lost their appetite can be advised to do the following:
• Eat little and often, for example, having snacks between meals throughout the day. • Have nourishing drinks such as full-fat milk, hot chocolate, malted drinks, flavoured milk and milkshakes or smoothies. • Avoid drinking before a meal instead drink after eating and between meals. • Fortification of meals, i.e. having full-fat items, adding cheese or milk to foods. • They may need nutritional supplements, or add three to four tablespoons of dried skimmed milk powder to a pint of milk. Local meal delivery services may be beneficial, or referral to a social services team which might be able to provide an occupational therapy assessment and equipment around the house to make life easier.
Summary check list: • Working towards an optimal weight and waist circumference • Balanced and varied diet in line with Eatwell Guide • Adequate protein • Sources of calcium • Vitamin D supplement may be required • Well hydrated • Is lack of food or too much food affecting their symptoms? SUMMARY
In summary, being a healthy weight and having good nutritional intake are very important for people living with COPD. If a patient is very overweight, it becomes harder for their heart and lungs to supply oxygen to the body. Likewise, if they are too thin they are at an increased risk of infections. Eating a balanced and varied diet will aid them in fighting infections. When patients are feeling strong and well, healthy eating will also help keep them stay this way.1
For further information: • British Lung foundation at www.blf.org.uk. The BLF Helpline on 03000 030 555 have a friendly helpline team who can offer advice on healthy eating and answer questions on any aspect of living with a lung condition. • For more information on healthy eating go to www.nhs.uk or the British Dietetic Association food facts website www.bda.uk.com/foodfact ; • For details of local food delivery services go to www.gov.uk www.NHDmag.com June 2017 - Issue 125
Why we’re simply made from whole goat milk.
In the management of healthy babies who are not being breast-fed, Nannycare First Infant Milk provides an effective alternative to standard cow’s milk formula. Made from fresh whole goat milk, it has a mild taste, requires minimal processing and has no unnecessary added ingredients. Nannycare formulations, from the originator and innovator of goat milk formula worldwide for over 20 years, are fully regulated and approved for infant feeding. Readily available in leading supermarkets:
For Healthcare Professional Use Only Helpline UK 0800 328 5826, ROI 1800 937 375 firstname.lastname@example.org www.nannycare.co.uk IMPORTANT NOTICE: Breastfeeding is best for babies. Infant formula should only be used on the advice of a healthcare professional. Good maternal nutrition is important for breastfeeding. Reversing a decision not to breastfeed is difﬁcult and combined breast and bottle feeding in the ﬁrst weeks of life may reduce the supply of your own breastmilk. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. Please note that Goat Milk formula is not suitable for conﬁrmed cases of cow’s milk protein allergy (CMPA), unless directed by a suitably qualiﬁed healthcare professional.
INFANT AND YOUNG CHILD FORMULA MILKS: THE CURRENT UK MARKET Jacqui Lowdon Paediatric Dietitian, Team Leader Critical Care, Therapy & Dietetics, RMCH
The infant and young child formula milk market in the UK is dominated by four major brands. However, there is an increasing range of formulae becoming available even though infant and young child formula milks* are amongst the most strictly regulated foodstuffs. Here, Jacqui Lowdon takes a look at the products on the market and the related legislation and regulations.
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.
There are currently four major brands in the UK offering infant and young child formula milks: Aptamil (Nutricia, owned by Danone), Cow & Gate (Nutricia, owned by Danone), SMA Nutrition (owned by Nestlé) and HiPP Organic (owned by HiPP). This can make it difficult for parents to choose an appropriate formula for their infant, but also can make it difficult for health professionals to keep up to date (see Table 1, p21, 22). There are three types of standard formula: • Infant formula (IF) is designed to fully satisfy the nutritional needs of babies from birth to six months old, where a mother cannot or chooses not to breastfeed. • Follow-on formula (FOF) is designed to satisfy the nutritional requirements of infants from six months to 12 months in conjunction with complementary foods. • Young child formula (YCF) is suitable for young children from 12 to 36 months. • They can then be further divided into cows’ milk-based, goat milkbased and soya-based. There are then the formulae for lactose intolerance, reflux and partially hydrolysed formulae.
For full article references please email info@ networkhealth group.co.uk
Regulation EU No 2016/127;3 EU Directive 2006/141/EC41 Legislation is strictly enforced, incorporating the principles and aims of the World Health Organisation’s (WHO)
Code on Breastmilk Substitutes.2 In 2016, there was an increasing focus on the regulatory arena. In May, a call for banning of advertising of all formulae for the first three years of life was proposed by the World Health Assembly (WHA).3 At the same time, the Royal College of Paediatrics and Child Health (RCPCH) consulted its members on whether the RCPCH should receive any funding from formula milk companies. Later in 2016, a Bill was introduced to the House of Commons, Feeding Products for Babies and Children (Advertising and Promotion).4 Although “welcomed with appreciation” by its member states, the recent WHA Resolution was not ‘endorsed’, being concluded that its following proposals were too extreme: • to prohibit contact between healthcare professionals and industry; • to further restrict funding; and • to consider foods given to a child up to 36 months as breastmilk substitutes. The membership agreed that the RCPCH should continue to accept funding from formula milk companies, obviously within strict, specified conditions.5 They felt that, although any promotion of IF milk over breastfeeding is unacceptable, an open dialogue between manufacturers, researchers and healthcare professionals relating to clinical research and product development, is essential, so long as it is transparent and accountable. www.NHDmag.com June 2017 - Issue 125
The Bill that was put forward aimed to establish an agency (the ‘Infant and Young Child Nutrition Agency’) to set, monitor and evaluate compositional, safety and quality standards, labelling and nutritional claims for formula milks for babies and young children. However, this would merely duplicate the work already undertaken by existing law. CURRENT REGULATION IN THE UK
In February 2016, the European Commission Delegated Regulation (EU) 2016/17,6 which updates the specific compositional and information requirements for IF and FOF, became a legal requirement, being fully applicable by February 2020 (February 2021 for protein
hydrolysate-based formulae). The previous regulations under Directive 2006/141/EC remain in force until repealed at this date. This regulation specifies the nutritional composition of IF and FOF, including labelling and claims specific to this group. It remains unclear how the UK may determine and enforce regulations as it negotiates an exit from the EU. REGULATIONS AND INNOVATION
In order to reflect the ever-increasing knowledge of infant nutrition, regulations are not fixed, but are subject to change. As would be expected, there is often a time lapse between our scientific knowledge and development.
Table 1: The standard infant and young child milk formulas presently available in the UK (reproduced from First Steps Nutrition, Infant milks in the UK 2017) IF suitable from birth (cows’ milk-based)
Aptamil 1 First Milk Aptamil Profutura 1 First Infant Milk Bebivita 1 First Infant Milk Cow & Gate 1 First Infant Milk HiPP Organic Combiotic First Infant Milk Holle Organic Infant Formula 1 Kendamil First Infant Milk Kendamil Mehadrin First Infant Milk Mamia First Infant Milk Similac First Infant Milk SMA Pro First Infant Milk
IF suitable from birth (goat milk-based)
Goat Milk Formula 1 Holle Organic Infant Goat Milk Formula 1 Kabrita Gold 1 Infant milk NANNYcare First Infant Milk
IF marketed for hungrier babies, suitable from birth (cows’ milk-based)
Aptamil Hungry Milk Cow & Gate Infant Milk for Hungrier Babies HiPP Organic Combiotic Hungry Infant Milk SMA Extra Hungry
Thickened (anti-reflux) IF suitable from birth
Aptamil Anti-reflux Cow & Gate Anti-reflux HiPP Organic Combiotic Anti-reflux SMA Staydown
Soya protein-based IF suitable from birth
Lactose-free IF suitable from birth
Aptamil Lactose Free SMA LF
Partially hydrolysed IF suitable from birth
Aptamil Comfort Cow & Gate Comfort HiPP Combiotic Comfort SMA Comfort SMA HA
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PAEDIATRIC FOF suitable from 6 months of age
Aptamil 2 Follow-on Milk Aptamil Profutura 2 Follow-on Milk Bebivita 2 Follow-on Milk Cow & Gate 2 Follow-on Milk HiPP Organic Combiotic Follow-on Milk 2 Holle Organic Infant Follow-on Formula 2 Kendamil Follow-on Milk Mamia Follow-on Milk Similac Follow-on Milk SMA Pro Follow-on Milk
FOF suitable from 6 months of age (goat milk-based)
Holle Organic Infant Goat Milk Follow-on Formula 2 Kabrita Gold 2 Follow-on Milk NANNYcare Follow-on Milk
Good night milks
HiPP Organic Good Night Milk
Growing-up milks and toddler milks suitable from around 1 year of age (cows’ milk-based)
Aptamil 3 Growing Up Milk 1-2 Years Aptamil Profutura 3 Growing Up Milk Bebivita 3 Growing Up Milk Cow & Gate 3 Growing Up Milk 1-2 Years HiPP Organic Combiotic Growing Up Milk 3 Holle Organic Growing Up Milk 3 Kendamil Toddler Milk Kendamil Mehadrin Toddler Milk PaediaSure Shake Similac Growing Up Milk SMA Pro Toddler Milk
Growing-up milks suitable from around 1 year of age (goat milk-based)
Holle Organic Infant Goat Milk Follow-on Formula 3 Kabrita Gold 3 Toddler Milk NANNYcare Growing Up Milk
Soya protein-based growing-up milks and toddler milks suitable from 1 year of age
Alpro Soya +1 Complete Care
Growing-up milks and toddler milks suitable from around 2 years
Aptamil 4 Growing Up Milk 2-3 Years Cow & Gate 4 Growing Up Milk 2-3 Years HiPP Combiotic Growing Up Milk 4
For example, the decision to include DHA (omega-3) in the list of mandatory ingredients from February 2020.7 Clinical research has been ongoing in this area for the last 20 years and has clearly demonstrated the benefits of DHA for non-breastfed infants. This is also an example of where industry collaborating with healthcare professionals has produced an advancement for the benefit of babies who are not fed with breast milk. UPDATE ON FOLLOW-ON FORMULAE
In January this year, the EFSA Panel on Dietetic Products, Nutrition and Allergies produced a draft scientific opinion on ‘The safety and suitability for use by infants of 22
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follow-on formulae with a protein content of at least 1.6g/100kcal’. The level of protein discussed represents a minimum protein content of around 1.1g/100ml. This is lower than the average for follow-on milk products currently available in the UK. It was concluded that the use of FOF with a protein content of at least 1.6g/100kcal from either cows’ milk protein or goat milk protein and complying with EU legislation is safe and suitable for infants living in Europe with access to complementary foods of a sufficient quality. The safety and suitability of FOF made from either protein hydrolysates or soya protein isolates could not be established with the available data.8
It is essential that health professionals keep themselves updated on the various formulae now available, in order to best advise parents. WHAT IS THE FUTURE OF PRESCRIBABLE INFANT FORMULAE?
Within certain Clinical Commissioning Groups (CCGs), prescriptions of IF are at risk of being restricted. Proposals have included restrictions to soya-based IF, thickened IF, formulae for lactose intolerance and for cows’ milk protein allergy (CMPA). It is imperative that children with CMPA are diagnosed and managed with the most appropriate formula, be that an aminoacid based formula (AAF,) or extensively hydrolysed formula (eHF), as stated by NICE and the MAP Guideline.9,10 Already in some areas, CCGs are removing certain formulae from being prescribed. The risk is that shortterm financial savings may negatively impact on patient outcomes and effectively cost the NHS more money in the long term. UPDATE ON PARTIALLY HYDROLYSED FORMULA
A recent systematic review by The Food Standards Agency11 concluded that there was no consistent evidence that partially hydrolysed formula reduces the risk of allergic disease. Furthermore, ESPGHAN working group consensus12 also concluded that evidence on efficacy of partially hydrolysed formula on prevention of atopic
disease is limited and highlighted the lack of any evidence on long-term metabolic consequences and outcomes of using these products. UPDATE ON THICKENED FORMULA
The NICE Quality Standard (QS112, NICE 2016) outlines how gastro-oesophageal reflux should be diagnosed and managed in infants. Regurgitation is a common and normal occurrence in infants, not normally requiring any investigation or treatment. Where there may be significant symptoms of frequent regurgitation with distress, a thickener added to milk or a prethickened formula can be recommended. SUMMARY
It is essential that health professionals keep themselves updated on the various formulae now available, in order to best advise parents. It is also essential that we understand and are knowledgeable on the legislation and regulation of these formulae to reassure parents on their suitability. * In this article, the term ‘infant formula milks’ is used generically to include infant formula, followon formula, young child formula and infant foods for special medical purposes (iFSMPs). www.NHDmag.com June 2017 - Issue 125
CONDITIONS & DISORDERS
BODY IMAGE AND EATING BEHAVIOURS Nikki Brierley Specialist Dietitian and CBT Therapist
Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist. She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust.
Body image dissatisfaction can negatively impact on an individual’s health and wellbeing and directly influence eating behaviours. With a reported 50% of the UK population suffering with a negative body image,1 it is clear that this is a subject which needs further discussion and better understanding/ management. The idea of body image (BI) was first developed by neurologists, whilst research was undertaken to understand how the brain interprets information received from different parts of the body. The term BI now refers to how an individual perceives their physical body (i.e. height, shape, weight, size and general appearance) and the thoughts/ feelings that this creates. This results in an internalised sense of what the individual thinks they look like. The subjective appearance may or may not accurately match the objective appearance (i.e. how they appear to others). As such, BI can be described as positive/ healthy or negative/dissatisfied (briefly summarised in Table 1 overleaf), and this can change over time.2 DEVELOPMENT OF BODY IMAGE
The development of BI is understood to be complex and influenced by individual and environmental factors.1 Babies and very young children appear to show little awareness of their own or others’ appearance; however, by the age of around seven, children are able to discriminate between ‘good’ and ‘bad’ appearance. This is reinforced by childhood literature that commonly links goodness with beauty and evil with ugliness.2 Adolescence is a time when the vulnerability to BI concerns increases, as the physical body endures many changes and becomes associated with sexual attractiveness. It is common for teenage girls to worry about their 24
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appearance and strive to the ideal ‘weight and shape’, it is also not uncommon for young males to develop concerns that their appearance differs from the projected ideal of ‘strong and muscular’. This is also a time when the risk of bullying increases and as physical appearance is obvious, any variation form the average is common a target. In addition, mainstream media continues the theme that was commenced in childhood and portrays attractiveness as being linked to success and happiness.2 There can be the assumption that with age, BI concerns reduce and individuals become less concerned with their appearance; however, the very lucrative ‘anti-aging’ market would strongly suggest otherwise. It is also true that if someone’s sense of self-worth has been largely dependent on their appearance, this is unlikely to change with age alone.2 NEGATIVE BODY IMAGE
There is no denying that physical appearance does hold some importance and that first impressions are partly formed due to the judgements made on how someone looks. Indeed, wanting to be attractive makes good sense as it conveys evolutionary and social advantages, with evidence suggesting that attractive children and adults are treated more favourably. However, the way someone feels about their body has a greater influence on the quality of life than how physically attractive they actually are.3
Table 1: A brief comparison of positive and negative body image Positive body image
Negative body image
• Accurate perception of body and physical appearance
• Negative/distorted perception of body and physical appearance
• Appreciate and accept own unique body
• Dissatisfied and frequent negative comparison to others
• Self-concept/value/worth is drawn from a variety of sources (i.e. friends/family, work/education, hobbies and physical appearance) • Comfortable and confident in own body
• Self-concept/value/worth is based largely on physical appearance (i.e. importance of physical appearance is overvalued)
• Don’t spend an unreasonable amount of time worrying about diet, weight and exercise
• Uncomfortable, ashamed, self-conscious, anxious about own body
• Changes to diet and/or exercise may be present, focus on improvements to health rather than based mainly on changing physical appearance
• Excessive worry about diet, weight and exercise
• Realistic/obtaining goals relating to appearance • Understand a person’s body size/shape says little about their character and values
• Attempts to diet and/or exercise in order to alter physical appearance (sometimes to the detriment of health and wellbeing) • Unrealistic/unobtainable goals relating to appearance • View ability to control body size/shape sign of personal success/failure
Source: Information collected from references 1, 2 and 3
Table 2: The glorification of thinness/leanness3 Thinness/leanness
• Success and status
• Failure/lack of
It is also essential that the importance of physical appearance is kept in perspective, as an excessive preoccupation with appearance can be very unhelpful and lead to distress and interfere with daily activities. When the significance of appearance becomes overvalued, this gives rise to a negative BI and BI dissatisfaction.2 Worryingly, recent findings suggest that 50% of the UK population suffer with negative BI and, furthermore, that one in four individuals are depressed about their bodies.1 Culture is described as the most powerful influence on BI, with the media’s portrayal of the ‘glorification of thinness’ (summarised in Table 2) cited as significantly contributing to body dissatisfaction. Over the past 30+ years, as the general population has increased in size and weight, the projected ideal has become thinner/ leaner and, as such, can only be obtained by extreme diets/exercise/other behaviours. It is also evident that increasingly drastic measures
(including cosmetic surgery) are being viewed as normal behaviours, as populations buy into the ‘myth of personal transformation’ (i.e. if you try hard enough these goals can be attained). What this does not take into account is the natural diversity of body shape and size and that for some, these ideals are completely unrealistic. What further compounds the problem is that many of the images used to project these ideals have also been digitally manipulated, making them simply unobtainable.3 When comparisons are inevitably made and efforts to change appearance do not deliver the required changes/long-term results, this places individuals at an increased risk of anxiety about their appearance and, for some, this results in excessive worry and a negative/dissatisfied BI. Although certain groups are more at risk of developing BI concerns, it is important to understand that it can affect all society, regardless of age, ethnicity, gender, sexuality, disability, body size or shape.3 www.NHDmag.com June 2017 - Issue 125
CONDITIONS & DISORDERS Table 3: Potential effect of negative BI •
Low self esteem
Unhealthy eating behaviours
• Malnutrition •
• Anxiety • Depression •
Avoidance of activities that require to show body (i.e. exercise, sex, going to the doctors, swimming)
Source: Information collected from references 1, 2 and 3
Experiencing a negative BI (summarised in Table 1) can range from mild feelings of unattractiveness to severe obsessions with physical appearance that impairs normal functioning.3 BI dissatisfaction can impact on certain areas and/or the general quality of life and is associated with an increased risk of a variety of physical and mental health conditions. It can also impact on relationships and social engagement (Table 3 lists the potential effects of a negative BI). IMPACT ON EATING BEHAVIOURS
Inevitably, a negative BI can result in attempts to change the body by altering eating behaviours and/or increasing exercise. The combination of the distorted view of the body, unrealistic/ unobtainable ideals and the level of importance associated with the success of achieving the desired body, can give rise to extreme dieting, over exercising and other body changing behaviours. This results in an increased risk of disordered eating and eating disorders (ED). Indeed, BI dissatisfaction is a fundamental feature in the aetiology and maintenance of an ED. Conversely, a positive BI is associated with a reduced risk in developing an ED. Furthermore, improving BI can help to break the cycle of ED behaviours.3 The attempts to restrict intake to obtain a thinner/leaner body can increase the risk of malnutrition, nutritional deficiencies and/ or subsequent over eating/bingeing. This can further intensify the feelings of failure and dissatisfaction and a cycle can easily become established (as demonstrated in Figure 1). 26
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IMPROVING BODY IMAGE
It is clear that cultural changes are required to cultivate a positive BI and that the promotion of body respect, appreciation and importantly acceptance are required at a society level to reduce the prevalence of BI dissatisfaction. There is a variety of campaigns and organisations that are challenging the current practises including the ‘Be Real campaign for body confidence’ (www.berealcampaign. co.uk/the-campaign.html) that promotes education, health and diversity and ‘Health at Every Size UK’ (www.healthateverysize.org. uk) an approach that promotes not pursuing a specific weight, but instead the health benefits that can practically be achieved by the individual. It is, however, recommended that additional research and evidence is needed to ensure that these approaches are effective.1 Cognitive Behavioural Therapy (CBT) has been clinically proven to enhance BI by challenging negative thoughts, utilising mindfulness, adopting a non-judgemental stance and fostering self-compassion.2,3 There are self-help programmes available (i.e. Overcoming Body Image Problems, 2009) that include an evidence-based, step-by-step package that can be followed independently or with the support of a CBT therapist. The British Association for Behavioural and Cognitive Psychotherapist provides further details regarding CBT and how to access an accredited CBT therapist (www.babcp.com/ Default.aspx).
Figure 1: Cycle restriction and/or over eating
ROLE OF THE DIETITIAN AND OTHER HEALTH PROFESSIONALS
It is essential that as dietitians and health professionals (HPs) we are aware of the potential risks of negatively impacting on individuals BI. It seems vital that we actively aim to promote a positive/healthy BI in everyone we encounter and, thus, ensure that we are part of the solution and not indeed adding to the problem. In order to do this, we too need to adopt and model the behaviour of acceptance, non-judgement and compassion. This may require changes in the way healthcare is provided and the focus of the outcomes measured/goals that are set (i.e. health-based outcomes, not weight-based goals). It may also require us to look at the language that is currently used when referring to weight, shape and size (i.e. ‘ideal weight’) and the impact that this can potentially have on an individual who is not within the ‘ideal range’. This seems especially relevant given that we are regularly aiming to assist individuals in making positive changes to their diet and lifestyles and if we indivertibly contribute to the development of a negative BI, the opposite may occur (extreme/ over restricted diets and overeating).
Recent reports suggest that 50% of the UK population experience a negative BI. The development of a negative BI appears to be complex and involves personal and environmental factors. The effects can range from mild to severe and can drastically impact on normal functioning and overall quality of life. Furthermore, they are associated with an increased risk of a number of physical and mental health conditions. A negative BI can also directly impact on eating behaviours and increases the risk of developing disordered eating patterns and indeed eating disorders. It is clear that a cultural shift is required to prevent the promotion of a negative BI and there are a number of campaigns that aim to influence society and promote body confidence and acknowledge the natural diversity of body shape and size. CBT is an evidence-based and clinically proven method to improve BI, by adopting acceptance, non-judgement and selfcompassion. It seems important that HPs are aware of the prevalence and risk of a negative BI and that an approach that at least does not further contribute to the problem is adopted.
References 1 Reflections on Body Image (May 2012). All Party Parliamentary Group on Body Image. YMCA Central 2 Overcoming Body Image Problems (Jan 2009). Veale, Wilson and Clarke. Constable and Robinson Ltd 3 Overcoming Body Image Disturbance: A Programme for people with Eating Disorders (Feb 2008). Bell and Rushworth. Routledge
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PKU IN THE UK: THE EARLY YEARS (1949-1979) Compiled by Suzanne Ford NSPKU Dietitian for Adults Suzanne Ford works as a Metabolic Dietitian for Adults at North Bristol NHS Trust. She has been a Dietitian for 21 years, with six of them working in Metabolic Disease.
Memoirs of Christine Clothier, Paediatric and Metabolic Dietitian at Alder Hey Hospital (1965-1992)
HORST BICKEL ARRIVES IN BIRMINGHAM 1949
In 1949, Horst Bickel, a clever, dynamic young German doctor, joined Birmingham Children's Hospital. He was interested in phenylketonuria and proposed all 'mentally retarded' patients attending the hospital should be screened for the condition. In March 1951, the urine of the third child who was screened, tested positive. SHEILA JONES AND HER PIONEERING MOTHER
Sheila Jones was a 17-month-old badly brained-damaged child who could neither sit nor stand and who took no interest in her surroundings. Her Mother, refusing Figure 1: Sheila’s phenylalanine and tyrosine levels as shown in Horst Bickel’s article, The Lancet, 29 June 1953
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to accept that there was no treatment, waited every morning by the laboratory door and begged Dr Bickel to treat Sheila. He accepted the challenge and considered how he might construct a diet based on a phenylalanine-free protein. Louis Woolf, the biochemist at Great Ormond Street, suggested removing phenylalanine from the milk protein casein, by filtering it through charcoal - after seven months covered in charcoal-smelling soot, Dr Bickel produced a phenylalanine-free casein. The prepared formula was bitter and unpalatable, but Sheila, at the age of two years and two months, accepted it. Over the next six months, Sheila's general health and appearance gradually improved as she learnt to crawl, stand and then walk. For three years, Sheila’s dietary management continued successfully; it was compromised when her mother had a fourth child and then later, when her Mother's marriage broke up, Sheila returned to a normal diet. A video of Sheila in 1987 shows her severely brain damaged - she is sitting on the floor rocking backwards and forwards, clearly very unhappy. In February 1999, she died aged 50.
1950’S DIET FOR PKU IN BRISTOL, BELFAST AND GREAT ORMOND STREET (GOSH)
One of the first dietitians to treat phenylketonuria was Pam Williams in Bristol, and some of the difficulties of early treatment can be perceived from her records dated 1954. Casein hydrolysate was now manufactured by Allen and Hanburys, but no literature was available relating to the product. Pam had to seek advice from the dietitians in London and Belfast, who were also involved in treatment. All information was exchanged by handwritten letter and Pam had to have scoops sent from the GOSH dietitian Miss Dillistone Pam had just one small and one large scoop! The hydrolysate, yet to be named Cymogran, was made to order only at 170 shillings per kilogram; at the time this was the average weekly wage for a working man. (It became the practice, at least until the 1970s, for the dietitian to issue all new ‘Special Products’ until they were accepted for prescription by the NHS. I was sometimes in the office issuing parcels to parents after 9pm - they didn’t seem to notice the late working hours! Such was the laborious nature of metabolic dietetics in the 1960s - and earlier.) CHRISTINE’S EXPERIENCES IN LONDON 1964 AND LIVERPOOL FROM 1965 ONWARDS
My introduction to phenylketonuria came at five o’clock one Thursday evening in 1964 (in London), when to my horror I found on my desk a brief note saying, "Please provide a low phenylalanine diet for patient aged six weeks”. Under the guidance of Dorothy Francis at GOSH, and with the support of the hospital biochemist, I undertook the management of this child for the next 10 months. I saw the mother each Friday when the baby’s serum phenylalanine was estimated by a test which involved the use of snake venom, required complicated calculations and took over 24 hours to produce a result. In 1964, four casein hydrolysates were available on the market, but preparing a feed was still not simple. For example, 'Albumaid XP' contained only protein and carbohydrate, so double cream was included as a source of natural fat. Each formula had to be supplemented according to its constituents; 'Ketovite liquid and tablets' contained the most complete range of vitamins, but, unfortunately, the taste caused some babies to vomit!
EXPANDING THE ‘FOODS ALLOWED FREELY’ LIST
In 1965, I went to work at Alder Hey Children's Hospital in Liverpool where less than 10 families attended the PKU clinic. We attempted to relieve a little of the stress by allowing the patients to take butter and the majority of fruit and vegetables freely. We believed the amount of fruit and vegetables consumed by a child daily to be equal to five phenylalanine portions. So, with a few exceptions, we transferred fruit and vegetables to the ‘List of Foods Allowed Freely’ and reduced each child’s allowance of phenylalanine by five. Until then, only 33 foods were allowed freely and they were mainly condiments, flavourings and some unpronounceable ingredients used in the Baking Trade. Examples of such gastronomic delights were: Agar Agar, Celacol powder, Edifas A, Glucono Delta Lactone and Wheatstarch. Agar Agar made very acceptable jelly, but it cost £2 per pound. Consequently, Agar Agar was only consumed by hospital inpatients! Fortunately, it was eventually replaced by a much cheaper jelly made from Carrageen Moss. Celacol powder is methyl cellulose, used to strengthen bread. Edifas A, a product which looks like stuffing out of the sofa, was used to make meringues. Glucono Delta Lactone was also used to strengthen bread. The many weeks I spent experimenting with a recipe based on this product prompted the catering officer to ask me if he should ask Liverpool Corporation to supply him with extra swill bins! COMMUNICATION METHODS OF THE 1960s
In the 60s and 70s, many households did not have a telephone, so for these parents, communication was by handwritten letter, as the dietitian did not have a secretary. For them to contact the dietitian, they would have to use a public telephone, which could be some distance away and if there was a queue at the box, they might have to wait some time for their turn. Once through to the hospital, immediate contact was not guaranteed as the operator had to first locate the dietitian as her status did not merit a bleep. Long distance calls were expensive and limiting, as they were strictly terminated after three minutes if further money was not paid. Frequently, callers were cut off in mid-sentence having to go for more coins. www.NHDmag.com June 2017 - Issue 125
In 1965, only two low protein products were available on prescription. Wheatstarch and 'Aminex' Rusks. Mothers had to make their own biscuits, cakes and bread.
The families who suffered most were those on The Isle of Man. Their calls were classified as long distance and, therefore, expensive; the NHS would only pay for one visit a year to the PKU clinic, one parent only to accompany the child to Liverpool. Occasionally, the dietitian was given a neighbour’s telephone number, but this method of contact entailed a long wait while the neighbour set off to fetch someone. The delay was even longer if they were elderly, lived further away than next door, or because of the inclement weather if they had first to put on a coat. If the neighbour returned alone, no matter how willing they were, we could not rely on them to pass on a message. PRESCRIBABLE PRODUCTS - WHAT A RANGE!
In 1965, only two low protein products were available on prescription. Wheatstarch and 'Aminex' Rusks. Mothers had to make their own biscuits, cakes and bread. It was the dietitian’s duty to demonstrate these unpredictable recipes, a task that can only be described as an ordeal! Small equipment is not available in a large kitchen and making a single loaf in a four quart bowl is not easy! Kitchen staff tended to be hostile to amateurs tinkering about in their territory and products made with Wheatstarch were most inconsistent. At the bottom of Pam Williams’ original recipe was a footnote from Ida Stevenson, the dietitian in Belfast: "Perhaps this bread recipe will be of use to you, though as you may expect, it's not a terrific success.” She wasn’t kidding! 30
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Creating low phenylalanine recipes was the dietitian’s responsibility. A simple enough task, I thought: just select some suitable recipes and substitute Wheatstarch for flour. My loaves either did not rise at all or they rose through the bars of the oven! The rock-hard ginger biscuits defied both my whacks with a poker and the dog’s teeth - I had many failures! (We shouldn’t underestimate the skill and proficiency of an expert like Eileen Green. Dietitians today are indeed fortunate to have the support of her excellent recipe books and expertise.) In 1968, low protein semolina and spaghetti were then introduced by Carlo Erba. The initial excitement at the availability of spaghetti soon diminished when it was discovered that all the instructions were in Italian and as pasta had yet to become popular in the UK, no one knew how to cook it! The introduction of tinned bread was a major step forward in dietary management as it released Mothers from the burden of having to make their own. INTRODUCTION OF NEWBORN SCREENING AND FORMATION OF THE NSPKU
1968 also saw screening laboratories throughout the world replace the 'Phenistix' urine test with the more accurate 'Guthrie' blood test, so enabling phenylketonuric children to be identified as early as four days of age. In 1971, a PKU baby was adopted in Liverpool by a social worker and his wife; in November 1973 they founded The National Society for Phenylketonuria and in June 1975 the
CONDITIONS & DISORDERS Not everyone, however, developed such expertise. Here are just some of the many despondent accounts that I have heard in relation to the protein hydrolysate: "I found it everywhere, down the toilet, under the carpet, in the bed." "I held her nose until she needed air so much she had to swallow the stuff." "In the end things got so bad, he gave up his job."
first Medical Advisory Panel met. Its members included the physician and dietitian from the clinics in Liverpool, London and Manchester. The immediate task for the dietitians was to prepare for publication a set of diet sheets that would be accepted nationally. Though we thought it would be a fairly simple task in reality it was a nightmare. Estimating the phenylalanine content of hundreds of foods was both time-consuming and problematic and took over a year to complete. To determine each 50 milligram portion involved numerous calculations all done by mental arithmetic with the aid of our fingers. To insure accuracy, we then checked each other's results. The many difficult issues we addressed included converting ounces to grams and question like, ‘Should we multiply by the accurate figure 28.4 or round it up to 30?’ Portion size discussions followed and agreement was eventually reached. UNPLEASANT AMINO ACIDS
The unpalatability of the protein hydrolysate (a perennial problem), meant that giving the protein substitute was often said to be the most exhausting, time-consuming and disturbing feature of dietary management. One baby had a fascination for clocks, so at feeding time all the portable alarm clocks in the house were assembled around him to hold his interest. If he showed a reluctance to take the feed, the Grandfather would set off the alarm bells at regular intervals, then as his mouth dropped open in surprise his mother would thrust into it a spoonful of feed.
BREAKTHROUGHS IN THE 1970S
A breakthrough came in 1970, when two amino acid mixtures, 'Aminogran' and 'PK Aid', were introduced for toddlers and older children. Although still not exactly appetising, they were well accepted and refusal, dawdling and vomiting were said to be difficulties of the past. Children of five and six years of age who required spoon feeding with the protein hydrolysate, now fed themselves, their appetites improved and they took more interest in food. In the 1978 edition of McCance and Widdowson’s Food Tables, the amino acid tables were expanded, meaning a revision and improvement of the PKU food lists. Then, in 1979, the introduction of 'Egg Replacer’ really improved PKU living as it enabled mothers to bake an attractive variety of luxuries, such as loaves and rolls, Barm cakes, quiche, doughnuts, Parkin and meringues. Although there have been many further, welcome improvements to the treatment of phenylketonuria, the dietary management remains stressful. Nevertheless, improvements are constantly being made and all those associated with this disorder are most grateful to Professor Horst Bickel for accepting the challenge of Sheila Jones’s Mother. www.NHDmag.com June 2017 - Issue 125
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DIET TRENDS: HIGH PROTEIN DIETS FOR WEIGHT LOSS Claire Chaudhry Community NHS Dietitian/ Private Dietitian BCUHB/ Claire Sports Nutrition
‘Trend’: meaning; to roll around, turn, revolve.1 Popular trends, like diets and styles of denim jeans, often complete a full circle many times throughout our adult lives. Now we are seeing a comeback for the high protein diet for weight loss. Here, Claire examines the advantages and disadvantages of this kind of diet.
In Claire’s 15 years of experience she has worked in acute and community NHS settings. Claire has taught Nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private. www. dietitianclaire.com
In 2004, I had my second interview with a journalist for a local paper, with a sensational headline: ‘Fad diets like Atkins could be harmful’. The headline was decided by the journalist Justine Bailey and not quoted by me. In the article, I emphasised the importance of a balanced diet for weight loss, steering clear of diets that omit food groups and offer quick fixes. I also emphasised consulting a dietitian for sound individual nutritional advice. Sian Porter RD also provided the same advice to the BBC in 2013: ‘Atkins and the never-ending battle over carbs’.2 Now, in 2017, here we trend again! The high protein diet for weight loss has been making a comeback recently thanks to celebrity’s promotion from Kim Kardashian and actress Melissa McCarthy. According to an internet search on ‘high protein diet’ you will: • lose weight and tame hunger; • do your body good; • help with efforts to build muscle; • lose fat; • improve your sleep.
For full article references please email info@ networkhealth group.co.uk
The three popular high protein diets that are available for weight loss are the Dukan diet by Dr Pierre Dukan,3 the Atkins diet by Dr Robert Atkins,4 and the Paleolithic diet made popular by Loren Cordain.5 These diets were first devised in the 1970s and have evolved over the past 40 years, yet, even today, they remain controversial with regards to long-term health. These diets promote a high dietary intake of protein
foods and encourage the complete omission, or a very low intake of other food groups, e.g. starchy carbohydrates, fruit, legumes and dairy. HOW MUCH PROTEIN DO WE NEED?
DRVs for protein intake in the UK are set for different populations; the RNI for protein for adults ages 19-50 females and males is 45gm and 55gm daily respectfully.6 Daily RNI of protein as part of a balanced diet can be obtained from: 200mls of semi skimmed milk, 130gm of roasted chicken and four tablespoons of baked beans = 51gm.7 The majority of the UK’s free living adult population consume more than this amount on a daily basis. HOW MUCH IS HIGH PROTEIN?
A Department of Health panel recommends a maximum amount of protein in a day for an adult to be no more than 1.5gm per kg, yet, there is insufficient evidence regarding this maximum amount. The Dietetic Manual states that over-consumption of protein above the maximum intake, offers no increased benefit in the body and may have certain health risks, e.g. kidney disease and osteoporosis.8 As well as the above high protein diets being advertised for weight loss, there are also food manufacturers that have launched their own range of high protein products. The number of products launched with an increase amount of protein added has increased by almost 40% in the last year and by www.NHDmag.com June 2017 - Issue 125
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WEIGHT MANAGEMENT 500% in the last five.9 Manufacturers or brands jumping on the protein bandwagon include Weetabix, GoNutrition, Shreddies, Special K, Arla (Dairy) and Weight Watchers. European labelling states that a food claim of ‘high in protein’ may only be made where at least 20% of the energy value of the food is provided by the protein.10 ARE THERE ANY ADVANTAGES OF HIGH PROTEIN DIETS IN WEIGHT LOSS?
Reduces hunger Speaking from dietetic consultations over 15 years, individuals following a high protein diet reported that protein foods helped with their satiety and reduced hunger. This made them less likely to over eat and snack in between meals thus reducing their overall calorie intake. Reduces overeating and possibly binge eating on carbohydrate foods Consuming foods high in carbohydrate (e.g. bread, potatoes and pasta) resulted in eating larger amounts, admitting that it was easier to completely stop eating carbohydrates rather than reducing the portion size. Shopping and eating out Shopping was quicker as you missed aisles. Eating out in restaurants was easier on the high protein diet, as restaurants and cafes also offered more choices to the consumer. Celebrity endorsement and another diet to try Individuals wanting to lose weight and ‘yo-yo’ diet for years, said that they were willing to trial any diet that had shown amazing physical results and were endorsed by famous people. WHAT ARE THE DISADVANTAGES OF A HIGH PROTEIN DIET IN WEIGHT LOSS?
Unpleasant side effects Self-reported side effects from 429 participants following the Atkins diet showed that they suffered from the following side effects (highest incidence reported to the lowest): constipation, loss of energy, bad breath, difficulty concentrating and kidney problems including reduced kidney function. Also, heart-related problems were reported, including elevated serum cholesterol levels, plus gallbladder problems, gout, diabetes, and osteoporosis.11
Another study showed side effects following the Atkins diet were headaches, fatigue, depressed mood and hypoglycaemia.12 A dangerous side effect of the Dukan diet was a female aged 42 (no prior medical issues) who suffered 10 hours of nausea and vomiting secondary to ketoacidosis, whilst following the Dukan diet for two days.13 Difficult to get a correct balance of vegetable and animal protein and can be open to interpretation Individuals commencing on a high protein diet may not differentiate between processed meats and unprocessed meats, therefore, could actually be obtaining a large amount of protein from bacon, sausages, salami whilst also increasing salt and fat intake, leading to other potential health issues like cardiovascular disease and bowel cancer. A lot of individuals do not like vegetable protein foods, e.g. beans, lentils, or do not know how to utilise them in their diet. Often, vegetable protein rich foods which are high in fibre, are often not included in the diet, thus consuming higher amounts of animal protein instead of vegetable protein. A large Meta-analysis looking at over 12,700 participants found that non meat eaters had significantly lower ischaemic heart disease mortality at 29% and an 18% reduced overall cancer incidence than meat eaters.14 The balance of vegetable and animal protein can affect long-term health. Long-term adherence to a high protein diet can be difficult and could be expensive The high protein diets exclude other food groups, namely carbohydrates. One Atkins meal plan advises less than 20gm of carbohydrate daily. Many individuals admit to coming off the diet and start eating carbohydrates again when they pass a bakery and/or go on holiday. Certainly, there are European holiday destinations where carbohydrates are the main staple of the diet, with foods including pizza, pasta, risotto, paella and continental fresh bread. This can make the high protein diet difficult to follow. High protein labelled food products can be more expensive, Weight Watchers high protein wraps are priced at 23p each compared with Tesco white wraps at 11p each, making the high protein www.NHDmag.com June 2017 - Issue 125
WEIGHT MANAGEMENT wraps nearly double the price.15 The three diet websites do not offer completely free information, for further advice payment is required. May have an increase in calorie intake instead of a deficit and the diets and the high protein foods can be confusing Fat intake may also increase, due to the increased consumption in high protein foods, e.g. 100gm of nuts will provide 595kcals (about a third of an average female’s daily energy requirements). The diet may also suggest using different cooking methods, e.g. frying steak which could also increase calorie intake. Atkins and Dukan have developed over the years and both now have ‘phases’ which can be confusing to follow, the Dukan also has a ‘Nutritional staircase’! The Paleo diet has also changed over the years due to different author’s promotion, so may depend on which book you buy, or which website you go to. High protein labelled foods, such as breakfast cereals or yoghurts, could also contain higher amounts of sugar, fat and calories when compared with the same brand non high protein cereal, thus leading to weight gain.There can be confusion surrounding labelling and consumers already are desperately trying to understand labels on products: low fat, low sugar, low salt, high in fibre; the ‘high protein’ claim on the label is merely adding to the confusion. Free available meal plans will not suit every individual’s requirements There are basic meal plans with portion sizes available on the Atkins website for free, which will not suit everyone. The Paleo website also offers some free downloads; however, you have to pay for an individual plan on the Dukan website. Nutritionally unbalanced An assessment of the food intake of females in Poland on the Dukan diet showed that they were high in animal protein, high in iron and vitamins A
and D. However, they were low in fibre, vitamin C and folate.16 Reported nutritional intake whilst on the Atkins diet, resulted in significant decreases in fibre intakes, decreased micronutrients such as non-haem iron, folate/folic acid, thiamine, magnesium, calcium, potassium and vitamin C. There were high intakes of vitamin A and D and phosphorus in the more restrictive low carbohydrate high protein diets.17 The paleo diet advocates omission of dairy, cereals, potatoes and legumes including peanuts. Following these diets long term will result in vitamin and mineral deficiencies and constipation. WHAT ABOUT LONG-TERM HEALTH AND HIGH PROTEIN DIETS?
There is a cause for concern in individuals wanting to start a high protein diet with kidney disease, osteoporosis, and gastrointestinal conditions, e.g. constipation, diverticulitis and individuals with Type 2 diabetes. A low dietary intake of vegetable protein and a high intake of animal protein has been shown to have a negative effect on long-term health in relation to increasing body weight, an increase prevalence of diabetes Type 2 and higher LDL cholesterol levels. This was found in the Adventist study looking at the diets of over 60,000 adults.18 CONCLUSION
As dietitians, it is our role to explain the disadvantages and contraindications to individuals about the high protein diet used for weight loss. Despite the possible unpleasant and even dangerous side effects of a high protein diet, they continue to be publicised positively and are aimed at anyone wanting to lose weight. The three examples in this article of high protein diets would not earn half as much money if an internet search revealed honest examples of what the diet can do to the body. There remains to be no current evidence for superiority with weight loss on a high protein diet and should be actively discouraged.
For further information on diet trends: How to lose weight well presented by Dr Chris Van Tullekan and RD Hala El-Shafie: www.channel4.com/ programmes/how-to-lose-weight-well Information about the Diet Composition of the Paleolithic Diet and evidence summary, see the PEN website www.pennutrition.com/KnowledgePathway.aspx?kpid=23246&trid=23440&trcatid=2 36
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FACE TO FACE Ursula meets:
Ursula meets amazing people who influence nutrition policies and practices in the UK.
Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
STEFAN GATES Food writer and broadcaster Host of 300+ food science live shows Gastronaut - explorer of food frontiers
When Stefan invited me to his house, he promised me magic - and delivered! After being told to eat two thirds of a digestive biscuit, not-more-not-less, he lit some bioethanol in a large container: “The huge flame exactly demonstrates the energy in the biscuit you ate,” he said . . . We then juiced some red cabbage and added lemon juice or washing powder (acid or alkali), to watch a constant back and forth of pink and blue colour change: “Red cabbage juice contains a pH indicator,” he said. The last feat involved licking dabs of citric acid, bicarbonate of soda and icing sugar aka sherbet: “A great way to demonstrate the production of carbon dioxide with the addition of water from saliva,” he said. Stefan is known for being a food adventurer, and I knew enough not to accept the cup of tea he then offered. He will be familiar to younger dietitians, or those with children, as a presenter of many CBBC programmes about food, and has presented hundreds of large venue live shows to both adult and school audiences, to support a more scientific interest in the foods we eat. In fact, all school children in Camden, London, will enjoy attending one of his food-is-amazing shows at the new Francis Crick Institute this summer. You might have even seen him at the Big Bang Science Fair in Birmingham in March earlier this year.
Perhaps his showman skills started when his mum let him and his sister miss chunks of schooling to do smallpart film roles during childhood, which did not hinder his getting into Oxford University to read English. Between literature and endless essays, Stefan delighted in trying new foods. “But the herring toasted sandwich was perhaps a step too far,” concedes Stefan. His early career was at the BBC as a scriptwriter and director and he enjoyed the variety and challenge of a career in visual media. But food was always a big interest to him: the-what and the-why of food choice. He was inspired by the fresh approach of the chain-smoking, hard-drinking TV chef Keith Floyd and the genius food writings of MFK Fischer. “At the time, so much that was written and shown about food was so timid and boring and only related to etiquette or trivia.” He was sure he could do better, and started producing screen clips of food presentations, which he shared with friends and media contacts. In due course (in 2004), Stefan was invited to present the BBC2 series Full on Food. During very competitive interviews for the role, everyone was asked to describe favourite foods. Others selected rare delicacies; Stefan chose ‘cheesy Wotsits’ (which must have convinced the selectors of his original and left-field approach - just what was needed for the show). The series was a huge success, but would another www.NHDmag.com June 2017 - Issue 125
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F2F series be commissioned? His producer contacted him with the good-news, yes, but bad-news, not with you call. Instead, experimental chef Heston Blumenthal was selected as the next presenter. But Stefan had made his mark as an adventurous food explorer and sparky presenter and the next decade involved writing many books and hosting many TV shows about food. The BBC2 series Cooking in the Danger Zone looked at the politics and culture of food and was a tight mix of great fun and very scary. “We travelled to many different countries to try to really understand the challenges around food choices. From Uganda, to Afghanistan, to Tonga, to Japan, people were welcoming and keen to share their cuisines. But many foods selected were outcomes of extreme and challenging environments, and we often felt sad at the difficult choices people were forced to make,” said Stefan. Further shows steered towards science aspects of foods. BBC2 commissioned a series looking at E-Numbers used in food and Stefan had to steer carefully between the expert views of some scientists and the strongly held views of some consumer groups. He researched and presented the BBC4 documentary Can insects save the world? And he has just released a book this month on eating insects. Although insect eating is being much discussed as a future more sustainable food source, I suggested that the excitements were premature. “Why would we all start eating insects to replace beef, when beans and pulses are so protein rich and readily available?” I pondered. Stefan looked at my halfwit comment with astonishment. “People don’t seek meat because of its protein. They choose it for its flavour. It is astonishing how much people in poverty are willing to do, to flavour starchy foods, with almost unaffordable small amounts of meat. Insects will be the protein flavourings of our future foods,” he insisted. “I would give it about 20 years for insects to become a common
feature in UK diets.” Other than insectology, Stefan’s future plans relate to discussions of food physics and food engineering, and no doubt food technologists will be delighted to have such a communication champion on their side. “Dietitians are the good guys,” said Stefan, unprompted. We discussed the issues of nutrition professionals battling the very public arena of nutrition advice, with bloggers promoting books and beauty. He described the concerns of a wellknown celebrity over ‘de-natured’ proteins. He said, “she is right, of course, that so many of the foods we eat are de-natured: it is because they are cooked… duh!” He thinks that much more should be done to teach and support children to understand foods and health. But flashing the Eatwell Guide around will never achieve anything. “Dry messages will never motivate children to change their diets. Information needs to be entertaining and engaging,” he said. He is right, but a difficult challenge for dietitians communicating in a professional environment. And did watching visually stunning shows presented with drama and slickness really inspire children to improve their food choices? He couldn’t prove this, or provide any data, but said that so many parents contacted him describing a more open and interested approach to the food choices their children made. It was a big step forward for many children to try different and hopefully healthier foods. Stefan really is an amazing culinary adventurer. And while open to every cultural and historical and anthropological aspect of foodism, he is keen to steer science-wards. It may be a challenge to sprinkle culinary sparkle onto insect eating, but he is fully engaged to try. Ditto food science and technology. His career as a food obsessive has opened many minds to different ways of eating; I left our meeting, openminded and open-mouthed.
If you would like to suggest a F2F date
(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact:
email@example.com www.NHDmag.com June 2017 - Issue 125
DIETITIANS WEEK 2017: EMPHASISING EVIDENCE AND EXPERTISE - 12TH-16TH JUNE www.bda.uk.com
The BDA’s fourth annual Dietitians Week is taking place from 12th-16th June and the 2017 edition promises to be the biggest yet. Dietitians Week is a chance to promote the role and expertise of dietitians to the public, press and other health professionals. We’ve decided to focus specifically on evidence and expertise this year in order to counter the often confusing and downright dangerous advice and reporting that unfortunately continue to be a part of our public discourse on nutrition and diet. While this year has seen something of a media backlash against clean eating’ and similar fads, we have also seen new nonsense diet trends gaining traction. Set against a background of ‘fake news’ and ‘alternative facts’, it has never been more important to stand up for evidence and expertise. A survey that we undertook with polling firm Populus has highlighted the continuing problem. 40% of those surveyed admitted that they had considered or tried one of 10 fad diets highlighted by the BDA in our annual ‘celeb diets to avoid’. This proportion was even higher amongst women and younger respondents. The survey also found that the public place their trust in a wide range of people for diet and nutrition advice, even those with no qualifications or skills to do so; three in five said they’d trust a personal trainer, while over a third would trust a TV Chef. POSITIVE MESSAGES TO COUNTER THE PSEUDOSCIENCE
We want our expert dietetic members and their supporters to have conversations with patients, friends 40
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and colleagues about why they should ask for the facts when they read a story about nutrition or diet, and why dietitians have the expertise to make sense of it all. Dietitians Week is an opportunity to promote positive messages about nutrition to counter the fads and pseudoscience we see on blogs and in newspapers. As part of the week, we’re very excited to be holding a free public event on 12th June at Leeds Horizon entitled Eat Fact Not Fiction. We have a fantastic line up of speakers, including dietitians Anne Holdoway, Rachael Masters and Mary O’Kane, as well as blogger and campaigner Natasha Lipman, writer and ‘Angry’ chef Anthony Warner, and award winning filmmaker Kimberley Littlemore. All our speakers will be offering different perspectives on the importance of evidence and expertise in what promises to be a really interesting afternoon. You can apply for tickets online at bda.uk.com/ eatfactnotfiction. If you can’t come along, we’ll be recording the whole thing and making the talks available online for all to see and share. Of course, a big part of the week’s awareness raising takes place on social media, and we are urging the dietetic profession to get involved on Facebook, Twitter and Instagram to share their activities from the week and promote positive messaging around the importance of evidence and expertise.
Our members always do a fantastic job of promoting the profession via tabletop stands and innovative promotion at their workplaces and we’re sure 2017 will be no different. We’re also working with partners from Sense about Science, the Science Media Centre and the British Nutrition Foundation to promote the week and important messages
about science and evidence. The BNF are holding their Healthy Eating Week during the same week, so we’ll be cross-promoting throughout the week. If you want more information on DW2017, you can visit the website at www. dietitiansweek.co.uk, or get in touch by emailing firstname.lastname@example.org.
ARE YOU A BDA MEMBER? We run important campaigns such as Dietitians Week because, as the professional body and trade union for the dietetic profession, we have a vital role to play in representing, promoting and protecting our members. With approximately 80% of all HCPC registered dietitians within BDA membership, there has never been a better time to consider joining your professional body and trade union. If you are keen to share your enthusiasm, knowledge and experience and get involved in programmes to help advance dietetics and the dietetic profession, then joining the BDA is a great place to start. Membership is open to registered dietitians, dietetic support workers, dietetic students and those with an occupational interest in diet or food, so the BDA invites you to take a look at the benefits of becoming a BDA member at www.bda.uk.com/membership and consider joining at:
www.bda.uk.com/join www.NHDmag.com June 2017 - Issue 125
Simon Langley-Evans Professor of Human Nutrition, University of Nottingham
Simon has 25 years’ experience in nutrition research, with expertise in maternal and infant nutrition. He is Chair in Human Nutrition and Head of School of Biosciences at the University of Nottingham and is the Editor-inChief of The Journal of Human Nutrition and Dietetics.
EARLY ORIGINS OF DISEASE: YOU ARE WHAT YOU EAT, BUT ALSO WHAT YOUR MOTHER ATE! Obesity and the conditions it causes - Type 2 diabetes and cardiovascular disease - are a major threat to the health of populations all over the world. It is estimated that there are already 400 million people with diabetes and that by 2040 the global total will be over 600 million. Action is needed to manage and prevent this rapidly developing health crisis. Our understanding of the causes of obesity and related disorders has long centred on the fact that adult diet and lifestyle plays a major role in determining risk. We are all familiar with the phrase ‘you are what you eat’, but we should also bear in mind that what our mothers and even our grandmothers ate has a significant bearing on our health.1 The first clues that this is the case came from studies which followed up men and women who had been born in the 1920s and 30s and considered whether their health in their 60s and 70s might be related to the environment that they had experienced before birth. These studies showed that being of low birth weight, but still within the normal range, was associated with greater risk of Type-2 diabetes, the metabolic syndrome, high blood pressure and death from coronary heart disease. Other measures of size and shape at birth were also related to later disease, with thinness at birth being predictive of insulin resistance and diabetes. In short, to be born small and thin appears to predispose to major disease many decades later. Measurements of anthropometry at birth are a simple proxy for the nutritional exposure of the foetus during key periods of growth and development. Low birth weight and thinness at birth are generally, but not always, associated with undernutrition, whilst higher birth weights (>4kg) are
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often observed with maternal obesity. More direct evidence that maternal nutrition during pregnancy influences disease patterns in offspring has come from follow-ups of the Dutch Famine of 1944-45. Adults whose mothers were caught by this famine during pregnancy (at its’ peak the daily ration was just 600kcal) show increased prevalence of obesity in early adulthood, Type-2 diabetes and coronary heart disease. More recent studies have confirmed these early observations. For example, blood pressure in four-year-old children is related to the fat and carbohydrate intakes of their mothers during pregnancy.2 Such work has reinforced the studies of historical cohorts that gave rise to the developmental origins of health and disease hypothesis (DoHaD). Essentially, the DoHaD concept is that factors experienced during early development permanently shape or ‘programme’ long-term physiology and metabolic functions. Such factors include maternal nutrition, smoking, infection and psychological trauma. Although there are problems associated with linking current disease states to events that occurred 50 to 60 years ago, with no direct measurements of maternal nutrition, we know from experimental studies with animals that both maternal undernutrition (low protein, micronutrient restriction) and maternal obesity during pregnancy has lasting effects on disease
Are disease processes associated with ageing already in motion?
Human foetus at 20 weeks gestation.
risk in offspring. For example, offspring of rats and mice fed a low protein diet develop high blood pressure, atherosclerosis, insulin resistance and live shorter lives.1 Some of these effects persist across two or even three generations. Maternal nutritional status in pregnancy plays a key role in setting the structure and hence the later function of organs, such as the kidney and the pancreas. In animals, both iron deficiency and protein restriction reduce the number of nephrons in the kidney and this makes the development of renal disease more likely. The time frame in which health and disease is programmed goes beyond pregnancy and continues into childhood. There are many reports that breastfed infants are less prone to obesity and related disorders than those who are formula fed. Reports also suggest a higher IQ and reduced risk of atopic conditions. Growth in childhood is also important. A study of women born in Helsinki in the 1930s showed that those who went on to develop coronary heart disease as adults had been born smaller than average and remained so until aged four to five years. They had then gained weight more rapidly, such that, by the age of 11, their BMIs were higher than average. Studies of this
nature tell us that the factors that contribute to disease in adult life are complex and are a combination of genetic inheritance, early life programming and adult lifestyle. In effect, our risk of disease at any stage of life is a product of our cumulative experiences across the whole lifespan from the moment of conception. The link between maternal diet and longterm health poses a challenge for public health policy. Most current health promotion activities which focus on diet and health have a onesize-fits-all approach, so, for example, we are all encouraged to reduce salt consumption and consume at least five portions of fruit and vegetables a day. When thinking about obesity and health we focus most heavily on promoting health messages to adolescents and adults. If part of our fate is set before we are born, then are these policies and interventions appropriate? Should we adopt a more personalised approach based on experiences in foetal life or infancy? At the moment it may be too early to tell, but we can be certain that optimising maternal weight and diet before and during pregnancy is of huge importance. The message that â€˜you are what your mother ateâ€™ needs to be widely publicised and promoted.
References 1 Langley-Evans SC (2015). Nutrition in early life and the programming of adult disease: a review. J Hum Nutr Diet. 28 (Suppl 1), 1-14 2 Normia J, Laitinen K, Isolauri E, Poussa T, Jaakkola J and Ojala T (2013). Impact of intrauterine and post-natal nutritional determinants on blood pressure at four years of age. J Hum Nutr. Diet. 26, 544-552
You can read more Prof Blogs from Simon Langley-Evans in the Student zone at www.NHDmag.com
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WEB WATCH Useful information, research and updates. Visit www.NHDmag.com for full listings. NICE UPDATES
GOV.UK - PUBLIC HEALTH ENGLAND
NICE GUIDELINE (NG28) TYPE 2 DIABETES IN ADULTS: MANAGEMENT Published Dec 2015. Updated May 2017. This guideline covers the care and management of Type 2 diabetes in adults (aged 18 and over). It focuses on patient education, dietary advice, managing cardiovascular risk, managing blood glucose levels and identifying and managing long-term complications. Updates include: 1. additional text on sodium-glucose cotransporter 2 (SGLT-2) inhibitors to the section on initial drug treatment; 2. updated version of the algorithm for blood glucose lowering therapy in adults with Type 2 diabetes; 3. additional new information on SGLT-2 inhibitors when metformin is contraindicated or not tolerated. The full guideline can be viewed at www.nice.org.uk/guidance/ng28
SUGAR REDUCTION: ACHIEVING THE 20% - REPORT Published 30th March 2017. This report sets out guidelines for all sectors of the food industry on how to achieve a 20% sugar reduction across the top nine categories of food that contribute most to intakes of children up to the age of 18 years. The guidelines for each food category detailed in this report include: • overall levels of sugar per 100g of products needed to achieve the 5% and 20% reductions; • average and maximum calorie or portion size guidelines for products likely to be consumed by an individual at one time. To download the report visit www.gov.uk/ government/publications/sugar-reductionachieving-the-20
SCIENCE FEST! - PINT OF SCIENCE Bringing science to the masses is a tall order, but universities across the UK, including King’s College, London, University of Liverpool and Liverpool School of Tropical Medicine and the University of Glasgow have made some great strides in doing just that. Pubs have become a new venue to talk about science! The festival is now in its fourth year and the Pint of Science festival hosts academics from leading universities. Plenty of academics contributed this year in pubs and other venues to talk about their research in an engaging and accessible way. The festival took place in May over three days in 27 cities across the UK, with over 35 universities taking part. A variety of themes were included: ‘Beautiful Mind’, ‘Atoms to Galaxies’, ‘Our Body’, ‘Planet Earth’, ‘Tech Me Out’ and ‘Our Society’. If you managed to get to one of the sessions why not get in touch and tell us more about it? Alternatively, this could be a festival to keep an eye out for next year and beyond. Read more at www.pintofscience.co.uk/
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MENTAL HEALTH SURVIVING OR THRIVING? THE STATE OF THE UK'S MENTAL HEALTH – REPORT PUBLISHED BY MENTAL HEALTH FOUNDATION Published May 2017. ‘In March 2017, commissioned by the Mental Health Foundation, NatCen conducted a survey amongst its panel members in England, Scotland and Wales. This aimed to understand the prevalence of self-reported mental health problems, levels of positive and negative mental health in the population and the actions people take to deal with the stressors in their lives. 2,290 interviews were completed, with 82% online and 18% by phone.’ Key findings: • Only a small minority of people (13%) report living with high levels of good mental health. • People over the age of 55 report experiencing better mental health than average. • People aged 55 and above are the most likely to take positive steps to help themselves deal better with everyday life - including spending time with friends and family, going for a walk, spending more time on interests, getting enough sleep, eating healthily and learning new things. • More than four in 10 people say they have experienced depression. • Over a quarter of people say they have experienced panic attacks. • The most notable differences are associated with household income and economic activity - nearly three in four people living in the lowest household income bracket report having experienced a mental health problem, compared to six in 10 of the highest household income bracket. • The great majority (85%) of people out of work have experienced a mental health problem compared to two thirds of people in work and just over half of people who have retired. • Nearly two-thirds of people say that they have experienced a mental health problem. This rises to seven in every 10 women, young adults aged 18-34 and people living alone. Read more about the work of the Mental Health Foundation and to download this report for free visit www.mentalhealth.org.uk/publications/surviving-or-thriving-state-uks-mental-health
PHE BUSINESS PLAN 2017 TO 2018 Published 12th April 2017. The plan outlines the main steps and actions PHE will be focusing on over the next year to protect and improve the public’s health and reduce health inequalities. It also describes how PHE will deliver the second year of the strategic plan ‘Better outcomes by 2020’ and should be read in conjunction with this document. Full details can be found at www.gov.uk/government/ publications/phe-business-plan-2017-to-2018
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DATES FOR YOUR DIARY UNIVERSITY OF NOTTINGHAM SCHOOL OF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals • Obesity Management (D24BD3) 3rd/4th October, 5th/6th December
• Gastroenterology (D24GE1) 10th/11th October, 12th/13th December
For further details please contact email Katherine.email@example.com 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'.
Coming up soon . . .
Diabetes Week 11th to 17th June www.diabetes.org.uk/Get_ involved/ Diabetes-Week
Dietitians Week 2017 12th-16th June Emphasising evidence and expertise www.dietitiansweek.co.uk Nutrition support across the continuum of care 15th June Nutricia free symposium London www.nutriciaevents.org.uk New and refresher - Ketogenic Therapy 27th-29th June West Sussex Matthew's Friends Ketocollege www.mfclinics.com/keto-college Kindful Eating Part 1 and Part 2 28th-29th June Manchester Please contact firstname.lastname@example.org
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MEDICAL AFFAIRS-MARKETING DIETITIAN - VITAFLO Salary is negotiable dependent on experience. knowledge of Vitaflo’s overall product portfolio, Vitaflo International Ltd is currently looking to recruit whilst developing a deeper expertise in an assigned a full-time permanent Medical Affairs-Marketing portfolio of products. Education and training: Deliver Dietitian to work at its head offices just outside of product training and related disease area training to Liverpool City Centre. This role functions within the both internal and international teams. Informational marketing team to provide technical support to both services: responsibility for UK and international internal teams and external customers. If you are HCP/patient/colleague queries and providing passionate about nutrition and dietetics, but would informational services to healthcare providers in the like to experience a role outside the clinical setting that community. Please email a copy of your CV and cover encompasses scientific, informational, communication letter to email@example.com. For an informal and interpersonal activities, this may be the ideal discussion about the role, please contact Carleen opportunity for you. Key job responsibilities include: McCarney, Medical Affairs - Marketing Manager on Product understanding: Maintain a good working 07741 264229. Closing date: 23rd June 2017.
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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.
Over a ‘dietetic lifetime’ of 50 plus years, I have seen many patients, met many colleagues, encountered many changes and expressed many views . . . In this penultimate Final Helping I shall share some final thoughts before giving some further thought to my ‘lifetime top 10 dietetic moments’ in my final column next month. When I was a boy, there were no ‘fat kids’ in my class in primary school. All the way through secondary school there was only one boy in the class who would possibly be considered overweight… just. What happened in the intervening years? Well I think you can all work out the answer. Did successive governments and food retailers play a part I wonder? One provided the means to simplify our eating behaviour and one realised too late that just setting unachievable targets to reduce obesity was not the answer. Obesity…a word once never heard, and mentioned only once in the Manual of Nutrition published by MAFF in 1966. It stated, ‘Individuals vary in their propensity to get fat, usually because they differ in the activity of their daily life.’ It continued, ‘Appetite is also a factor and obese people tend to have a larger one than thinner people.’ Hmm! It was finally realised that managing the now ‘obesity epidemic’ alone could quite easily bankrupt the NHS, and still can. What did health professionals such as our small profession do? Well, not enough probably and dare I say that the handing out of diet sheets (as per my own training) was probably not that effective. I don’t think anyone or anything could have stopped the ‘March of Obesity’ because there were too many overwhelming
commercial forces at play controlling both our eating habits and our behaviour. Our own profession was developing sideways with more dietitians becoming specialists in other areas and weight management became far less attractive or rewarding to work in. I personally found it richly rewarding. During my first job in Dietetics, I coined my own ‘weight management pathway’ which I tried to follow with patients, simple stages which necessitated a degree of contact and a degree of commitment (on both sides). My previous role as a dietitian working for Slimming Magazine had confirmed to me that the best results in a slimming club environment were achieved by the bestor most-liked group leaders (who had to set an example in their own life and be and maintain a ‘healthy weight’)…not the diet sheet. It’s a bit late, but here is my personal ‘let’s ion it out’ plan, first used in 1974, which was discussed at the first patient/dietitian meeting (usually 30 minutes): Information. Explanation. Education. Motivation. Castigation (support). Realisation. Three minutes or so on each and then free speech! For my part, when I was undertaking my Fitness and Fatness Final Year Dissertation (1969), I weighed 10st 4lbs, had a 30-inch waist, 36-38 chest and was five feet four and three quarter inches tall. Today I’m still five feet four and three quarters inches. 36-38 chest, prefer a 32 inch waist and this morning weighed 10st 4 lbs on my scales. Yes, I know! See you next time for my final Final Helping. www.NHDmag.com June 2017 - Issue 125
THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all. • Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.
REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Date of preparation: July 2015 RXANI150143
The Magazine for Dietitians, Nutritionists and Healthcare Professionals Issue 125