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Additional articles for subscribers only

NHDmag.com

November 2017: Issue 129

FOCUS ON FOOD ALLERGY: SMARTPHONE APP SURVEY by Carina Venter

LOW CARB DIETS Articles by Maeve Hanan and Alice Fletcher

NHD-EXTRA: CONDITIONS & DISORDERS

TYPE 2 DIABETES: LOW CARBOHYDRATE DIETS AS TREATMENT Alice Fletcher RD Community Dietitian, Countess of Chester NHS Foundation Trust

Alice has been a Registered Dietitian for almost three years working within NHS community-based teams. She is passionate about evidence-based nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time.

NutritionIn Wonderland.com

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

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There is increasing media coverage regarding low carbohydrate diets as a treatment for Type 2 diabetes (T2DM), particularly in place of drug therapies.

As a result, more and more people with T2DM are asking if they should “cut out the carbs”. Many dietitians are finding that this style of eating is becoming more difficult to advise against. Is it time that we changed our practice?

As a Community Dietitian who delivers diabetes education sessions to those diagnosed with T2DM, I am often asked if service users should “cut out the carbs”. Considering blood sugar levels are directly affected by the carbohydrates (CHOs) that we eat, this does seem like a logical solution and can at times be difficult to advise against.

The television coverage of low CHO diets as a treatment for T2DM appears to be increasing over recent years. During an episode of Doctor in the House aired by the BBC in 2015, key sources of CHOs for the person with diabetes were removed, with emphasis placed on removing dairy and wheat containing foods.

Time-restricted eating/fasting was recommended, along with suggesting that the 5-a-Day for the individual came from vegetables only, avoiding fruit completely. Shortly after this programme was aired, Dr Duane Mellor gave the following statement on behalf of the British Dietetic Association (BDA): ‘This advice is potentially dangerous with possible adverse side effects. Not only is there limited evidence around CHO elimination and time-restricted eating for those with diabetes, but cutting out food groups and fasting could lead to nutrition problems, including nutrient deficiencies and adversely affect their blood sugar control, particularly in individuals taking certain medications or insulin.

‘Whilst reducing refined CHOs and sugar intake is definitely a positive,

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many of the other recommendations lack evidence from scientific research base.

People living with diabetes watching the programme are advised to stick with their current treatment and discuss any changes with their diabetes team, which can include a consultant or GP, dietitian and Diabetes Nurse.’1 The statement was clear: the advice given to hundreds of thousands of people in this programme was not supported by the BDA. The recommendation of low CHO diets for T2DM continues within magazines, newspapers and social media. Often there is emphasis on not needing to count calories and being able to eat as much fat as you would like to, as well as having increased satiety secondary to this. This mantra is particularly backed by Dr Mark Hyman, the American Author of Eat Fat, Get Thin.

Dr Hyman is an advocate of a very low CHO diet for T2DM with the majority of calories coming from fat, followed by protein. Dr Hyman is also a fan of ‘bulletproof coffee’ (blending butter into black coffee). Within his latest book he argues that recommendations to cut down on fat and to base meals around starchy CHOs have fuelled the epidemic of obesity and T2DM.2 We know from national databases that across the UK, America and other countries, our intake of starchy CHOs has increased alongside intake of total fat and added sugars.

Here in the UK, Dr Michael Moseley has written a book The Blood Sugar Diet

where a low CHO Mediterranean style diet is recommended. The advice within this is similar to that of Dr Hyman, with less sensationalism and dietary restrictions. CHOs such as quinoa, bulgur, whole rye, wholegrain barley, wild rice and buckwheat are recommended in sensible amounts.3 Dr Michael Mosley has T2DM and controls his blood sugar levels into the ‘normal’ range following this style of eating alongside intermittent fasting (the 5:2 diet).

When it comes to Registered Dietitians, Dr Trudi Deakin is also an advocate of low CHO diets for the management of T2DM alongside ditching low fat products. Dr Deakin developed the X-PERT education programme for those with T2DM, and it is utilised by many NHS Trusts across the UK. In November 2015, Dr Deakin released a book Eat Fat, Step-by-Step Guide to Low Carb Living alongside the X-PERT programme.

She highlights that the programme continues the same, but with less emphasis on low fat, and supports participants with trying different dietary approaches.4 If current trends persist, one in three people will be obese by 2034 and one in 10 will develop T2DM.5 Is it time that we changed our practice?

WHAT IS CURRENTLY RECOMMENDED FOR THE DIETARY MANAGEMENT OF T2DM?

Low added (free) sugar diets are recommended for Type 1, 2 and gestational diabetes, as well as generally for a healthy balanced diet. Presently, adults are recommended to consume no more than 30g of added ‘free’ sugars per day (roughly seven sugar cubes), but they are estimated to consume on average two to three times this amount.6 When it comes to T2DM, the advice does

not differ, but added sugars are recommended to be reduced as much as possible.7 When it comes to starchy CHOs, we are recommended to have a large proportion of our diet based on them, as shown in the Eatwell Guide. The advice from Diabetes UK is actually quite vague, stating on their website: ‘Try to include some starchy foods every day.’ The reference intake for CHOs at present as listed on the NHS website, is 260g per day in total.

It remains unclear exactly where this reference intake has been devised from.

HOW CAN A ‘LOW CHO DIET’ BE DEFINED?

There is presently no specific definition of a low CHO diet, however, studies into low CHO diets usually use a maximum of 20% calories coming from CHOs. Dr Trudi Deakin has suggested the following: • Less than 136g per day = low CHO diet • Less than 50g per day = very low CHO diet4 This article will not specifically discuss levels of CHO intake needed to induce ketosis.

WHAT ARE THE COMMONLY DISCUSSED POSSIBLE RISKS OF A LOW CHO DIET FOR THOSE WITH T2DM?

Increased fat intake The general concern from healthcare professionals in the past is that if little or no energy is coming from dietary CHO, then the diet will be higher in total fat as well as saturated fats and, therefore, the risk of cardiovascular disease will rise further (having T2DM already increases this risk). However, as yet, there is not sufficient evidence to prove either way. www.NHDmag.com November 2017 - Issue 129

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NHD-EXTRA: CONDITIONS & DISORDERS Many high-profile advocates of low CHO diets are sceptical, regarding blood cholesterol levels as an indicator of cardiovascular disease risk and saturated fat in excess of current recommended limits having a negative impact upon health.

There are several populations around the world that have been reported to eat almost zero CHOs for the majority of their lives (the Masai in Africa, the Inuit people of the Canadian Arctic), yet maintain a healthy body mass index with low incidence of chronic illness. When this is delved into further, however, some studies do show that the Inuit eat a low CHO diet,9 whereas a literature review of the subject found the Inuit diet to generally consist of around 37% CHO, rising up to 53%. This was found to be the case as early as the 1930s. Heart disease and atherosclerosis have also been found to be relatively common.10 Fibre and wholegrains with a low CHO diet There has been further concern from healthcare professionals regarding reduced fibre intake as a result of a low CHO diet. Provided that people eat a diet abundant in vegetables and around two portions of fruit per day, advocates of low CHO diets protest that this should not be an issue. If, however, somebody very adverse to vegetables embarked on a low CHO diet, this could in theory become a problem.

Nutritional inadequacy, particularly in regard to micronutrients A presentation on low CHO high fat diets by Dr Trudi Deakin in June 201511 demonstrated through nutritional analysis that a low CHO high fat diet was nutritionally superior to a high CHO low fat diet in regard to vitamin D, calcium, magnesium, zinc and iron, as well as omega-3 to omega-6 ratio. Much like the argument with wholegrains, if vegetables are eaten in very small amounts, it would make a low CHO diet less nutritionally adequate in regard to some important micronutrients.

Low CHO diets and medications If people take medications that have a risk of causing hypoglycaemia to control their diabetes, it is likely that low CHO diets without adequate 60

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supervision from healthcare professionals may cause more incidences of hypoglycaemic episodes and this would only be compounded by increasing physical activity.

Low CHO diets lead to low levels of glycogen stored in the muscles and liver. Glycogen is important for people with diabetes as a ‘back up’ for the body when blood glucose falls below normal levels, so not having enough of it increases risk of hypos and can make them more difficult to recover from. Low CHO diets should theoretically be safe if a service user does not take any oral hypoglycaemic agents.

WHAT DO THE STUDIES SHOW?

A large percentage of those with T2DM are overweight or obese. Low CHO diets have been found to improve overall weight loss in some studies and are generally seen to be the ‘way to lose weight’ by the mainstream media.

Notably, in 2014, General Practitioner Dr David Unwin undertook a pilot study with 19 people with borderline and T2DM over an eight-month period where a low CHO diet was advised (under the supervision of Registered Dietitian Heather Crossley). The results of this small study were hugely positive. In summary: • Blood glucose control improved.

• By the end of the study period only two patients remained with an abnormal HbA1c (>42mmol/mol); even these two had seen an average drop of 23.9mmol/mol.

• Weight fell significantly (an average of 9kg lost).

• Waist circumference decreased from 120.2±9.6 to 105.6±11.5cm (p<0.0001).

• Blood pressure improved.

• Total serum cholesterol decreased.

Only one of the 19 people dropped out of the study because the diet didn’t suit them. When it comes to dietary advice provided, participants were given a small diet sheet of just over 500 words. All starchy CHOs were prohibited and fat is said to be ‘fine in moderation’. This is very different to what is recommended in mainstream media or low CHO diets where fat is extensively promoted without the word moderation being used. A control group was not used in this study.12

A different study including 13 people with T2DM and 13 non-diabetic people found weight loss to be significantly greater for those following a low CHO diet compared to standard healthy eating advice. However, HbA1c and lipid levels did not significantly differ between groups. This was, however, a short study of only 12 weeks with a small sample size.13 A recent meta-analysis of 10 randomised trials (1,376 people in total) showed that low to moderate CHO diets have a greater glucoselowering effect compared with high-CHO diets, even without weight loss.

Within this review, it was noted that the greater the CHO restriction within studies, the greater the glucose lowering. This metaanalysis did, however, find that apart from improvements in HbA1c over the short term, there is no evidence regarding superiority of low-CHO diets in terms of glycaemic control, weight, or LDL cholesterol in the longer term (after one year).14 A large systematic review and metaanalysis of 20 randomised control trials found a Mediterranean style diet to improve HbA1c levels more than a low CHO diet, although both induced significant weight loss comparatively to a control group. The Mediterranean style diet contained moderate amounts of carbohydrate.15 Snacking In all of the above studies, snacking has been discouraged. The main reason behind this is that insulin (fat storage hormone) levels and incidence of insulin secretion are aimed to be reduced to improve outcomes of weight loss.

Low CHO diets may prove more useful in some people than others Studies overall do show a lot of variability. If somebody has insulin resistance, eating a large amount of CHO and then injecting insulin may not result in inadequate blood glucose lowering as it is the resistance that is the main issue, not the lack of circulating insulin. In these cases, lower CHO (and ketogenic diets) may be more useful to reduce insulin levels as well as excess body fat mass.16,17,18

FINAL THOUGHTS

This area of research is mammoth, complex and difficult to sum up in just a few words.

As dietitians, we do know that for a lot of people with T2DM, making small realistic changes that can be stuck with forever has lasting effects. However, there are a large number of people who feel that the age old mantra of ‘eat less and move more’ is simply not enough.

Not everyone with T2DM will be the same, and some people have a lot more lifestyle changes that they could employ at baseline comparatively to others with the same HbA1c level. For example, one person may consume a lot of added sugars, large starchy CHO portions, be obese and do little physical activity. Another person with a similar HbA1c reading may already consume under the recommended 30g maximum added sugars per day, eat moderate complex CHO portions, be a healthy weight and be regularly active. A diet with extra emphasis on all sources of CHO may be more beneficial for one of these people than the other.

Diabetes UK summed it up well in May this year with an update to their position statement on low CHO diets: ‘The current evidence suggests that low carb diets can be safe and effective for people with Type 2 diabetes. They can help with weight loss and glucose management and reduce the risk of cardiovascular disease. So, we can recommend a low carb diet for some people with Type 2 diabetes. But there is no consistent evidence that a low carb diet is any more effective than other approaches in the long term, so it shouldn’t be seen as the diet for everyone.” 19 As Dietitians, it is our job to not just focus on one nutrient, but look at a client’s overall nutrition, lifestyle, likes and dislikes, cooking skills, medications, readiness to change habits, as well as other health conditions and give dietary advice accordingly. Low CHO diets for the management of T2DM may be more appropriate for some people than others and, in my view, should be utilised accordingly. www.NHDmag.com November 2017 - Issue 129

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NHD-EXTRA: WEIGHT MANAGEMENT

CLINICAL USES FOR LOW CARBOHYDRATE DIETS Maeve Hanan Registered Dietitian (full time), City Hospitals Sunderland

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

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

The recommended daily intake of carbohydrates for the general public is around 50% of daily total dietary energy, which is roughly 313g of carbohydrates per day for the average man and 250g for the average woman.1 Low carbohydrate diets (LCDs) involve eating less than 26% of your daily total calorie intake from carbohydrates.1,2 MECHANISM OF LCDs

There are many variations of low carbohydrate diets (see Table 1) which can either be viewed as a fad or a valid clinical diet depending on the context.

Limiting carbohydrate intake reduces the rate of insulin released from the pancreas and promotes glucagon secretion which causes the following:3 • Glycogenolysis: the breakdown of carbohydrate stored in liver and muscle tissue so that glucose can be used as an energy source.

• Gluconeogenesis: creating new glucose (to be used as an energy source) using non carbohydrate sources such as certain amino acids, pyruvate, lactate and glycerol.

• Lipolysis: the breakdown of fat into glycerol and free fatty acids.

More extreme LCDs cause a type of fat burning called ketosis which is a compensatory mechanism usually occurring in starvation. When glycogen

stores are depleted, fatty acid oxidation can occur in the liver which produces ketones (or ketone bodies) which can be converted and used as an energy source. However, roughly 10-20% of ketone bodies are thought to be excreted via the skin, urine and breath without being metabolised.3 Although ketosis can result in acidosis in a person who has diabetes, this is not usually seen to occur in starvation or carbohydrate restriction in non-diabetic subjects.3 EPILEPSY AND METABOLIC DISORDERS

The ‘ketogenic diet’ (KD) is a low carbohydrate, high fat diet which was developed in the 1920s to treat epilepsy in children. This can still be used today under medical and dietetic guidance for children who don’t tolerate or don’t respond to epilepsy medication.4-5 Although NICE supports this use of the KD, there is no official recommendation related to the treatment of adult epilepsy due to limited evidence.6

Table 1: Classification of LCDs1-2 Classification

Daily carbohydrate limit*

% of daily calorie intake from carbohydrates

Examples

Moderate carbohydrate diet

130 - 225g

26 - 45%

The Scarsdale Diet The Zone Diet

Low carbohydrate diet

Less than 130g

Less than 26%

The Paleo Diet The Drinking Man’s Diet

Very-low carbohydrate diet

Less than 30g

Less than 6%

The Ketogenic Diet The Atkins Diet

*Based on a 2,000kcal daily intake (the recommended daily calorie intake for a moderate active woman who weighs about 60kg) www.NHDmag.com November 2017 - Issue 129

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NHD-EXTRA: WEIGHT MANAGEMENT Table 2: Variations of ketogenic diets Type of diet

Diet composition

The Classical ketogenic diet (KD)

A ratio of 3-4g of fat is given for every 1g of carbohydrate and protein.7

The Modified Atkins diet (MAD)

Restricts carbohydrates to 15-20g per day but doesnâ&#x20AC;&#x2122;t restrict protein and encourages fat intake.8

The Low Glycaemic Index Treatment (LGIT)

40-60g of carbohydrates are allowed per day (portion sizes are used as a guide), low GI options are encouraged, fats are encouraged and protein is unrestricted.4,9,10

The medium chain triglyceride (MCT) ketogenic diet

60% of energy is derived from MCT fat, or a modified version to improve tolerance which has 30% MCT, plus 30% from long chain fatty acids.7

Table 3: Carbohydrate sources and cardiometabolic health associations (SACN 2015)1 Carbohydrate

Association

High intake of sugars-sweetened beverages

Increased risk of Type 2 diabetes.

Diet high in Glycaemic Index or glycaemic load

Increased risk of Type 2 diabetes.

High glycaemic load

Increased risk of cardiovascular disease.

High intake of white rice

Increased risk of Type 2 diabetes in certain Asian populations.

Consuming brown rice

Reduced risk of Type 2 diabetes.

High intake of potatoes

Increased risk of Type 2 diabetes - but it is not possible to establish a causal link due the confounding factors such as varied cooking methods (e.g. frying potatoes).

High intake of dietary fibre, cereal fibre and wholegrains

Reduced incidence of Type 2 diabetes, cardiovascular disease and coronary events.

High intake of bran and beta-glucan

Lower total cholesterol, LDL cholesterol and blood pressure.

The KD can also be used under medical and dietetic supervision with certain metabolic conditions such as: pyruvate dehydrogenase deficiency (PDH) and glucose transporter type 1 deficiency syndrome (GLUT1).4 The main types of KDs used in clinical practice are outlined in Table 2.

WEIGHT MANAGEMENT

Although some meta-analyses identified that LCDs resulted in more weight loss than other dietary methods,11-12 when SACN reviewed the overall evidence base in 2015 they concluded that energy-restricted high carbohydrate low fat diets were more beneficial in reducing BMI as compared to LCDs.1 Some suggested reasons for the weight loss seen on LCDs include a loss of fluid as the process of breaking down glycogen stores can result in about 1kg weight loss as a 63

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result of fluid loss,3,13 and a reduction in calories which may be partially due to the satiating effect of a high protein intake.4,14-15 However, SACN (2015) found no significant difference in energy intake when diets with different proportions of carbohydrates, protein and fat were compared.1 SACN also found that although sugar-sweetened drinks were associated with weight gain and a higher BMI in children and adolescents, when the total amount of carbohydrate in the diet was examined in this group, no association was found between carbohydrate intake and BMI or body fatness.1 Evidence is conflicting in terms of compliance when LCDs are compared with low fat diets.15-16 However, for some individuals, restricting the intake of a specific food group may increase the risk of binge eating and subsequent weight gain.17

In terms of cardiovascular disease, some trials have identified an association between total carbohydrate intake and fasting blood lipids and systolic blood pressure.

CARDIOMETABOLIC HEALTH

Some studies have found an association between LCDs and improved glycaemic levels,18-19 but SACN (2015) found that ‘total carbohydrate intake appears to be neither detrimental nor beneficial to cardiometabolic health’, which included glycaemia and incidence of Type 2 diabetes.1 More recently, Diabetes UK released a position statement which concluded that for Type 2 diabetes, LCDs can be safe and effective.

However, there is not enough evidence that this approach is better than others in terms of longterm weight management and glycaemic control and that ‘there is no strong evidence to say that [LCDs are] safe or effective for people with Type 1 diabetes’.20 However, there is ongoing research into carbohydrate intake and diabetes.

In terms of cardiovascular disease, some trials have identified an association between total carbohydrate intake and fasting blood lipids and systolic blood pressure.1 However, due to confounding factors such as weight loss, it is not possible to establish a causal relationship and SACN (2015) found that total carbohydrate intake had a neutral effect on cardiovascular disease endpoints.1 However, when different sources of carbohydrate are examined, the associated cardiometabolic health outcomes vary (see Table 3).1 CANCER

There is a hypothesis that KDs may be useful in combatting cancer which is based on ‘The Warburg Effect’; an observation that cancer cells prefer producing energy via anaerobic glycolysis rather than oxidative phosphorylation.21 Although there are some animal and in vitro studies which support the use of the KD with specific types of tumour cells,22-24 there is also some contradictory research25 and other studies have identified that ketones may actually fuel certain cancer cells.26-27 Research is ongoing in this area, but currently,

more evidence is needed before the use of the KD can be promoted as a routine treatment option for cancer, especially as this patient group are already at risk of malnutrition and cachexia.21 NUTRITIONAL CONSIDERATIONS

Although most people in the UK would benefit from reducing our intake of ‘free sugars’ (those added to foods by manufacturers, cooks or consumers, and the sugar found naturally in syrups, honey, syrups and unsweetened fruit juices), vilifying total carbohydrates intake can be harmful as it is recommend that 50% of dietary energy should come from carbohydrates.1 Carbohydrates are the main source of fuel used by our body and are also found in many nutritious foods such as wholegrains, fruit, vegetables and dairy products.1,26 There is strong evidence that fibre and wholegrains are associated with a lower risk of cardiovascular disease, diabetes and colorectal cancer.1 Furthermore, an LCD may result in an increased intake of saturated fat and a high intake of saturated fat is associated with an increased risk of cardiovascular disease.29-30 Considering that on average, UK adults already consume less fibre and more saturated fat than the recommended level,31 an LCD could potentially have an adverse nutritional effect.

CONCLUSION

There are some well-established clinical uses for LCDs, such as using KDs with certain metabolic disorders, or for seizure control in children with epilepsy which is unresponsive to medication. However, the current evidence is more conflicting in terms of weight management and cardiometabolic health. Although in the UK we should be aiming to reduce our intake free sugars, carbohydrates are also found in many nutritious foods. Therefore, LCDs should only be encouraged in specific situations when there is a clinical indication for their use. www.NHDmag.com November 2017 - Issue 129

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NHD-EXTRA: RESEARCH & RESOURCES

SMARTPHONE APPLICATIONS: ARE THEY A HELP OR A HINDRANCE? Dr Carina Venter PhD, RD Assistant Professor, University of Colorado Denver School of Medicine, USA Carina is currently an Assistant Professor of Paediatrics, Section of Allergy and Immunology at the Children’s Hospital Colorado and University of Colorado Denver School of Medicine, where she is conducting research and working with children and adults with a range of food allergies.

Kate Maslin PhD RD Research Fellow at the University of Southampton, UK

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

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In this article, Carina and Kate report on a survey that was conducted with users of an electronic smartphone application specifically designed for the management of food allergies in adults.

The prevalence of food allergies in children range between 0.1-6.0% in Europe,1 and 1.1-10.4% worldwide.2 Prevalence data on adult food allergies is scarce and no data establishing the true prevalence of food allergies in adults exists.2 Diet plays a crucial role in the management of food allergies. Although the dietary management of food allergy extends beyond individualised allergen avoidance, this aspect will always remain the most important part of patient management.3 Recent studies clearly indicate that food allergies affect quality of life. This is also true for those with self-reported food allergies/ intolerances, who avoid foods due to perceived symptoms.4 Food allergy affects quality of life (QoL) in four domains: food anxiety, emotional impact, social and dietary limitations.5 Venter et al4 found that there was no difference in QoL in those trying to avoid food due to a perceived or proven food allergy (p = 0.062), clearly indicating the burden of food avoidance in both groups. In addition, Greenhawt et al6 showed that anaphylaxis, multiple food allergies and food allergies other than just peanuts or tree nuts were associated with a significantly worse QoL score, most likely due to the vigilance required to avoid the trigger foods.

Adhering to a restrictive diet can also affect the time taken to shop and the cost of buying food.7 Wolf et al8 showed that the average weekly price of the six food exclusion diet (SFED) at a standard US supermarket was $92.54

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compared to $79.84 for an unrestricted diet (p = 0.0001). Patients also often had to visit a second specialist grocery store to obtain all the foods needed.

Food allergy and nutrition related papers mention that the future of food allergy management should include the use of electronic diaries and software applications to improve patient food intake and nutritional care.9 One of the questions we raised, however, was whether these technologies truly benefit our patients/clients.

SPOON GURU

We report below about a brief survey that was conducted with UK users of the electronic smartphone application, Spoon Guru (SG). SG is available in the UK and has just launched in the US (see www.spoon.guru/app for more details).

This smartphone application allows the user to find products which match the individual’s dietary requirements, through barcode scanner and search functionality. In order to instil cooking skills and prevent unnecessary reliance on packaged food, the smartphone application also provides recipes matched to the individual’s dietary needs.

The smartphone application contains pre-set lifestyle and allergen/intolerance dietary options for the user to select.

The list of lifestyle options to choose from include vegan, vegetarian, ovovegetarian, lacto-vegetarian, pescatarian, palm oil free, paleo, organic, low sugar, low salt, low fat and yeast avoidance.

The list of allergen options to choose from include the 14 major allergens as identified by the European Union, as

The smartphone application contains pre-set lifestyle and allergen/intolerance dietary options for the user to select. well as other allergens or causes of intolerances as requested by Spoon Guru users. This, for example, includes pulses, beans and peas and SFED. The app allows for extra refinement, for example, you can exclude specific types of nuts, fish, shellfish, beans and gluten containing grains. In addition, if your intolerance is not as severe as a food allergy and you can tolerate trace amounts within your food, you can allow products that have a precautionary ‘may contain’ allergen statement on the label.

Current users of the smartphone application (SG app) were asked to complete a very basic 10-question electronic questionnaire between April 2017 and August 2017.

SURVEY RESULTS

One hundred and sixty three SG app users completed the survey; 63 (38.7%) with food allergies (FA) or intolerances (FI) or both (FAI) (25 FA, 29 FI and nine FAI) and 100 (61.3%) using the SG app due to personal preferences, lifestyle or other reasons. The survey was completed by 36 males (22.1%) and 127 females (77.9%). The age ranges were: 17 years or younger (6, 3.7%), 18-24 years (12, 7.4%), 25-34 years (32, 19.6%), 35-44 years (39, 23.9%), 45-54 years (45, 27.6%), 55-64 years (16, 9.8%), 65-74 years (11, 6.7%) and 75 years or over (2, 1.2%). For the analysis, we have grouped those with food allergies and/or intolerances (FAI) in one group and compared them against those using the SG due to personal preferences (lifestyle and/or other: LSO). The data is summarised in Table 1.

Recoding all the variables in two categories, with the lower three options together (e.g. not at all difficult, a little difficult and somewhat difficult as one variable/option vs quite a bit difficult and very difficult as one variable/option), we found no statistical differences between the answers provided by the FAI group vs the LSO group, the female demographic vs the male, or those 34 years and younger vs those 35 years and older. However, significant differences related to QoL were found. Women indicated that the SG app was more effective in reducing difficulties with shopping

(57% women vs 34% men; Chi square test p-value: 0.037). In addition, women found the recipes more helpful than men (55% females vs 33% men; Chi square test p-value: 0.024) and stated that the SG app was more helpful in improving their QoL than men (74% females vs 42% men; Chi square test p-value < 0.001).

Comparing the before and after answers relating to difficulty shopping between the FAI group and the LSO group (question 2 and question 3) showed that the ease of shopping improved significantly for both groups (McNemar’s test: FAFI P<0.001 and LFO p-value <0.001). In the FAI group, 33% (21/63) found shopping difficult before the SG app and only 1.6% (1/63) afterwards. In the LSO group, 23% (23/100) found shopping difficult before using the SG app and 1% (1/100) after using the SG app.

IN SUMMARY

Suffering from food allergies, intolerances or even a self-perceived need to avoid certain foods can negatively affect QoL. Two of the main factors include the difficulty as well as the time required to shop for suitable foods. Smartphone applications may assist in making shopping experiences more positive. We set out to determine how the SG app was perceived by its users.

Our findings indicate that the SG app significantly reduced difficulties encountered during shopping, but that men may have particular requirements that require further investigation. This survey was conducted in a 10-question simple format with a relatively small sample size. Longer, more in-depth surveys with larger numbers are required to get a better idea of the individual needs of users and how smartphone apps can be improved. www.NHDmag.com November 2017 - Issue 129

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NHD-EXTRA: RESEARCH & RESOURCES Table 1: Comparison of Spoon Guru users with food allergies and/or intolerances vs those using the smartphone application for personal preferences Subset with food allergies and intolerances (n=63) n(%)

Those using the app for lifestyle or other reasons (n=100) n(%)

Before using the smartphone app, how difficult was it to access information on foods that may be unsuitable or problematic?

Not at all difficult

2 (3.2)

4 (4.0)

A little bit difficult

21 (33.3)

29 (29)

Somewhat difficult

19 (30.2)

44 (44.0)

Quite a bit difficult

11 (17.5)

19 (19.0)

Very difficult

10 (15.9)

4 (4.0)

How difficult is it for you now to access information on unsuitable or problematic foods now that you are using the smartphone app?

Not at all difficult

22 (34.9)

34 (34.0)

A little bit difficult

33 (52.4)

52 (52.0)

Somewhat difficult

7 (11.1)

13 (13.0)

Quite a bit difficult

0 (0)

0 (0)

1 (1.6)

1 (1.0)

Very difficult

How much easier is it to shop since using the smartphone app?

Not at all easier

6 (9.5)

4 (4.0)

A little bit easier

16 (25.4)

34 (34.0)

Moderately easier

10 (15.9)

8 (8.0)

Quite a bit easier

24 (38.1)

37 (37.0)

7 (11.1)

17 (17.0)

Very easy

How helpful are the recipes provided by the smartphone app?

Not at all helpful

5 (7.9)

6 (6.0)

A little helpful

15 (23.8)

18 (18.0)

Moderately helpful

13 (20.6)

24 (24.0)

Quite a bit helpful

23 (36.5)

34 (34.0)

7 (11.1)

18 (18.0)

Very helpful

What do you like best about the smartphone app? (More than one choice allowed.)

Less stress or frustration

22 (34.9)

30 (30.0)

Time or cost saving

17 (27.0)

22 (22.0)

Safety and peace of mind

39 (61.9)

52 (52.0)

More choice

15 (23.8)

16 (16.0)

None/other

3 (4.8)

7 (7.0)

Overall, did the smartphone app improve your quality of life?

Not at all

6 (9.5)

11 (11.0)

A little

14 (22.2)

34 (34.0)

Moderately or somewhat

16 (25.4)

24 (24.0)

Quite a bit

21 (33.3)

25 (25.0)

67

www.NHDmag.com November 2017 - Issue 129

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