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

June 2017: Issue 125


More information from the BDA page 40


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. 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 June 2017 - Issue 125



11 COVER STORY COPD: Nutrition and weight management




Sugar & salt update

Latest industry and product updates

New initiatives to reduce intake


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


PKU in the UK: the early years

& updates

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 and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

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


Advertising Richard Mair Tel 01342 824073 Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES June 2017 - Issue 125

@NHDmagazine ISSN 2398-8754

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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. @DrDerbyshire

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

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:;

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

6 June 2017 - Issue 125

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 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 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

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 June 2017 - Issue 125

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)

Salt (g/day)

Under 1 year

Should not be given

Should not be added

1-3 years

No recommendation


4-6 years



7-10 years



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 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

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; June 2017 - Issue 125





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.


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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. 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

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