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

October 2016: Issue 118



DYSPHAGIA Pages 29 to 36

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


WELCOME Emma Coates Editor

As the leaves start to become golden and red and you pull out your woolly jumpers and scarves for the first time, NHD brings you a warm, nutritional hug as the nights draw in. We’re just too good to you, I know!

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.

I’ve thoroughly enjoyed reading through this issue whilst we have prepared it for all of you. As always, we love to share a diverse range of articles from fantastic contributors, giving you the latest insights and recommendations for your practice, and this month is no exception. In return, can I take a few minutes of your time? I have a few questions for you. What counselling theories do you currently use in your obesity management strategy? Claire Chaudhry, Freelance Sports Dietitian, takes us through typical practice, Transactional Analysis and Rational Emotive Behaviour Therapy, highlighting their potential benefits when tailoring your approach. Ever thought about autism and its impact on dietary intake? Most commonly addressed in paediatrics, autism can have a huge impact on dietary intake and nutritional status. Our Cover Story by Darran Tunnah, Secondary School SENCo in Shrewsbury, sheds light on the excessive food selectivity which occurs in this challenging and fascinating patient group. Do restricted diets have an impact on iodine levels? Rachel Wood, Specialist Paediatric Allergy Dietitian, Royal Manchester Children’s Hospital, presents an interesting article discussing the risks of iodine deficiency in restrictive diets. She explores current recommendations and shares some of her clinical experience in this area, whilst managing her paediatric allergy caseload. Dysphagia: what more can you learn? Well, we have an update on current products available and a most interesting

case study by Victoria Williams RD, involving a motor neurone disease patient and the dietetic management of his dysphagia. We never stop learning! Veganism: healthy or not? It has become more popular as a dietary choice over the last 10 years, possibly driven by research and celebrity endorsement, with the likes of Jennifer Lopez, UK singer Ellie Goulding and even with music royalty such as Beyoncé and Jay-Z reportedly giving plant-based diets a go. The Vegan Society reported results of a poll, earlier this year, which revealed that over half a million people in the UK are now choosing a vegan diet. We asked Charlotte Sterling-Reed, Registered Nutritionist, to take a closer look at this growing dietary trend, focusing on how to achieve a balanced vegan diet and where it all fits into healthy eating. I think that’s enough questions for now! But our October articles continue: IMD Watch is brought to you by Suzanne Ford, Adult Metabolic Dietitian who shares her knowledge and experience of the dietary management of Tyrosinaemia Type I and II. We are also pleased to introduce Aoife Hanna, Freelance Dietitian and founder of Eat Right Ireland. She brings us her first NHD article, which discusses the controversial use of low carbohydrate diets in Type 1 diabetes. Aoife takes us through the evidence surrounding their use. And be sure to visit our subscriber zone on our website to access more great articles via NHD Extra - So, thinking about answers to all of those questions was definitely worth it, wasn’t it? Emma October 2016 - Issue 118



13 COVER STORY Autism and excessive food selection



42 VEGAN DIET: How healthy is it?

Latest industry and product updates

9 OBESITY MANAGEMENT Counselling theories

45 On behalf of PENG Clinical Update Course 47 Web watch Online resources

17 Iodine deficiency Restrictive diets 21 IMD watch Tyrosinaemia Type I and Type II

29-36 DYSPHAGIA 30 Product listing 33 Motor Neurone Disease 38 Low carb diets Type 1 diabetes: are they suitable?

and updates

48 Book review Obesity: The Biography

Copies to give away

50 Events & courses, dieteticJOBS Dates for your diary and

job opportunities

51 The final helping The last word from Neil Donnelly

Copyright 2016. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

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


Advertising Richard Mair Tel 01342 824073 Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email


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Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd Emma is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health.

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.

UK Obesity ‘Plan for Action’ Well, the much awaited Obesity Plan1 has now been published, resulting in real disappointment across the board. The Plan for Action sets out to focus on two main areas within the next 10 years, by encouraging: 1. Industry to cut the amount of sugar in food and drinks and 2. Primary school children to eat more healthily and stay active. Unfortunately, as we are well aware, obesity will only truly be solved by taking ‘multi-faceted’ approaches across the life-course. For example, many infants are born overweight due to high rates of maternal obesity and rising rates of gestational diabetes. In fact, healthcare costs are 72% higher amongst infants born to obese mothers compared with those born to healthy weight mums.2 A little down the line, lack of education about appropriate weaning and feeding of toddlers seems to be contributing to the commonly quoted statistic that ‘a third of children aged two to 15 are overweight or obese’.3 So, whilst sugar may be one factor contributing to obesity, we can see that there are other causes. We also need to consider the sheer volume of unhealthy foods surrounding children today - the forces of so many temptations. Whilst parents have an important role in influencing children, so do their friends, with friends’ junk food habits appearing to have a stronger influence than parents’ encouragement to eat healthily.4 Education is also important as children need to understand about why healthy eating is important for benefits to embed to a deeper level - an aspect overlooked in the report. Interestingly, whilst there is mention of a soft drinks levy, the simplicity of encouraging children to drink water appears to go unmentioned. The 13-page report also fails to refer to the World Health Organisation (2016) End to Obesity Report.5 This is a brilliant report; a real ‘gold-standard’ in terms of what we should be striving for. Given that we usually look to the World Health Organisation’s guidance, in this instance, it was most disappointing to see that much of its excellent context was not utilised. So, where to go from here? Well, clearly there is scope to write to the Secretary of State for Public Health and Innovation to identify the shortcomings of this report. Otherwise, it seems that it’s up to us to drive ideas forward, ideally targeting the actions justifiably put forward by the World Health Organisation. References 1 HM Government (2016). Childhood Obesity: A Plan for Action. Available at: childhood-obesity-a-plan-for-action 2 Morgan KL et al (2015). Obesity in pregnancy: infant health service utilisation and costs on the NHS. BMJ Open 5(11): e008357 3 Health and Social Care Information Centre (2009). Children’s overweight and obesity prevalence, by survey year, age-group and sex to_1997_Revised_Childrens%20 Table%204.xls 4 Guidetti M et al (2012). The transmission of attitudes towards food: twofold specificity of similarities with parents and friends. Br J Health Psychol 17(2):346-61 5 World Health Organisation (2016). Report of The Commission on Ending Childhood Obesity. Available at: iris/bitstream/10665/204176/1/9789241510066_eng.pdf

For more news and additional articles see NHD Extra online: 6 October 2016 - Issue 118

NEWS VITAMIN D ENHANCED EGGS One way to top up dietary vitamin D intakes could be to eat vitamin D-enriched eggs. Now, pioneering research has tested whether eating these eggs could help to improve vitamin D status. An eight-week randomised-controlled trial was carried out on 55 healthy adults aged 45 to 70 years. Participants either ate ≤2 eggs per week (the control group; vitamin D status was expected to decline), or seven vitamin D3 or 25(OH)D3 enhanced eggs per week. Results showed that vitamin D status was 7-8nmol/L lower in the control compared with the vitamin-D enhanced eggs. Vitamin D status also declined significantly in the control group during the winter, but was sustained in the vitamin-D enriched egg groups. These innovative findings suggest that eating seven vitamin-D enhanced eggs a week could help to improve vitamin D status and help to sustain this during the winter months. For more information, see: Hayes A et al (2016). American Journal of

PRODUCT / INDUSTRY NEWS WILTSHIRE FARM FOODS HEALTHY BALANCE RANGE It’s normal to lose bone density as we age, but increasing vitamin D and calcium intake can help reduce these effects and encourage maintaining bone health. Each meal in Wiltshire Farm Foods’ new Healthy Balance range has been fortified with enough calcium and vitamin D to provide at least 70% of the new SACN guidelines of 10μg a day. Visit for more details. Lo

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DIGES T HEALTH nals NETW ORK The Magazine October

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DYSPHAGIA to 36 Pages 29

Clinical Nutrition [Epub ahead of print].

NEW VITAMIN D RECOMMENDATIONS The much anticipated vitamin D recommendations have now been published by the Scientific Advisory Committee on Nutrition. In a nutshell, everyone aged one year and above should be aiming for a daily vitamin D intake of 10 micrograms. However, whether we strive to obtain this via dietary sources, or take a supplement, varies according to age, season and degree of skin pigmentation. The main overarching recommendations are shown in Figure 1. Within these overarching guidelines, there are a number of specific recommendations. These include that breastfed babies (partially or exclusively breastfed) should be given a daily supplement (typically ‘drops’) containing 8.5 to10 micrograms vitamin D from birth up to one year of age. Formula-fed babies needn’t take vitamin D supplements unless they are receiving less than 500mls (about a pint) of formula a day, as these tend to be fortified with vitamin D. For children aged one to four years, a daily supplement containing 10 micrograms vitamin D is recommended. Equally, for those aged five years and older, including pregnant and

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Figure 1: UK vitamin D recommendations (SACN, 2016) From birth up to 1 year of age

A vitamin D intake in the range of 8.5 to 10 micrograms/day is recommended, including those of are exclusively or partially breast fed.*

Ages 1 year and above

A vitamin D intake of 10 micrograms/ day is recommended, including pregnant and lactating women and population groups at risk of vitamin D deficiency (those with minimal sun exposure or from ethnic minority groups with dark skin).

*Precautionary recommendation due to insecurities in the data.

breastfeeding women, a daily supplement containing 10 micrograms of vitamin D is advised from October to March when sunshine exposure is limited. All year-round supplementation with 10 micrograms vitamin D daily is advised for people who rarely go outdoors, such as frail or housebound individuals. Those with dark skin, or who habitually wear clothes that cover most of their skin while outdoors have also been guided to supplement.

For more information, see: SACN (2016). Vitamin D and Health Report. Available at: October 2016 - Issue 118



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Discover more at 1 Contains 1.89g/100kcal of protein, including α-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as of May 2016. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.


COUNSELLING THEORIES AND OBESITY MANAGEMENT Claire Chaudhry Community NHS Dietitian/Private Sports Dietitian BCUHB/Claire Sports Nutrition Consultancy

Obesity in the UK is currently the biggest public health concern and addressing obesity is the responsibility of all healthcare professionals.2 The UK has the highest rate of obesity compared with other European countries and costs the UK economy £47 billion pounds a year.3 There are a number of genetic, medical, social and psychological factors that contribute to obesity and counselling theories can help with understanding psychological factors.

In Claire’s 14 years of experience she has worked in acute and community NHS settings and has taught Nutrition topics at universities and colleges and regularly provides talks to groups, NHS and for the private sector. Her dissertation at university was ‘Eating behaviours in students’, leading her to undertake a Certificate in Counselling in 2014 accredited by the BACP.1

Counselling involves working with individuals or groups of people who may be in crisis and/or who require support, guidance or problem solving. The task of counselling is giving the ‘client’ the opportunity to explore and discover new ways of living their life to the full. Counselling in obesity management provides: • insight into understanding the origins of the behaviour, leading to more of a rational control over feelings and eating behaviours; • self-awareness, with the client becoming more aware of thoughts or feelings about food; • self-acceptance, developing a positive attitude towards themselves, whatever size or shape; • problem solving, finding a solution to a problem which the client hasn’t been able to resolve in the past; • behaviour change, which is vital with regards to changing eating behaviours for the benefit of the client; • empowerment, working on skills and knowledge to help the client achieve empowerment and confidence, hoping to tackle coping mechanisms, i.e. binge eating; • restitution to help the client to make amends for previous mistakes or previous attempts at behaviour changes.4

For full article references please email info@ networkhealth


There are many theories in counselling that can help provide further under-

standing of the psychological aspects of obesity. Cognitive behaviour therapy (CBT), developed in the 60s by American psychiatrist Aaron Beck (1921), has shown to be evidenced based and works in obesity management. CBT involves practical solutions based on the individual client’s requirements and dietary goals, e.g. always taking a shopping list to the shops, not snacking in between meals etc. CBT has to be revisited regularly for behaviour change to be maintained.5 As dietitians, we take the patientcentred therapy (PCT) approach with all clients, based on Carl Rogers (19021987). PCT must encompass three basic core conditions for a beneficial relationship to occur. Creating a comfortable, non-judgemental environment by demonstrating; congruence (genuineness), empathy and unconditional positive regard (respect) for their client.6 The most recent theory to emerge in obesity management is mindfulness, which is based on Gestalt therapy by Fritz Perls (1893-1970). Gestalt therapy looks at the healthy functioning adult and keeping in touch with oneself. Goals for Gestalt therapy are heightened awareness and ‘being mindful’; yoga can also be termed as a form of Gestalt therapy. An article in Dietetics Today (January 2016) shows results from a mindfulness course of five sessions in a group, which found that clients attending said they were paying more attention to how they relate to food and October 2016 - Issue 118


• Adult: a state of the ego which is making logical predictions and decisions about major emotions affecting development. While a person is in the Adult ego state, he/she is directed towards an objective, they are rational, calm and logical, e.g. talking and laughing with a close friend/ partner is an adult-to-adult transaction. The aim of TA is to strengthen this adult ego. • Child: a state in which people behave, feel and think similarly to how they did in childhood, e.g. a person who receives a poor evaluation at work may respond by comfort eating, as if shouted at as a child, or rewarding them with food if they receive a good evaluation from their employer. found this approach more understanding and compassionate.7 There are other theories that can prove useful in obesity management and can enable the dietitian to understand more about the client’s beliefs and behaviours surrounding food. The two to discuss further are Transactional analysis by Eric Berne (1910-1970) and Rational Emotive Behaviour Therapy (REBT) by Albert Ellis (1913-2007). Transactional Analysis (TA) by Eric Berne This looks at the transactions (relationships) that have taken place or are taking place between the Parent, Adult and Child ego states. This involves understanding each of our ego states and their transactions in our ‘life scripts’. At any given time, at work, at home with your partner or children, every adult experiences and manifests his or her personality through a mixture of behaviours, thoughts, and feelings. The aim of TA is learning to strengthen the adult in all relationships/transactions and to be aware of the child and parent influences. • Parent: a state in which people behave, feel and think in response to an unconscious mimicking of how their parents (or other parental figures) acted, or how they interpreted their parent’s actions, e.g. a client may influence their children’s eating habits by telling their child to finish what is on your plate (despite fullness in the child) as this was demonstrated in their own childhood; therefore, they are taking on the parent script. 10 October 2016 - Issue 118

Here are examples of statements related to TA that have been said during consultations: “My husband is always on at me to lose weight and he says that I can’t have that food or this food, so then I hide what I am eating so he can’t see me, when he does find out he gets frustrated and shouts.” In this instance the client is in a Child ego and her husband has taken the part of the Parent ego. “My mum used to reward me with chocolate if I had been a good girl; I still do that now, reward myself with food, when I have been ‘good’!” This client is in the Child ego and is repeating her positive childhood script from her parent. “We were punished at school for not finishing our food off our plate, I make sure I never leave anything on my plate now.” This client is in the Child ego and is repeating negative memories from their childhood script. Using the knowledge of TA in dietetic consultations will enable dietitians to understand how the person’s eating behaviours and the emotions associated with them, have developed and also offers guidance on how best to question their client’s beliefs. It is the goal of TA that the adult in obesity management is aware of their Child state when it comes to their eating behaviours. Unhealthy childhood experiences can lead to the client being pathologically fixated in the Child and Parent ego states, bringing discomfort to an individual and/or others in a variety of forms, including mental illness, binge eating and other eating disorders.8 Often ‘childhood scripts’ surrounding food continue within the family from

WEIGHT MANAGEMENT generation to generation, contributing to obesity throughout the family tree. REBT by Albert Ellis Dr Ellis explains that any irrational beliefs we have lead to negative feelings, which also leads to actions that can be self-defeating. The aim of this theory involves disputing the client’s irrational beliefs and replacing them with rational beliefs. Irrational beliefs in obesity clients can be: • biological, e.g. resistance to change becomes ingrained in the eating habits of the whole family; • emotional, e.g. they fail to see how upset they are and can often deny, or try to hide, or ignore their feelings with comfort eating; • insufficient scientific reason, e.g. not seeing the bigger picture of their eating behaviours and health consequences; • unrealistic beliefs about change, e.g. expectations of themselves such as losing five pounds every week; • focusing on their past failures, as this will only reinforce irrational beliefs and lead to them being unsuccessful in their dietary goals. Here are examples of statements related to REBT that have been said during consultations in obesity management: “By going off my diet when I go out for an evening proves I cannot stick to it.” “I must be perfectly thin for me to be successful, if not, I am a terrible person.” “I cannot possibly say no to someone who has offered me food, what would they say?” “I have to lose weight; I look disgusting to everyone!” The aims of REBT in aiding with obesity management: • Dispute irrational beliefs, why? What is the reasoning behind this thought? • Dispute the terribleness of the situation; is it really terrible, awful, horrendous or even catastrophic that you have put one pound on in weight? • Dispute self-hatred, learning to love you, flaws and all. • Dispute seeing things as black and white, e.g. there are no good and bad foods only good and bad diets.

• Helping to use coping statements and changing expectations of the client: “It is certainly not bad that I haven’t lost two pounds this week. I am happy with one pound weight loss this week.” REBT states that one of the changeable reasons to help with obesity management is that clients hold unrealistic and inflexible expectations about their weight and eating behaviour. REBT can help with being more tolerant, more accepting, more understanding of human fallibility and being rational about eating behaviours which can help with tackling obesity.9 CONCLUSION

As dietitians, our knowledge is based on scientific evidence and practical dietary advice to help aid weight loss in obesity management. Counselling in Dietetics is covered in our degree. However, there is more to learn regarding the counselling theories and the practicality of using them in a clinic or group setting in obesity management. We require to be aware of our own limitations as healthcare professionals and we are not trained counsellors. We need to ensure that we are able to signpost our clients to other departments, e.g. psychologist, psychiatrist, or mental health team when required. Other limitations regarding the counselling theories include that they are not to be used in isolation with clients; very rarely does ‘one size fit all’; we know through evidence that obesity management within the NHS setting can work individually and within group sessions for different clients. The counselling theories require an attitude of a tool bag: which counselling theories better aid your client in their dietary goals depends on their explanation to you of their thoughts, beliefs, and behaviours surrounding food. Further reading Cooper Z, Fairburn C and Hawker D (2003). Cognitive behavioural treatment of obesity, a clinician’s guide. the Guilford press, New York Hunt P and Hillsdon M (1996). Changing eating and exercise behaviours, a handbook for professionals. Blackwell publishing, Oxford Sawkill S et al (2013). A thematic analysis of causes attributed to weight gain: a female slimmer’s perspective. Journal of human Nutrition and Dietetics, Vol 26, issue 1, pg 78-84 Hancock REE, Bonner G, Hollingdale R and Madden AM (2012). ‘If you listen to me properly, I feel good’: a qualitative examination of patient experiences of dietetic consultations. J Hum Nut Diet. 25, pg 275-284 Nash J (2013). Diabesity: What have emotions got to do with it? Diabetes in practice 2, pg 48-56 October 2016 - Issue 118


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AUTISM: CAUSES AND IMPLICATIONS OF EXCESSIVE FOOD SELECTIVITY Darran Tunnah Secondary School SENCo, Meole Brace School, Shrewsbury

Autism spectrum disorder (ASD) comprises a set of related developmental disorders, which have implications in several areas of a person’s life, such as communication, social interaction and very strict daily routines. Autism is a lifelong developmental condition that can have a profound effect on how autistic people interact with others and how they view the world. This article looks at how food selectivity can impact on the lives of this patient group.

After leaving university, Darran worked as a Research Scientist and then as a Science teacher for 11 years before taking on the appointment of school SENCo. His main role is to make sure that the provision of educational statements is met.

If you are autistic there is no cure, but, with the right support, you can lead a very fulfilling and rewarding life, learning and developing in much the same way as a neuro-typical person. Being autistic, to an autistic person, can be a huge part of their identity. They know they are ‘different’, they just don’t know why, and everyday things like school, family, work and social life can be much more difficult and full of anxiety. Nevertheless, they would not want to have their autism ‘cured’. It is now thought that roughly one in 150 children are autistic and it is thought to cause severe difficulties in, not only the health and education of the child, but also in their eating habits.1 Being the parent of an autistic child can be very difficult for many reasons. Some people just think that their child is naughty; they tend to be very socially awkward with very few friends; changes to their routine can have major implications to everyone around them and meals out, or even at home, can be a constant battle.

For full article references please email info@ networkhealth


Studies amongst autistic and non-autistic people have looked at food selectivity and nutritional adequacy amongst these groups of people. It was found that autistic children refused 41.7% of the foods offered to them, whilst only 18.9% of foods were refused by nonautistic children. The autistic children

were also found to choose a more limited range of foods. Compared to non-autistic children.2 As well as being selective with their food, behavioural issues, such as choking and aggression associated with food refusal, have been shown to put the child, and whoever is feeding them, at risk of harm.3 With regards to eating habits, autistic children can be seen to not only have restrictive eating habits, but also ritualistic ones too. Some children have such a restricted diet that it leads to nutritional deficiencies, leading to weight loss, malnutrition and even inadequate growth. Some feeding issues can be so severe that they qualify as a disorder. For instance, an autistic child may only eat a very particular brand of pasta sauce, and if a parent gives them an alternative, the child may respond with a severe tantrum, known as a meltdown. The ‘five-a-day’ for an autistic child can literally mean eating the same thing, but five times a day, or even only eating five things or less. This selectivity of food could be due to only eating particular colours of food, or specific textures of food. Some autistic children will not touch food, such as peas, if they are touching carrots. They won’t eat food that has cooled slightly, or if there is a mixture of textures, for example butter on bread. Even more difficult is the instances where an autistic child will only eat yellow, crunchy food like crackers, waffles and toast. October 2016 - Issue 118


What is interesting is that in the age group 2-5 years, more autistic children were obese and 5-11 years, more autistic children were underweight.

It has been shown that the foods autistic children like tend to be full of carbohydrates and not much fibre, which can lead to other complications.4,5 Several nutrients have been identified as those that are least likely to be eaten by autistic children due to the types of food they often refuse to eat. These nutrients are found to include vitamins A and E, calcium and fibre.6 Protein7,8 and vitamins B12 and D, have also been noted as being deficient in autistic children.8 RESEARCH OUTCOMES

Due to this very selective diet that autistic children have, studies have been carried out to assess whether this leads to an increase in gastrointestinal symptoms compared to a control, non-autistic population. One particular study looked at the incidences of different symptoms such as constipation, diarrhoea, abdominal bloating, discomfort or irritability, gastroesophageal reflux or vomiting and feeding issues or selectivity in people aged under 21. The study noted significant differences in the incidence of constipation (33.9% in autistic children compared to 17.6%) and feeding issues/ food selectivity (24.5% in autistic children compared to 16.1%). Constipation and feeding issues/food selectivity often have behavioural causes, so this data suggests that neurobehavioural rather than organic gastrointestinal causes may account for this higher incidence in symptoms within autistic children.9 Sensory over-responsivity, being over sensitive to taste, texture, temperature and colour, for example, has been noted to be one of the main reasons for 14 October 2016 - Issue 118

How parents deal with the food selectivity issue can bring about a great deal of change to the child’s behaviour or it can exacerbate the situation. autistic children being so selective about the food they choose to eat.10 In another study, children with social withdrawal, irritability and other issues that generally affect autistic children, were also more likely to have gastrointestinal symptoms compared to children with typical development.11 It must also be taken into consideration that food selectivity, amongst other autistic behaviours, may very well not stop once a child has reached adulthood, and the complications of this selective diet may continue into later life.12 Compared with non-autistic children, it has also been noted that obesity levels are also higher in the autistic community (30.4% compared to 23.6%). What is not certain is whether this is due to the restricted diet that they eat, a marked decrease in the levels of physical activity they partake in, or even possibly due to both. More research is needed to ascertain what the cause is.13 Although there is a definite issue with regards to autistic children not eating a wide range of food, there are other reports that show that, whilst they may not have a diverse range of eating habits, in some studies they have found that nutrient intake is

CONDITIONS & DISORDERS not too dissimilar to those children who eat a much wider range of food. In one study14 some children did consume less vitamin A and C and zinc than typical developed children, but overall nutrient intake was similar between the two groups. What is interesting is that in the age group 2-5 years, more autistic children were obese and 5-11 years, more autistic children were underweight. Whilst nutrient intake may not be an issue, either the amount of food eaten or another possible reason, inactivity, may be the cause of this.14 In another study of children with autism and language regression, it was noted that there were other diseases and illnesses linked to gastrointestinal issues in this group of children. For instance, it was noted that 40% of ASD children with language regression had abnormal stool samples compared to just 12% of non-ASD children. There was also a higher familial history of coeliac disease (24% in ASD, 0% in non-ASD) and Rheumatoid arthritis (30% ASD, 11% nonASD). The study also noted a higher incidence of familial autoimmune disease in ASD children with language regression than typical developed children (78% compared to 15%). It would, therefore, seem that there is a link between autism with language regression, autoimmune disease and gastrointestinal symptoms.15 BEHAVIOUR MANAGEMENT

Behavioural procedures, such as non-removal of spoon, to deal with food selectivity is well documented in research. The non-removal of spoon technique, for example, requires the feeder to place food on a spoon and keep it there in close proximity to their lips until the child decides to eat the food. Behaviours such as crying, self-injury, pushing the spoon away and aggression should not result in the food being taken away, the spoon must be put back into position until it is eaten.16

This repeated taste exposure, along with escape prevention, can lead to the child becoming much less selective in their food choice.17 It has been shown that behavioural management techniques have a very strong link to how an autistic child responds to the food they have been given. If preferred food access is limited, then an autistic child is much more likely to access a wider range of foods. If they are given their preferred foods and then also non-preferred foods and punished for not eating them, this negative reinforcement has a detrimental effect on the behaviour of the child. Positive reinforcements and a limited access of their preferred foods is the best way to change this selectivity of foods.18 How parents deal with the food selectivity issue can bring about a great deal of change to the child’s behaviour or it can exacerbate the situation. CONCLUSION

What is clear from the research, in summary, is that there is a definite selectivity of food choices being made within the autistic child community and these choices are most probably due to over sensitivity of colour, taste, smell and even texture of the foods on offer. More research needs to be undertaken to look at the long-term implications of this food selectivity, and it needs to be recognised that each autistic child has different food choices and possibly bodily needs. More research also needs to be undertaken to ascertain why there is a higher level of obesity within autistic children and whether this is down to food selectivity, decreased physical activity or both. Finally, and probably most important, it needs to be shown that this food selectivity doesn’t just end when a child becomes an adult, so longer-term implications of this need to be looked into on an individual basis.


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IODINE DEFICIENCY: THE RISK OF RESTRICTIVE DIETS Rachel Wood Specialist Paediatric Dietitian in Allergy & Gastroenterology, Royal Manchester Children’s Hospital Rachel works as a Paediatric Dietitian in a large tertiary children’s hospital where she specialises in allergy and gastroenterology. She previously worked at Sheffield Children’s Hospital. Allergy has become one of Rachel’s main interests.

For full article references and further reading please email info@ networkhealth

Food allergy is a major public health concern. This article will look at the real risk of becoming iodine deficient during infancy by avoiding not only milk, but other important food groups. The perception of food allergy is far greater than confirmed allergy. Cows’ milk allergy prevalence during infancy ranges from 1.9% to 4.9%, with perceived allergy in up to 17.5%.1 More and more infants, children and adults are following restrictive diets and seeking alternatives to dairy, either due to diagnosed allergies or as a lifestyle choice, with health professionals focusing on ensuring that calcium and vitamin D is supplemented. Iodine is a mineral that forms part of the thyroid hormones T4 and T3. These hormones are necessary for regulating metabolism, thermoregulation, protein synthesis and growth. It is also a key component necessary for brain and neurological development, particularly during gestation.2 It has been shown that supplementing iodine at a population level and correcting mild deficiencies is beneficial for public health and the economy. The prevalence of iodine deficiency has reduced following an initiative by the World Health Organisation of using iodised salt and, although this was mandatory in many European countries, it was discretionary in the UK; but now, very little iodised salt is consumed in the UK.3,4 Supplementation of iodine in foods could prevent mild to moderate deficiencies that we know already exist from causing more serious health implications. Dietary intake data from the National Diet and Nutrition Survey (NDNS) indicates that at least one fifth of non-pregnant girls aged 11-18 years in the general population are at risk of low iodine intakes.5

What we do know is that the iodine content in foods can vary considerably dependant on where in the country cereals and crops are grown. This is due to inorganic iodine salts being water soluble and leached out of surface soils. Geographical areas that are prone to ice, high rain, snow fall or floods have low iodine levels in the soil and, therefore, any crops grown here have low iodine content, making those who live in these areas at risk of iodine deficiency unless they receive alternative sources in the diet.6 Iodine levels in cereals and grains, therefore, depend on the soil in which they are grown. Iodine levels in meat, chicken, eggs and dairy depend on the iodine content of animal feed. Dairy and milk products are a major source of iodine in the diet (33% in adults and even higher in children and infants). The breakdown of foods that contribute to the population’s iodine intake are shown in Tables 1 and 2.6 There are also many varying factors that contribute to how much iodine is in our cows’ milk, i.e. how much iodine is supplemented in animal feed; cleaning equipment used in dairy farms always used to be cleaned with iodised salts, contributing to exposure and quantity of iodine in milk (there has been a reduction in the use of this in recent years) and the use of a cow fodder fortified with iodine in winter months. In recent years, we have seen ‘organic’ foods becoming more popular, but it is important to note that organic milk is reared from cows that don’t receive the feed containing fortified iodine and is 42% lower than conventional milk.7 This also October 2016 - Issue 118


FOOD ALLERGY Table 1: Iodine content of selected foods in the UK (FSA, 2002) Food


Iodine content (μg/100g)

Mussels, cooked Cod, baked Egg yolk, boiled Eggs, whole, boiled Milk chocolate Sea salt Whole milk, pasteurised, average Semi-skimmed milk, pasteurised, average Skimmed milk, pasteurised, average Cheddar cheese Ice cream, dairy Whole milk yoghurt, fruit Kippers, grilled Peanuts, plain King prawns, cooked Tuna, canned Infant formula Beer, bitter, canned Human milk, mature Chicken breast Butter, spreadable White bread, sliced Spinach, raw Bananas Onions, raw

Purchased Baked in the oven, flesh only Chicken eggs Chicken eggs

Average of summer and winter milk

247 (DH, 2013a) 161 (DH, 2013a) 137 (DH, 2013b) 52 (DH, 2013b) 51 (DH, 2013c) 50 31

Average of summer and winter milk


Average of summer and winter milk Mild and mature English cheddar Vanilla flavours, soft scoop Assorted flavours including bio varieties Analysed without butter Kernels only Purchased In brine, drained Commercial products as made up

30 30 30 (DH, 2013c) 27 24 (DH, 2013a) 20 12 (DH, 2013a) 12 (DH, 2013a) 10-13a 8 (Wenlock et al., 1982)b 7 7 4 (DH, 2013c) 4 4 (DH, 2013d) 3 (DH, 2013d) 2 (DH, 2013d)

Grilled without skin, meat only 75-80% fat Baby spinach Flesh only, raw Standard onions (not red)


data presented as μg/100ml. The term ‘infant formula’ refers to a food that can provide an infant with all its nutritional needs during the first six months of life. The data presented is the range for commercial products as declared on labels available in September 2013. data presented as μg/100ml. The iodine content of beer and lager available in the UK has not been analysed as part of Public Health England’s rolling programme of nutrient analysis since the late 1970s. As such, composition data may not be representative of the beverages currently on the market.


contributes to the public health concern. High levels of iodine are, however, found in marine fish and shellfish7 (see Table 1), mainly due to the high levels of iodine in sea water and brine. Despite this, ‘sea and mined salt’ is not a good source of iodine due to the evaporation process to form salt. As you can see from Table 2, which is the National Diet and Nutrition Survey 2008/092009/10, dairy products contribute a large amount of the general population’s intake of iodine. This is likely due to the quantity consumed. For example, fish has a high iodine content, but may only be eaten twice a week compared to dairy which does have a lower iodine content (see Table 1), but which is consumed daily in various forms such as 18 October 2016 - Issue 118

cheese, yoghurt and milk. Therefore, there are contributory factors on a national level that can impact on the general population’s risk of iodine deficiency. IODINE DEFICIENCY

The body’s own methods of homeostasis are very efficient at regulating thyroid hormone levels. If iodine levels fall below 100mcg, iodine uptake increases as well as the production of thyroid hormone. If levels fall below 10-20mcg per day, hypothyroidism occurs. Goitre is the earliest clinical sign of deficiency. Goitre is a swelling in the neck or larynx as a result of enlargement of the thyroid gland. It is associated with dysfunction of the thyroid gland and can range from a small lump to a very large mass.

Table 2: Percent contribution of selected food groups to daily mean iodine intakes for adults aged 19-64 years in 2008/09 to 2009/10c Milk and milk products total, of which cows’ milk Fish and fish dishes Beer and lager Cereal and cereal products Eggs and egg dishes Other c

33% 23% 11% 11% 10% 6% 29%

Secondary analysis of data from the NDNS 2008/09 – 2009/10 (Bates et al, 2011). Food sources only (excluding supplements).

Table 3: UK Dietary Reference Values for iodine (DH, 1991) Age 0-3 months 4-6 months 7-9 months 10-12 months 1-3 years 4-6 years 7-10 years 11-14 years 15-18 years 19-50 years 50+ years Pregnancy Lactation

Lower Reference Nutrient Intake Reference Nutrient Intake (RNI) (μg/ (LRNI) (μg/day) day) 40 50 40 60 40 60 40 60 40 70 50 100 55 110 65 130 70 140 70 140 70 140 No increment No increment

Globally, over 90% of the cases are associated with iodine deficiency. The Avon and Longitudinal study of Parents and children (ALSPAC) in 2013 enrolled 1,040 pregnant women in their first trimester and assessed the maternal iodine status and their child’s IQ at age eight years and reading ability at age nine years. This study showed that children of women with lower iodine levels were more likely to have scores in the lowest quartile for verbal IQ, reading accuracy and reading comprehension. The lower the iodine levels the lower the scores.2 This shows that iodine plays a crucial role in brain and neurological development, particularly during gestation, and it is vital that this is supplemented during pregnancy. MEASURING IODINE

It is extremely difficult to accurately measure the amount of iodine in foods using dietary

analysis, as the exact composition in food is uncertain and would vary greatly across the country. It is also very difficult to accurately measure iodine in an individual. Measuring the Urinary Iodine Excretion (UIE) over 24 hours is the reference standard for assessing iodine deficiency in a population. This, however, is very timely and impractical particularly in a clinic setting. Compliance from the individual is also often poor; therefore, a single non fasting casual urine sample is most often done. Unfortunately, the UIE can vary according to recent iodine intakes, so isn’t a true reflection of a deficiency. It is also influenced by age, gender, ethnicity and geographical location.6 CASE REVIEWS

We are presented with a very real risk of iodine deficiency within our population. Within our tertiary allergy service, we have had three cases of goitre linked with iodine deficiency October 2016 - Issue 118


FOOD ALLERGY Table 4: Recommended daily and annual iodine supplementation (WHO, 2007) Population group

Daily dose of iodine supplement (μg/d)

Single annual dose of iodized oil supplement (mg/y)

Pregnant women



Lactating women



Women of reproductive age (15–49 y)



Children < 2 yearsa,b




for children 0–6 months of age, iodine supplementation should be given through breast milk. this implies that the child is exclusively breastfed and that the lactating mother received iodine supplementation as indicated above. these figures for iodine supplements are given in situations where complementary food fortified with iodine is not available, in which case iodine supplementation is required for children of 7–24 months of age.


and, from investigating this further, it appears that Cheetham et al8 published a case review in the BMJ on this exact issue, entitled: Dietary restriction causing iodine-deficient goitre. The case they present is of a four-year-old boy with mixed IgE and non-IgE mediated food allergies with symptoms of chronic urticaria, atopic dermatitis, asthma and seasonal allergic rhinitis. The boy follows a very restrictive diet avoiding dairy, wheat, egg, cod, fish, shellfish, peanuts and tree nuts. As with the cases I have experienced, the child in Cheetham’s review has been following a restrictive diet since infancy. They become somewhat ‘fearful’ of trying these new foods even if the gold standard food challenges prove that tolerance and anxiety levels of the entire family are high, particularly around eating and mealtimes. All cases were resolved with adequate iodine supplementation. This, however, raises the question of could this have been prevented. One case was breastfed until three years of age; mum was excluding dairy and, although informed about calcium and vitamin D supplementation, she never considered that iodine would also be required. Yet, we know from the NDNS5 that one fifth of young females are already at risk of deficiency; then, to follow a restrictive diet during lactation only perpetuates this risk for mother and child, not only leading to symptoms such as goitre, but quite possibly affecting the brain development of the infant. Quite often these children become ‘fussy’ with eating and the idea of replacing this scary white liquid with an alternative becomes non-negotiable. It is useful to note that other than the well-known soya brand for one- year20 October 2016 - Issue 118

olds, none of the alternative shop-bought milks are fortified with iodine. IMPORTANT FACTORS TO CONSIDER

• With children on restrictive diets aim to normalise the diet as soon as possible. Often allergies are outgrown, but major food groups are never reintroduced fully back into the diet causing nutritional deficiencies. • Prevent pregnant women/mothers/teenage girls from avoiding important food groups unnecessarily, or ensure suitable supplementation of diet. • Selenium and iodine work together in the thyroid – deficiency of selenium affects the utilisation of iodine; therefore, ensure that there are no other nutritional deficiencies. • Severe iron deficiency if not treated affects the utilisation of iodine. • Prevention rather than treatment for those on restrictive diets: - Suitable vitamin and mineral supplement containing iodine; - Encourage infant formula if age appropriate; - Full diet history from mum and child and monitoring; - Regular dietary input to help liberalise the diet as soon as possible. SUMMARY

Iodine deficiency is on the rise and the government should be making it a public health priority. It certainly raises questions that deficiency can be linked with children’s behaviour and intellectual progress, but also raises the risk of developing goitre.



TYROSINAEMIA TYPE I AND II Suzanne Ford Dietitian in Metabolic Diseases

Sarah Howe Specialist Dietitian

For full article references please email info@ networkhealth

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.

Tyrosinaemias are a group of inborn errors of metabolism and for optimum adult functioning and outcome, lifelong treatment is needed1 with a low protein diet, amino acid supplements and regular monitoring of nutritional status. Tyrosine is a conditionally essential amino acid derived from dietary protein intake and the hydroxylation of phenylalanine. Tyrosine is either incorporated into proteins in the body, or it is degraded into fumarate (Krebs Cycle compound) and acetoacetate (ketone body). There is a five-step process to this2 which happens in liver cells and also the kidneys (Figure 1). Tyrosinaemia Type I: • Worldwide incidence of about 1 in 100,000 with a higher incidence in Norway and Canada and specifically in a region of Quebec where the frequency is as high as 1 in 700.2 • Originally the most severe type with high child mortality rate unless liver transplants were performed.

• Also known as hepatorenal tyrosinaemia. • Results from a defective enzyme fumarylacetoacetate hydrolase (FAH). • The toxic metabolite which accumulates and causes damage in liver and kidneys is succinylacetone. • Tyrosine levels are typically only moderately raised, at around 250-500umol/l in untreated disease.3 • Drug treatment with Nitisinone (NBTC) has greatly improved outcomes4 by effectively suppressing production of succinylacetone, although there is also an increase in serum tyrosine, making dietary treatment also an essential treatment.5 • Low protein diet with tyrosine and pheny-lalanine free amino acid supplements needed.

Figure 1: Catabolic pathway for phenylalanine and tyrosine

Sarah is a Specialist Dietitian working with adults with inherited metabolic disorders, with PKU being her biggest cohort of patients. October 2016 - Issue 118



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IMD WATCH Table 1: Recommended blood levels Cohort

Recommended tyrosine (µmol/l)

Recommended Phenylalanine (µmol/l)

Unaffected Adult


Tyr Type I



Tyr Type II



Tyrosinaemia Type II: • Incidence of about 1 in 250,000 • Also known as oculocutaneous tyrosinaemia or Richner-Hanhart syndrome. • Less severe than Type I although there is no drug treatment available. • Results from a defect in the enzyme tyrosine aminotransferase (TAT). • Tyrosine levels are typically >1,200umol/L.6 • The symptoms develop from an accumulation of tyrosine itself, crystallizing in the cornea and skin. • Neurological development can be affected with the potential for poor intellectual attainment.7 • Low protein diet, with phenylalanine- and tyrosine-free amino acid supplements needed METABOLIC AND NUTRITIONAL GOALS OF TREATMENT

The aims of treatment are to achieve blood tyrosine levels within the ranges shown in Table 1, whilst optimising nutritional status. WHAT ARE THE COMPONENTS OF THE DIET?

Protein substitutes A phenylalanine- and tyrosine-free amino acid supplement is important to avoid protein deficiency and prevent muscle catabolism. There is a small range of products available in ready-to-drink form and in powders which can be flavoured. The supplements should be taken throughout the day to optimise metabolic control, achieving the most stable blood tyrosine levels. Amino acid consumption is reported by people with IMD as the most difficult aspect of the diet.9 Amino acids are bitter and acidic tasting; they can cause gastrointestinal symptoms and bad breath and the prescribed amount is usually a significant volume: 400mls/ day in adults if taking a ready-to-drink version.

The amount or volume of amino acids prescribed needs to account for inefficiencies in amino acid and protein metabolism and as much as 140% of the RNI for protein may be needed in total.6 Micronutrients are needed as per the relevant dietary reference values (reference nutrient intake) for age, gender and life stage. A highly restricted protein intake results in low intakes of vitamin B12, long chain polyunsaturated fatty acids (LCPUFAs) and essential fatty acids, as well as minerals such as iron, calcium and zinc. Micronutrients are present in the protein substitute products, although LCPUFAs may not be, making compliance with these products even more important. Low protein foods Naturally occurring low protein foods, such as fruit and vegetables and fats and sugars, should form the bulk of the diet. Low protein foods which are available on prescription (e.g. milk substitute, flour, bread, pasta, crackers and biscuits) are a good way to make the diet palatable, varied and energy balanced. Consistent energy intake is important, as catabolism could cause muscle breakdown and raise blood tyrosine levels. Protein exchanges People with tyrosinaemia need to restrict high protein foods (meat, fish, eggs, cheese, nuts, beans, soya and dairy) and follow a tailored diet with a specific number of protein exchanges. One exchange = 1g protein, or an assumed 50mg tyrosine. Natural protein, (i.e. phenylalanine and tyrosine) tolerance varies with age, severity of the disorder and size of the individual, as well as their life stage, gender and general health. A certain amount of both tyrosine and phenylalanine will be needed to keep blood concentrations within range and prevent muscle breakdown. The balance between natural protein and October 2016 - Issue 118


IMD WATCH Table 2: Amount of food providing 1 tyrosine exchange or 1g of protein - a small sample6 Food Cows’ milk Single cream Double cream Yoghurt

Amount for 1 exchange 30mL 30mL 60mL 20g

Rice - boiled


Rice - raw


amino acids to meet overall nitrogen requirements is individualised and also may need adjustments over time to allow for growth, development and changes in health status, such as pregnancy. MONITORING

Monitoring is encouraged to ensure both metabolic and nutritional goals are met. Home-based monitoring and clinic monitoring is done, thus people with tyrosinaemia may need encouragement to comply with treatment and testing. Monitoring in adults with tyrosinaemia includes the following: • Monthly dried blood spots for plasma tyrosine and phenylalanine. • Annual or twice yearly nutritional bloods in clinic: - Plasma Amino Acid profile - Full blood count including haematocrit - Haematinics including serum ferritin, serum folate and serum B12 - Adjusted calcium and, if available, zinc, selenium and copper The nutritional deficiencies which are possible in IMDs are wide ranging and are more likely if someone follows a low protein diet, but is poorly compliant with their protein substitute. The nutritional deficiencies which may arise include protein deficiency, as well as vitamin, mineral and trace element deficiencies, such as anaemia and poor bone mineral density. PHENYLALANINE SUPPLEMENTATION

On routine blood monitoring, patients with both Type I (NBTC treated) and Type II tyrosinaemia have been found to have low blood phenylalanine concentrations and needed supplementation.10 Phenylalanine is an essential amino acid and deficiency can cause anorexia, skin rashes and, 24 October 2016 - Issue 118

Food Jacket or boiled potatoes Roast potatoes Chips Broad beans Peas (fresh, frozen and tinned) Spring greens (boiled)

Amount for 1 exchange 50g 35g 25g 12g 15g 55g

in the longer term, changes to skin and nails, lethargy, mental retardation, seizures and death. Phenylalanine monitoring is an essential part of treatment. If phenylalanine intake is insufficient then this amino acid will be rate limiting in bodily protein synthesis, potentially causing catabolism and thus raising tyrosine levels. Recently published data from a group of children with Type I tyrosinaemia11 suggests that morning blood phenylalanine levels are very different to afternoons; only 2% of fasting morning levels were under the treatment range, but in the same children 83% of non-fasting afternoon blood samples were below target range. Thus the timing of biochemical monitoring must be considered when interpreting data and making decisions about dietary control. The main concern raised is that, potentially, children or adults with tyrosinaemia may have periods of the day when phenylalanine levels are too low and this compromises growth, development or neurocognitive functioning. (The tyrosine levels were stable through morning and afternoon). The threshold to supplement with additional phenylalanine may need to be considered at a higher level in light of these findings. TREATING POOR METABOLIC CONTROL

Raised tyrosine levels, due to low phenylalanine levels, can be addressed by supplementing with phenylalanine. However, increased tyrosine levels due to inadequate energy intake are usually addressed by increasing calories, specifically with carbohydrates, such as a sugary or glucose polymer drink. Raised tyrosine levels in the absence of catabolism may be addressed by reducing protein exchanges, but in all of the above scenarios, attention should also be given to compliance with taking the tyrosine and phenylalanine-free protein substitute.


There has been a small number of encouraging reports of successful pregnancies in tyrosinaemia and these include pregnancy whilst taking NTBC. In Type II tyrosinaemia in particular, blood tyrosine control needed to be stricter than usual for a successful outcome (100-200umol/L).1 In practice, this means returning to a strict exchange system for counting natural protein and decreasing the number of permitted protein exchanges for the first and possibly second trimester. By mid-gestation, the foetus needs more protein for growth and protein tolerance, and permitted protein exchanges may be more than double the original number at the start

of pregnancy. Protein tolerance continues to increase throughout the third trimester. Untreated tyrosinaemia in pregnancy can, but not always, result in poor outcomes12 for the offspring. Pregnancy and post-delivery triggers for metabolic imbalance include: • the first trimester when energy intake may be difficult to maintain (if there is morning sickness); • post-partum (involution of the uterus and a large release of endogenous protein); • breastfeeding which imposes metabolic demands - however breastfeeding is strongly encouraged for people (mothers and babies) with metabolic disorders.

CASE STUDY - JANE: TYPE II TYROSINAEMIA Jane has Type II tyrosinaemia which was diagnosed at age 7. She previously had a gastrostomy tube inserted for receiving her amino acid supplement. She is 32 years old, married, without children and works as a care assistant. Jane’s medical history includes epilepsy, a cataract, dietary zinc deficiency, osteopaenia, low mood, miscarriages and, this year, she suffered from a fractured wrist. Jane’s diet • Low protein diet (about 15-20g/day, she doesn’t accurately count exchanges) • Prescribed three times daily protein substitute - with poor compliance • Tyrosine levels are rarely <700umol/L and often>1,000umol/L Issues • Jane moved house and changed GP which resulted in an incorrect prescription for her protein substitute and non-compliance for 12 months. • There was an 18-month loss of contact with the patient by her metabolic clinic. • Jane’s diet became nutritionally inadequate since she was still following a low protein diet without taking her protein substitute. • Jane’s eyes became intermittently itchy, but it did prompt her to seek help from her GP. The role of the dietitian The role of the dietitian is collaboration with the patient to motivate and provide practical ways to follow the diet for tyrosinaemia. Another significant role is to ensure that all healthcare providers, especially prescribers, completely understand the disease, the treatment and the products involved. Outcome for Jane Jane is trying to increase her intake of her protein substitute and manages the full prescribed amount on working days, but less so on weekend days. She continues with her low protein diet. Jane’s nutritional monitoring has increased in frequency, including monitoring of her bone health. Conclusion Tyrosinaemia Types I and II are conditions with low incidence; however, people with these conditions need careful consideration in their dietetic treatment. The evidence base is small for these conditions, but it is clear that for good outcomes, compliance with diet and monitoring is vital. For best functioning in adults, lifelong dietary treatment is needed. October 2016 - Issue 118


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DYSPHAGIA: THE HARD TO SWALLOW TRUTH Helen Willis BSc RD apetito and Wiltshire Farm Foods Dietitian

Helen Willis is a member of the British Dietetic Association and National Association of Care Catering. She previously worked in the NHS in both acute and community dietetics.

Education, awareness and team work combine to help improve the quality of life for those suffering with dysphagia. Imagine being afraid to eat a meal because you know you could choke on it, or adversely not wanting to eat at all because the ingredients have been pulverised to such an extent that they are devoid of any taste or flavour. This is the daily reality for millions of people all over the world who suffer from dysphagia, a secondary condition that makes it hard and sometimes impossible to swallow food and liquids. Dysphagia is estimated to affect approximately 8% of the world’s population - just under 100 million people. This figure is predicted to significantly increase over the next few years in line with an ageing population and, although a significant proportion of sufferers are elderly, it can impact people of all ages. Dysphagia often manifests in stroke survivors, those with multiple sclerosis, children with Acute Cerebral Palsy and those with dementia. It is not a condition that is always readily monitored or diagnosed in the UK. An assessment by a Speech and Language Therapist (SLT) is needed to make an accurate diagnosis. However, the Royal College of Speech and Language Therapists estimates there are 2.5 million people in the UK needing the help of its members, but there are only 14,000 qualified SLTs practicing in England. The issue posed by lack of diagnosis means that patients are not always getting the help they need or the nutritionally-balanced meals that they can easily swallow, either in a

healthcare setting or at home. Research also indicates that those working in the healthcare sector do not regularly ask patients about swallowing difficulties, which compounds this issue. Add to this a worrying lack of easily accessible information, not only for those living with the condition, but also for those who are advising and caring for them. The solution to preparing meals for someone with dysphagia is often deemed to be blending ingredients together to make them easier to swallow. Textures are then adjusted by adding water or other liquids to achieve a desired consistency. As dietitians and nutritionists know, this approach can impact on the flavour of the food and can result in patients not eating at all. This can then lead to further issues for the most nutritionally vulnerable. When questioned, over half of those working in healthcare said that their knowledge felt out of date on the current nutritional treatment approach for dysphagia. This indicates that education is key. Everyone deserves to dine with dignity and enjoy their food. But, it is clear that there is not enough information freely available via the NHS and other channels, as well as not enough education and training for those working with dysphagia patients on a daily basis. Action needs to be taken now to support healthcare professionals, allowing them to access specialised help and work together as a team in the best interests of the patient.

‘The Knowledge: Dysphagia - The Hard to Swallow Truth’ is the first in a series of white papers by apetito exploring some of the key health and nutrition challenges facing the health and social care sector. Download the report can be downloaded from October 2016 - Issue 118








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DYSPHAGIA AND MOTOR NEURONE DISEASE: A CASE STUDY Victoria Williams Registered Dietitian, Betsi Cadwaladr University Health Board

Motor neurone disease (MND), or Amyotrophic lateral sclerosis (ALS), refers to a group of related disorders caused by the degeneration of the motor neurones in the brain and spinal cord.1,2 It affects up to 5,000 people in the UK at any one time.3 The symptoms of MND can be widespread with motor neurone degeneration causing weakness and wasting of muscles which can affect mobility, speech, swallow and respiratory function.4,5

Victoria has worked as a Dietitian for over 10 years and has worked in both acute and clinical community settings. She is currently specialising in Stroke and Diabetes.

There is currently no cure for MND, so care is focused on symptom management and palliation4 in order to maintain quality of life. A multidisciplinary approach is essential, as care of patients with MND is complex and relies on expertise from different disciplines to undertake assessment and co-ordinate appropriate care and treatment.5,8,2 Dysphagia associated with bulbar muscle involvement is common in MND5

and is present in 45% of patients at diagnosis, with 81% of all MND patients experiencing dysphagia irrespective of onset.2,6,8 It can affect all stages of swallowing due to weakness developing in the muscles involved, including the tongue, lips, facial muscles, pharynx and larynx7,8 (see Table 1). Swallowing disorders resulting in dysphagia are by far the most important cause of nutritional impairment.8

Table 1: Stages of swallowing8,9 Stage of swallow

Characteristics in MND

Preparatory stage

• Difficulty getting food/liquid into the mouth • Weak movement of lips, tongue & jaw affecting ingestion and bolus swallowing • Leakage of fluid on drinking due to poor lip seal

Oral stage

• • • • • •

Weak movement of lips, tongue and jaw Poor mastication Difficulty in forming a food bolus Poor bolus manipulation Weak bolus propulsion Difficulty swallowing saliva

Pharyngeal stage

• • • •

Delay initiating pharyngeal swallow Pharynx residue post swallow Decreased laryngeal elevation Aspiration before, during and after swallow

Table 2: Weight and BMI Consultations

Weight (kg)

BMI (kg/m²)





















20.3 October 2016 - Issue 118


CONDITIONS AND DISORDERS CASE STUDY: 66-YEAR-OLD MALE DIAGNOSED WITH MND Here I detail the nutritional management of a 66-year-old gentleman named Jim, who was assessed by a dietitian two months following diagnosis of MND. He was referred from the multidisciplinary MND team meeting. Prior to initial assessment, I liaised with the Speech and Language Therapy (SLT) team to obtain details on recent swallow and communication assessments. At this point, he had no reported swallowing issues and was safe with normal diet and fluids. His main issues at this time was dysarthria. 1 Assessment Usual weight was reported to be 76kg which had remained stable for a number of years and body mass index (BMI) was within a normal range (Table 1, point 1). He was retired from employment, although he continued to maintain an active life through a house renovation project and was often working up to eight hours per day. He had no previous medical history and had recently been prescribed the medication Riluzole which can help to slow neurone damage. Dietary intake was varied, balanced and sufficient to meet his estimated nutritional intake at this time. No concerns were reported with fluid intake which appeared to meet his requirements. No issues were reported with coughing or choking on foods. The short-term dietetic aim was to maintain his current weight and nutritional status. Dietetic advice included a food-first approach with emphasis on the importance of maintaining dietary intake from energy dense meals, snacks and fluids. 2 Identification of nutrition and dietetic diagnosis As Jim had the bulbar form of MND knowledge of this led me to think about longer-term implications of dysphagia and how this would impact on his nutritional status. I therefore enquired regarding his knowledge of the condition and how much information they would like to receive. Although they had received some information from the neurologist and accessed the Motor Neurone Disease Association website, they wanted to know more about dysphagia and management options for the future. An explanation of this was provided in addition to looking into future options for nutritional support including gastrostomy placement. Although I acknowledge that these are quite difficult conversations to have with patients and their relatives, it is important to address these issues and options early to ensure that individuals can have time to make an informed choice. The importance of discussing nutritional management options issues early is widely documented,1-10 however, I acknowledge that this approach may not be suitable for all patients who may be struggling to come to terms with their condition and decisions involved in planning for the future.10 Jim was reviewed three months later; weight had decreased by 2.4kg (3.2%) (Table 2, point 2) and I had received information from SLT outlining their current recommendations of level E diet and stage 1 thickened fluids from a recent swallow assessment.11 Dietetic assessment revealed that he was still eating and drinking well and appeared to be meeting dietary and fluid requirements despite advised changes to the texture of diet and fluids. No changes had been made to his activity levels and he continued to work for eight hours a day on his house. 3 Plan nutrition and dietetic intervention The short-term dietetic advice focused on appropriate food and fluid textures, in addition to reiterating methods of food fortification. Weight loss at the time was thought to be due to his daily activity and/or muscle wastage; however, subsequent literature has shown that 60% of patients with MND show a 10% increase of resting energy expenditure.8 The use of nutritional products was suggested to maximise energy and protein intake and Fresubin thickened stage 1 twice daily was initiated to provide an additional 600kcal and 40g protein per day with a short-term aim to arrest weight loss. Jim and his wife had spent time thinking about our previous conversation and wanted to know more about the longer-term option of gastrostomy placement. A meeting was, therefore, set up with a Clinical Nutrition Nurse Specialist (CNNS). Four weeks later, a joint consultation with a CNNS took place. Nutritional assessment revealed further weight loss (Table 2, point 3) and Jim had started to visibly notice the loss of muscle mass on his arms. He reported reduced strength and fatigue and had decreased work time to two hours per day. Difficulties with maintaining nutritional intake were reported, with Jim becoming tired in the evening causing him to take longer to complete his evening meal. He remained on a level E diet and stage 1 thickened fluid and was continuing to take oral nutritional supplements twice daily. Speech was becoming slow and labored and he was experiencing excessive salivation for which his GP had prescribed a hyoscine patch.

34 October 2016 - Issue 118

The short-term goal was to prevent further weight loss and strategies were suggested to enhance his intake when feeling less lethargic; this included changing his meal structure by having his larger meal earlier in the day and smaller meal in the evening. Dessert based nutritional products were trialed, but he wished to continue with Fresubin thickened stage 1 with an increase to 3 x 200ml daily (900kcal, 60g protein). The CNNS discussed percutaneous endoscopic gastrostomy (PEG) tube and outlined the indications, procedure and possible complications. The risks versus benefits of the procedure were discussed12 and the implications of delaying the decision of PEG placement if respiratory function was to deteriorate, which is common in MND. Additionally, the options of continuing with oral intake versus gastrostomy were discussed alongside specific issues such as chest infections, reduced mobility and who would be responsible for the care of the tube. Jim expressed that he wanted to proceed with PEG placement and a planned admission was arranged. Unfortunately, one week before the planned admission for PEG placement, Jim had an emergency admission to hospital with a myocardial infarction and respiratory issues. He was commenced on non-invasive ventilation (NIV). SLT carried out a swallow assessment on the ward and found that swallow had deteriorated markedly and advised a period of Nil by Mouth (NBM). 4 Implement nutrition and dietetic intervention To provide nutrition, consent was obtained to place a Nasogastric tube (NGT) and a 15-hour continuous feeding regime commenced. PEG placement was cancelled due to increased risks. However, after a twoweek admission, Jim was deemed safe to go home with his NGT in place. In preparation for this, the feeding regime was changed from a continuous method to bolus regime to fit in with his daily life and a nasal bridle was placed to reduce the risk of NGT displacement. Training was delivered by a CNNS to ensure that Jim and his wife were competent in administering feed and medications and a timetable was devised with the assistance of a pharmacist. Prior to discharge, SLT had reviewed Jimâ&#x20AC;&#x2122;s swallowing and advised oral trials of 3 x 1/2 teaspoons of stage 2 thickened fluids no more than half hourly for comfort rather than rehabilitation of swallow. As this was insufficient to meet his nutritional requirements, full requirements were to be met via his NGT. Speech had significantly deteriorated during his admission and SLT had provided an iPad to help with communication; however, he preferred the use of a pen and paper to express his needs. October 2016 - Issue 118



Dysphagia is common amongst patients with MND . . . long-term methods of nutritional management need to be considered and discussed with patients, relatives and carers . . .

5 Monitor and review A domiciliary visit was carried out four weeks following discharge to review and assess nutritional status. Weight had continued to decrease (Table 2 point 4). Jim and his wife were administering 4 x 200ml bolus feeds per day which was providing approximately 1,600kcal, 68g protein and 2,000ml of fluid. No concerns were expressed with the management of administering bolus feeds and medications and this should have been sufficient to meet his current needs. During this period, there was no change to oral intake which remained as per SLT advice. He reported enjoying his oral trials for comfort and was taking Fresubin thickened stage 2 and thickened coffee. It was suggested that in view of weight loss, bolus feeds were to be increased to 5 x 200ml daily, providing 2,000kcal, 85g protein, 22,00ml fluid daily. Following his recent hospital admission, the CNNS had liaised with members of the Nutrition Support team who arranged a planned admission for a radiologically inserted gastrostomy (RIG). This was deemed a more suitable option than PEG at this point due to recent respiratory issues and the need for NIV. The RIG was placed with no issues and Jim resumed his usual bolus feeding regime. He felt his quality of life had improved and he no longer had the irritation from the NGT and no pressure of meeting his nutritional requirements orally. One month post-RIG placement, weight had increased (table 2, point 5) although swallow function dysphagia had deteriorated and he has been advised to remain nil by mouth due to frequent chest infections. He communicated that he was content with this as he had started to lose confidence with taking oral trials. 6 Evaluation In subsequent visits, no concerns were expressed regarding his bolus feeds or nutritional management, although Jimâ&#x20AC;&#x2122;s wife took over administering feeds when he started to lose strength in his hands. Weight decreased (Table 2, points 6 and 7) and symptoms of MND continued to progress rapidly post RIG placement and, unfortunately, he passed away eight months later. Dysphagia is common amongst patients with MND and although short-term methods of nutritional support can be put into place to prevent deterioration in nutritional status, long-term methods of nutritional management need to be considered and discussed with patients, relatives and carers at a timely point to ensure nutritional status does not deteriorate. For dietitians, it sometimes can be uncomfortable initiating conversations, but, irrespective of the decision made, early discussions allows individuals to make evidence-based informed choices. References 1 Rio A and Cawadias E (2007). Nutritional Advice and treatment by dietitians to patients with amyotrophic lateral sclerosis/ motor neuron disease: a survey of current practice in England, Wales, Northern Ireland and Canada. Journal of Human Nutrition and Dietetics 20; 3-13 2 NICE (2016). Motor neuron disease: assessment and management (accessed 05/08/16) 3 (accessed 06/08/2016) 4 Daniel I, Greenwood BA (2013). Nutrition management of amyotrophic lateral sclerosis. Nutrition in Clinical Practice 28(3); 392-399 5 Kent A (2012). Motor neuron disease: an overview. Nursing Standard 26, 46, 48-57 6 Braun MM, Osecheck M, Joyce C (2012). Nutrition assessment and management in amyotrophic lateral sclerosis Physical Medicine Rehabilitation Clinics of North America 23; 751-771 7 Stavroulakis T, Walsh T, Shaw PJ, Mcdermott CJ. On behalf of the PROGAS Study (2013). Gastrostomy use in motor neuron Disease (MND): A review, metaanalysis and survey of current practice. Amyotrophic lateral sclerosis and frontotemporal degeneration 14: 96-104 8 Muscaritoli M, Kushta I, Molfino A, Inghilleri M, Sabetelli M, Rossi Fanelli F (2012). Nutritional and metabolic support in patients with amyotrophic lateral sclerosis. Nutrition 28: 959-966 9 Walshe M. Oropharyngeal Dysphagia in Neurodegenerative Disease. Journal of Gastroenterology and Hepatology Research 2014; 3(10): 1265-1271 10 Stavroulakis T, Baird WO, Baxter SK et al (2016). Factors influencing decision-making in relation to timing of gastrostomy insertion in patients with motor neuron disease. BMJ supportive and Palliative care. 6; 52-59 11 National Patient Safety Agency (2011). Dysphagia Diet Descriptors. Accessed online at: for%20Industry%20Final%20-%20USE.pdf (06/08/16) 12 NICE (2006). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition

36 October 2016 - Issue 118


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References: 1. Khoshoo V et al. J Ped Gastroent Nutr 1996; 22:48-55. 2. Fried MD et al. J Ped 1992; 120:569-572. 3. Khoshoo V et al. Eur J Clin Nutr 2002; 56:1-3. 4. Rolandelli RH et al. Lipids and Enteral Nutrition. In: Clinical Nutrition: Enteral and tube feeding. J.L. Rombeau, R.H. Rolandelli. W.B. Saunders Company, 1997. 5. McClave SA et al. JPEN 2009; 33:277-316. 6. Meredith JW et al. J Trauma 1990; 30:825-829.

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Aoife Hanna runs her own dietetic practice, EatRight Ireland. She sees clients for diabetes, weight management and IBS and is a member of the Irish Nutrition and Dietetic Institute. Aoife also sits on the Weight Management Interest Group Committee for the INDI.

For full article references please email info@ networkhealth


Low carbohydrate diets are everywhere these days. You just can’t escape them, unless you switch off from all social media, TV, radio and never have a discussion about diet with anyone. Ever! So, it’s understandable that those with Type 1 diabetes are asking, “What about me? Am I ok to reduce my carbohydrate intake too?” Prior to the development of injectable insulin, low carbohydrate diets were the cornerstone for the treatment of diabetes. Since its discovery and with more flexible insulin regimes, people are encouraged to adopt a more ‘regular’ diet. For many, this means eating regular meals throughout the day, with each meal containing roughly the same amount of carbohydrate. Over the last number of years, carbohydrate counting, and adjusting insulin dosage accordingly, has become the gold standard dietary management for Type 1 diabetes. In fact, NICE guidelines recommend carbohydrate counting should be offered to all adults six to 12 months after diagnosis.¹ This approach allows people with diabetes much greater flexibility and control over their diet, thus improving their diabetic control. However, this approach, for some, still yields suboptimal control. We know that some patients have ended up restricting the amount of carbohydrates they eat, since large carbohydrate intake and a subsequent large insulin dose, led to increased unpredictability in their blood glucose levels. Additionally, many patients also report that they found themselves stuck in a carbohydrate ‘rut’. They knew the amount of carbohydrates in certain foods, and the amount of insulin they needed for it, and as a result they adopted the “I’ll stick to what I know” principle. We also now know that, even if the person with October 2016 - Issue 118

diabetes estimated their carbohydrate intake correctly, insulin absorption rates can vary by up to as much as 30% in some. In 2013, while working in New Zealand, a patient of mine asked me, “Am I ok to follow a low carbohydrate diet, even though I have Type 1 diabetes?” I was a practising Diabetes Dietitian within the hospital at the time, and I was at a loss. But then we thought, if we’re recommending insulin dose adjustments for carbohydrates that are consumed, surely we can dose adjust for carbohydrates that aren’t being consumed? And further still, with less carbohydrate coming in, the unpredictability in blood glucose levels would be less. Therefore, restricting carbohydrates may have the potential to further improve glucose control when one is carbohydrate counting. WHO IS FOLOWING A LOW CARB DIET?

I can say with certainty that any dietitian who has worked in the area of Type 1 diabetes has come across Dr Richard Bernstein, an 82-year-old American physician, who was diagnosed with Type 1 diabetes at the age of 12. He is probably the most famous advocate of low carbohydrate diets for the treatment of patients with both Type 1 and 2 diabetes. The author of six books on diabetes, his two most famous publications are Diabetes Diet and Diabetes Solution. His work is widely

published in numerous magazines and journals and, subsequently, he has received many awards for his contributions to the study of diabetes. Dr Bernstein adheres to a strict low carbohydrate diet, and has done so for years.² Vinnie Santana, the fastest diabetic ironman athlete of all time, swears by Dr Bernstein’s low carbohydrate approach.³ However, it is worth noting that Vinnie wasn’t following this low carbohydrate diet when he achieved his record breaking time. He has been following Dr Bernstein’s advice (less than 30g carbohydrates per day) since 2012. Although he no longer competes professionally, in the early days of following this diet he found some of his training sessions exhausting. But, since increasing the amount of fat in his diet, Vinnie has been able to sustain a more vigorous and regular training regime. He reports, since reducing his carbohydrates, that his HbA1c has never been greater than 40mmol/mol. Then there is Lewis Civin, a New Zealander who was diagnosed with diabetes at age 9. At age 38, he too completed an ironman event on a low carbohydrate, high fat diet under the guidance of his coach Stephen Farrell and Dr Bernstein’s book, Diabetes Solution. What’s interesting is Lewis discovered that, despite giving himself enough insulin to cover his carbohydrate intake, a large intake of protein would raise his blood glucose levels (BGL). To control this, he now keeps his protein intake to 30-40g per meal. Prior to beginning his low carbohydrate diet, he had a HbA1c of 53-64mmol/mol, but now reports a HbA1c of <42mmol/mol.4


Diabetic ketoacidosis (DKA) occurs when the level of ketones rise in the blood in conjunction with a low level of insulin and is potentially life threatening. Ketones are a by-product of fat breakdown and are used as fuel for the body. Franziska Spritzler, a registered dietitian from the USA and an advocate for low carbohydrate diets and diabetes, explains that ‘nutritional ketosis’ is normal when following a low carbohydrate diet and can occur when people with Type 1 diabetes follow this diet. She reports that it should not be confused with DKA.4 Professor Grant Schofield of New Zealand, also publically supports the use of low carbohydrate diets in Type 1 diabetes. According to his research, there has been no published report of a Type 1 diabetic developing DKA on a carefully implemented low carbohydrate diet,5 thus suggesting that there is a low risk of people with Type 1 diabetes developing ketoacidosis if following a correctly managed low carbohydrate diet. Another consideration is the long-term cardiovascular risk that a high fat, low carbohydrate diet might have on people with diabetes. Dr Troy Stapleton is an Australian radiologist, who at 41 years of age, developed Type 1 diabetes. Having received standard diabetes education, he found it frustratingly difficult to manage his BGL. He diligently undertook carbohydrate counting and adjusted his insulin levels accordingly, but suffered from a hypoglycaemic episode, on average, once a week. In an interview with Dr Norman Swan, on Australia’s ABC radio station October 2016 - Issue 118



Another consideration is the long-term cardiovascular risk that a high fat, low carbohydrate diet might have on people with diabetes. in August 2013, he discussed how oxidative stress on the endothelium of blood vessels, due to a spike in BGL, causes acceleration of atherosclerosis in people with diabetes. He also explained that every 1% of HbA1c (HbA1c as per DCCT) increase above 29mmol/mol increases the risk of myocardial infarction by 14% and risk of micro-vascular complications by 35-40%. Since following a low carbohydrate, high fat diet, Dr Stapleton’s BGL has gone from an average of 8.4mmol/l to 5.3mmol/l. His HbA1c at the time of the interview was 34mmol/mol. He also reports improved blood pressure, triglycerides, HDL and blood lipid profile since undertaking a low carbohydrate diet. He has gone from having a weekly hypoglycaemic episode, to about one a month. Dr Stapleton admits that the changeover from running off glucose to fat was challenging and he experienced symptoms of lightheadedness, headaches, lethargy and muscle aches, lasting for approximately four to six weeks. He reports now feeling “completely normal”.7 HAVE ANY TRIALS BEEN CONDUCTED?

In Sweden in 2005, Nielsen, Jönsson and Ivarsson found that 48 people with Type 1 diabetes, who followed a daily carbohydrate intake of 75g for 12 months, had mean HbA1c reductions from 57mmol/mol to 46mmol/mol, and a subsequent reduction of symptomatic hypoglycaemic from 2.9 to 0.5 per week.8 After two years, 48% of the participants were still following this diet to some degree, suggesting that this diet can be adhered to long term. They have also maintained a HbA1c reduction compared to their original levels, which has lowered the risk of cardiovascular disease by approximately 40% accordingly. Additionally, the improvement seen in the total chol/HDL ratio at the two-year follow-up was estimated to reflect a 20% reduction in the risk of myocardial infarction.9 In New Zealand in 2014, a small pilot randomised control trial compared five people who undertook carbohydrate counting and 40 October 2016 - Issue 118

advised to follow their standard diet, to five other people who also undertook carbohydrate counting, while being asked to follow a low carbohydrate diet. Those on the low carbohydrate diet were asked to restrict their carbohydrate intake to 5075g of carbohydrate daily.10 Unlike Nielsen’s trial, the participants failed to achieve this low level of carbohydrate intake and ate an average of 100g of carbohydrate daily, as they found the diet very difficult to stick to. They reported that they felt like they were “starving”, especially in the initials stages.¹¹ Similarly to that of Lewis Civin, some of the participants in this study found that the amount of insulin taken to cover the carbohydrate in their meals was inadequate, which is possibly caused by protein becoming a significant source of glucose owing to gluconeogenesis. So, if one was to consume larger quantities of protein when following a low carbohydrate diet, there may be a potential need for a carbohydrate and protein to insulin ratio to manage BGL. This study showed that glycaemic control improved in both groups, but there was no statistical difference between either group. Total daily insulin dose reduced significantly in the low carbohydrate group, but, unlike in Sweden, glycaemic control, as measured by continuous glucose monitoring and HbA1c, did not improve.10 FINAL THOUGHTS

This area of research is desperately lacking at present. As healthcare professionals, it is of paramount importance that we are equipped with scientifically sound, evidence-based guidelines to advise our patients on how to follow a low carbohydrate diet correctly and safely. The experiences of those involved in the trials discussed, Dr Bernstein, Dr Stapleton, Lewis Civin and Vinnie Santana, are only the tip of the iceberg, and I have no doubt that this topic will continue to be debated and explored over the next number of years.

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FITTING A VEGAN DIET INTO THE CONTEXT OF ‘HEALTHY EATING’ Charlotte Stirling-Reed Registered Nutritionist

In the last couple of years, veganism has become a food trend, hitting the mainstream as something of a new food fad. Whilst celebrities promote it for its health benefits, food ‘experts’ often tout it as a way to cure a seemingly infinite number of diseases.

Charlotte is a Nutrition Consultant with a wealth of experience. She has worked on a variety of projects in many sectors including the NHS, Commercial Companies, Local Authorities and Charities. Her specialist areas are infant and child nutrition, nutrition communications and weight loss. www.srnutrition.

In recent years, the popularity of vegan, vegetarian and plant-based diets has increased. The Vegan Society reports that there are three and half times as many vegans now as there were in 2006, making it the fastest growing lifestyle movement.1 They also define veganism as: ‘a plant-based diet avoiding all animal foods such as meat (including fish, shellfish and insects), dairy, eggs and honey.’1 The reasons why people take up a plant-based lifestyle include a mix of health, environmental, ethical and cultural factors.1 Food trends for 2015 and 2016 also highlight a growing public interest into where and how food is grown and produced: aside from plant-based eating, trends include sustainable diets, ‘clean eating’ and a desire for ‘natural’ ingredients.2 The actual health benefits of a vegan diet are, however, slightly harder to identify. As many of us working in the field of nutrition know, studying the diet we eat is both challenging and full of controversies. Our knowledge on veganism is limited by its inconsistent definition by study authors; veganism is often lumped together with vegetarianism and other forms of plant-based eating. Additionally, the meticulousness with which an individual decides to follow a vegan diet and the extent of the period of veganism, may influence findings.3 Additionally, the small vegan population (just ~1% in the UK) makes studies requiring large sample sizes difficult to complete.1

For full article references please email info@ networkhealth

42 October 2016 - Issue 118


Research into veganism also has problems in the form of multiple confounding factors. The unavoidable fact is that when you’re cutting out all animal products (including poultry, dairy, fish, gelatine, etc.), you’re also likely to be cutting out much in the way of ‘processed’ and discretionary foods too. For example, vegans are more restricted in their intake of accessible food items such as sweets, cakes, chocolates, biscuits and many fast foods. It’s also impossible to disregard the fact that vegans may simply be more astute in terms of what they are putting into their mouths.3 Despite a slight lack in our knowledge around vegan diets, research does point to the fact that vegan, vegetarian and plant-based diets do have many health benefits. However, for any diet or food trend that grows in popularity, nutritionists and dietitians need to have an understanding of its impact on the long-term health of individuals and, if necessary, what we can do to encourage these diets to fit in with our evidencebased healthy eating messages. The UK Government’s 2016 healthy eating guidelines5 - the Eatwell Guide - saw a significant shift towards plantbased foods. This comes as a wealth of research points to the benefits of plantbased diets for our health and our environment. Findings from two large epidemiologic studies - The Adventist Health Study-27 and the EPIC-Oxford study8 - show that vegans typically have lower BMIs,9 lower blood cholesterol,10

lower risks of Type 2 diabetes,9 and possibly a lower risk of cancer.3,11,12,13 Another report suggests that a shift from western diets to a plant-based diet could reduce global mortality by 6-10%, while a vegan diet could help avoid 8.1 million global deaths by 2050.4 Supporting this data, large cohort studies have linked increased red and processed meat consumption with higher mortality rates,7 which led last year to the International Agency for Research on Cancer (IARC) labelling red and processed meat as ‘probable’ and ‘definite’ causes of cancer, respectively.6 The Vegan Society certainly agrees with these findings, truly believing in the diet’s disease protective qualities and highlighting research which shows that vegans have a diet higher in fibre, lower in saturated fats and with higher fruit and vegetable consumption.14,15 Set up in 1994, the Vegan Society is reportedly the world’s first vegan organisation and is responsible for promoting and supporting veganism for the general public. Indeed, they first coined the term ‘vegan’, being the start and end of the word ‘VEGetariAN’. The aim of the Vegan Society is to educate the public via the media, as well as helping, advising and supporting new and existing vegans. Interestingly, they also work to support vegans in hospital and prison settings - playing the role of advocacy officers and acting on behalf of vegan individuals to help them gain access to appropriate vegan foods. As well as their supportive roles, the Vegan Society works together with the British Dietetic Association and has recently appointed a dietitian to join their team. So, how do we go about promoting a balanced, vegan diet? What can’t be ignored is that cutting out whole food groups can ultimately leave you deficient, unless you’re paying careful attention to what you’re eating each day. If you are planning well, it’s perfectly feasible to get all the nutrients your body needs on a vegan diet.16 Meat, for many people, is an important source of multiple nutrients, such as protein, iron, calcium, zinc, B vitamins, healthy fats and vitamin D. Dairy foods are also an important source of calcium, protein, iodine and vitamin B12. Replacing these nutrients is of paramount importance to anyone taking on a vegan diet and, as healthcare professionals, it’s our role to support plant-based eaters in doing this sufficiently.


Luckily, there are plenty of plant-based alternatives, to many of the nutrients found in meat and dairy; however, the absorption of minerals such as iron is likely to be less efficient and it is undoubtedly harder to get a complete set of amino acids.14 As the Eatwell Guide recommends, it is important to make sure that someone who is vegan is: • consuming five or more portions of fruits and vegetables every day; • basing meals around wholegrain starchy foods; • consuming some beans, pulses and alternatives; • and including some dairy alternative foods each day. There are some specific nutrients that vegans may want to pay particular attention to: Iron and protein Iron, especially due to its limited bioavailability, can be of concern for someone following a vegan diet.14 However, there are plenty of iron-rich plantbased foods that you can include in a vegan diet. Baked beans, kidney beans, all types of lentils, chick peas and garden peas all count as pulses and towards iron and protein intakes for vegan individuals. There are many other examples of pulses and beans too, so it’s easy to ensure that there is plenty of variety in the diet. In addition, these foods are often inexpensive and can add to other health benefits such as high fibre intakes. October 2016 - Issue 118



Eating a healthy, balanced diet for a vegan isn’t as challenging as it may initially seem. . . . Vegans may also benefit from taking a vitamin B12 and vitamin D supplement as a safeguard against deficiency. Other sources of protein and iron include plant-based alternative foods such as soy, Quorn and tofu. Wholemeal breads, fortified breakfast cereals, nuts and seeds, dark green leafy vegetables, such as broccoli and spring greens, and dried fruits are also a good source of iron for vegans. When consuming iron-rich plant foods, it’s a good idea to try and consume them alongside vitamin C-rich foods, such as fruit, vegetables and potatoes, to help increase the absorption of iron.

fatty acids from a plant-based diet. Flaxseeds, walnuts, rapeseed oil and some soya-based foods do contain a form of α-linolenic acid omega-3, which can be converted in the body to the longer chain eicosapentaenoic (EPA) or docosahexaenoic (DHA) acids; but this is at a fairly low efficiency.14 However, high quality, long chain, omega-3 (DHA) from algae is becoming more readily available as a vegan supplement. This is an option which can be recommended for vegans who are concerned about their omega-3 intakes.14

Vitamin B12 Vitamin B12 is another nutrient that may be harder to get from a vegan diet.14 Luckily, there are some B12-fortified foods, such as fortified breakfast cereals and fortified milk alternatives and yeast extracts, which can play an important role for vegans. Aside from this, the Vegan Society recommend that vegans, and anyone over the age of 50, take a supplement containing vitamin B12, as a safeguard against deficiency.1

Vitamin D Vitamin D is actually one of the most challenging nutrients to acquire in the diet, as it comes mainly from sunlight. Due to high levels of deficiency observed from the National Diet and Nutrition Survey data, suggesting that 40% of the UK population have low vitamin D levels in the winter months,17 there is some consensus that vitamin D supplements, or a fortification strategy, could be beneficial for all members of the public.18 Vitamin D is already fortified in some cereals, breads, milks and spreads in the UK, but as a population group, it may be beneficial for vegans to take a vitamin D supplement daily.

Calcium Calcium is another nutrient often highlighted as one to watch on a vegan diet. However, there are plenty of plant sources of calcium in the diet, making it easy for vegans to get their daily requirements. For example, fortified soya, almond and oat milks are readily available which contain calcium, vitamin D and added B vitamins. Additionally, foods such as tofu, nuts and seeds, pulses, bread (which is fortified with calcium in the UK), dried fruits and some dark green leafy vegetables such as kale, are all adequate sources of calcium for vegans. Omega-3 Omega-3 is a very important type of fat and is incorporated into the diet mainly through oily fish. It’s certainly more challenging for vegans to get a good source of quality, long-chain omega-3 44 October 2016 - Issue 118


Eating a healthy, balanced diet for a vegan isn’t as challenging as it may initially seem. Healthcare professionals such as dietitians and registered nutritionists should inform vegans that they can acquire all the nutrients they need by focusing on a diet that is in line with the Government’s Eatwell Guide. That is: based on eating five or more portions of fruits and vegetables every day; including plenty of wholegrain starchy foods and consuming some beans, pulses and alternatives alongside some dairy alternatives each day. Vegans may also benefit from taking a vitamin B12 and vitamin D supplement as a safeguard against deficiency.


PENG CLINICAL UPDATE COURSE Kate Hall, Communications Officer, Parenteral and Enteral Nutrition Group (PENG), a Specialist Group of the British Dietetic Association,

Anne Holdoway Chair, Parenteral and Enteral Nutrition Group (PENG), a Specialist Group of the British Dietetic Association,

PENG Clinical Update Course 26-29 June 2017. For more info please visit: www.peng.

Helping dietitians further master their skills in the safe and effective delivery of nutrition support. There are few specialist groups who run Masters level study to help develop advanced practitioners; however, PENG believe that to future protect our profession post-graduate training and lifelong learning is essential. To assist those who have graduated to enhance their knowledge and skills whilst remaining in a clinical post, the PENG Clinical Update (now offered at Masters level) is an option to consider for dietitians wishing to specialise in nutrition support. In this article, we aim to inform NHD readers, including those across the profession, those involved in nutrition support and members of other Specialist Group committees to reflect on why studying for a Masters in the workplace, facilitated by a specialist group and in conjunction with a higher educational institute, is of benefit to the individual on a professional basis but also the employing organisation. The PENG Clinical Update Course in Enteral & Parenteral Nutrition has been run annually for Registered Dietitians since 1985. With regular feedback and evaluation, it has evolved to keep abreast of developments in the workplace and individuals’ educational needs. In 1990, it was the first course to be validated by the British Dietetic Association. In 2010 it was accredited at Masters level by Queen Margaret University, Edinburgh. At the time of its inception, the aim of the course was to enable dietitians to consolidate and develop their knowledge of all aspects of artificial nutritional support. Today, 30 years on, the course has been updated in line with relevant current literature and the

components are developed by experienced dietitians with encouragement and emphasis on the delegates’ use of critical appraisal to reflect and develop their own clinical practice. Whilst some of the course and personal studies are undertaken remotely, the one-week residential component provides delegates with the opportunity to share clinical experiences, develop practical skills and establish professional networks, the latter being helpful for longstanding peer support. On successful completion, 15 Masters level credits are awarded from Queen Margaret University, Edinburgh. The course commences every March, when pre-course work is sent out, and ends in September when the post-course assessment is submitted. There is a fourday residential element in June 2017. WHEN IS THE BEST TIME TO DO THE PENG CLINICAL UPDATE COURSE?

It is likely that you will only attend once during your career, hence PENG encourage all dietitians contemplating this course to consider the ideal time in your career to attend. Some clinical experience is essential before attending, as the baseline clinical knowledge gained in practice provides a firm foundation to maximise learning. The course is taught at Master’s level and meets the KSF requirement to demonstrate masterly knowledge in clinical nutrition support. If you are not ready for the Clinical Update Course you may wish to consider attending the BDA’s introductory study days on enteral and parenteral nutrition beforehand ( as a stepping stone before embarking on the Clinical Update Course. October 2016 - Issue 118


ON BEHALF OF PENG We would always recommend discussing and planning your CPD requirements with your line manager or mentor, to help establish the level of learning to meet your individual requirements. HOW IS THE PENG CLINICAL UPDATE COURSE STRUCTURED?

The Clinical Update Course comprises a week-long residential component which provides a series of integrated lectures and workshops through which delegates and tutors explore clinical scenarios regarding nutritional assessment, interpretation of fluid and electrolyte status, estimating requirements, critical appraisal and enteral and parenteral nutrition. Independent study precedes the residential component and the course concludes with a Master’s level 15 credit module assessment. Although, historically, PENG stipulated that delegates were required to have been qualified for two years in order that they would have sufficient clinical experience to gain maximum benefit and contribute to the workshop discussions, we have in recent years removed this application requirement and instead suggest consideration of the points outlined below to help decide timely attendance: • Do you have adequate clinical experience to be able to contribute to the workshop discussions? • Have you identified differences between your practice and those of your colleagues and would like to explore the latest evidence in a constructive environment?

• Are you interested in improving your critical appraisal skills to improve your understanding and interpretation of research to further enhance your clinical practice? • Would you like to utilise your knowledge and evidence to formulate robust policies and procedures in your Trust? • Do you want to develop your anthropometric skills to perform a thorough nutritional assessment? • Are you struggling to assess and interpret fluid and electrolyte balance? • Do your patients experience complications of artificial nutrition and are you unsure of the best evidence-based practice to help them? • Are you keen to complete a Masters assignment in your clinical area and review the literature to support best practice? WHAT NEXT?

If you feel that the time is right for you to attend the course then we look forward to receiving your application and working together to help achieve best practice when providing artificial nutrition support for our patients. Five lucky PENG members won a free place on the 2016 course: Rebecca Coates, Rebecca Halsall, Lisa Hughes, Frances Bayley, Maria Cole and they will be sharing their experiences in the autumn edition of e-PENlines and via the PENG website in due course. For more information on the course and dates visit

“I had a great week at the Queen Margaret University Campus for the PENG Clinical Update Course 2015. The course, itself, was informative, well presented and relevant to all aspects of nutrition support in both community and acute settings. All the tutors were very approachable and presented well researched, clinically relevant topics. The campus was an excellent venue. Accommodation onsite was comfortable with cooking facilities and en-suite rooms. The university staff were helpful and friendly. The content of the lectures was excellent. Presented in a straightforward and easy-to-understand way. Every day had a clear set of topics with lecture and tutorials on each subject with practical workshops. This made absorption of the information easy and allowed discussion between us all. I learnt a lot from colleagues on the course working in different areas. We had community dietitians talking with ward dietitians and those who work on ITU. It was great to get a different perspective. Day one focused on nutritional assessment and refeeding syndrome. On day two we discussed fluid and electrolyte management. We also had a very useful workshop on the statistics we would need to use for the post coursework. I would recommend every dietitian to attend the PENG Clinical Update Course. The knowledge I gained has enriched my practice. It was also a great experience for networking. I met dietitians from all over the country that I have kept in contact with. As a lone working locum dietitian these connections are invaluable to me.” Roberta Forrester. (Roberta attended the 2015 PENG Clinical Update Course after winning one of the PENG bursaries to fully fund her place.)

46 October 2016 - Issue 118


WEB WATCH Useful information, research and updates. Visit for full listings. DEPARTMENT OF HEALTH

NICE GUIDELINES/STANDARDS UPDATES NICE QUALITY STANDARD [QS127] OBESITY: CLINICAL ASSESSMENT AND MANAGEMENT Published August 2016 Covering children, young people and adults, this includes those with established comorbidities and those with risk factors for other medical conditions. Full information is available at - www. ; This QS does not, however, cover public health strategies to prevent people becoming overweight or obese, or the delivery of lifestyle weight management interventions. These are covered by obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) and obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111).

NICE GUIDELINES [NG49] NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD): ASSESSMENT AND MANAGEMENT Published July 2016 This guideline covers the assessment and care of adults who are at risk of or who have cardiovascular disease (CVD), such as heart disease and stroke. It aims to help healthcare professionals identify people who are at risk of cardiovascular problems. Including people with Type 1 or Type 2 diabetes, or chronic kidney disease. It describes the lifestyle changes people can make and how statins can be used to reduce their risk. In July 2016, recommendation 1.2.2 was amended to clarify the advice on saturated and monounsaturated fat. www.

PUBLIC HEALTH ENGLAND 9% OF THE UK ADULT POPULATION HAVE DIABETES The Public Health England (PHE) National Cardiovascular Intelligence Network (NCVIN) have produced and launched the new Diabetes Prevalence Model. It estimates that the total number of adults with both Type 1 and Type 2 diabetes in England is around 3.8 million people - that’s 9% of the UK adult population - with approximately 90% of these being cases of preventable Type 2 diabetes. The burden of care this creates for the NHS is huge, costing around £8.8 billion each year. With overweight and obesity, ethnicity and age significantly contributing to the risk of developing diabetes, PHE has launched the Healthier You: NHS Diabetes Prevention Programme (NHS DPP), which can be accessed via NHS England and Diabetes UK and is to be rolled out across the whole of England by 2020. It aims to help those at high risk of Type 2 diabetes to reduce their risk through referral opportunities to improve their diet, discuss weight loss and increase physical activity.

HOT TOPIC: THE GOVERNMENT’S PLAN TO TACKLE CHILDHOOD OBESITY Published on 18th August 2016, this report was longawaited and left many healthcare professionals and lobbyists unsatisfied by its lack of stronger support for stricter legislation around food manufacturing (particularly the sugar content of food) and junk food advertising to children. The Government’s Childhood obesity - a plan for action publication aims to give guidance to reduce England’s rate of childhood obesity within the next 10 years. The key messages the plan focus on encouraging: • industry to cut the amount of sugar in food and drinks with Public Health England (PHE) to set targets for sugar content per 100g and calorie caps for certain products; • primary school children to eat more healthily and stay active through a new voluntary ‘healthy schools rating scheme’, which will be considered during school inspections. If you haven’t read it already, visit government/publications/ childhood-obesity-a-plan-foraction for the full version. October 2016 - Issue 118



OBESITY: THE BIOGRAPHY Review by Ursula Arens Writer; Nutrition & Dietetics Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula guides the NHD features agenda as well as contributing features and reviews.


Professor Gilman presents a dazzling tapestry of past and present confusions around our attitudes towards obese people. The current back-and-forth as to whether the obese suffer physiological or psychological impairment has also long been part of ancient debate, but medical or health aspects underlie more influential cultural veils defining human beauty and attractiveness. These still strongly arouse our attitudes as demonstrated by the internetexploding current interest in very large female bums (e.g. Kim Kardashian). And the astonishing development of private clinics in London offering very costly and painful buttock lifts and expansions; getting fatter not by the ‘old fashioned’ way of eating lots of chocolate cake, but by having fat surgically implanted!

“The desire for food is itself the Devil present in the body.”

Bishop Augustine (353-430)

Professor Sander Gilman has pulled together the definitive review of our cultural confusions of obesity, and beautifully weaves through many examples from literature, historic expert opinion from many different nations, and bizarre debates. It is a complete surprise to me how science may have progressed at a logarithmic rate, but how many current debates exactly mirror discussions of hundreds of years ago. On obesity research we have come so far, but 48 October 2016 - Issue 118

culturally we have not really moved at all. Within his review, Professor Gilman also pulls together what is in effect the history of Dietetics. We owe the author huge thanks for pulling the subject together into such a very neat and readable 200-page book. There are also 18 wonderful illustrations of famous fatties including ‘the very large man’ Daniel Lambert and the gawping Victorian drawings of demeaned largebottomed Hottentot women. What is obese (and what is not) is currently described via BMI cut-offs, or more precisely via percent body fat measures. In the prologue of the book, Professor Gilman describes the development of the long-used and still-used weight charts issued by the American life insurance company Metropolitan Life. In 1942, the MetLife statistician Louis Dublin examined the association between mortality and weight among four million insured Americans. The weight span for optimum longevity was about 30 pounds, so, for clarity, he neatly sectioned each height and gender group into the three sections of light/ medium/heavy frames, although these were difficult to define clinically, and from which the defence of being big boned (for being heavy) originated. The data allowed the development of life insurance risk evaluation, but was also intended as a motivational tool to support people in understanding the benefits of

weight loss to increase their life expectancy. There was much later discussion as to whether these figures should be described as ‘ideal’ or ‘desirable’ body weights, and there was later critique that the MetLife weight tables were biased towards the population of middle class, male, urban and white insured rather than the whole US population. There is much to say about Fat Joe, who was a character in the Charles Dickens book Pickwick Papers, published in 1837. Fat Joe became a code for many expert theories on obesity produced by endocrinologists and psychoanalysts and geneticists. Professor Gilman describes various case descriptions of obese children, where expert doctors refer to Dickens’ Fat Joe as the basis for discussion. Dickens rejected that Fat Joe’s condition was inherited, and medics came to suggest that the description matched hypothyroidism. Later medics suggested that Fat Joe suffered Froelich’s syndrome, and Fat Joe became the test case of medical debate (obesity from impaired thyroid or pituitary function). In 1956, Sidney Burwell, a Harvard professor researching obstructive sleep apnoea syndrome, claimed the Dickens character with the creation of the term Pickwickian syndrome. His descriptions of his patients matched many of the traits of Fat Joe described by Dickens, and the current medical term of obesity hypoventilation syndrome (OHS) still bears the Dickensian literature tag. It is difficult to imagine that any fictional character penned today could enjoy as much medical interest and retrospective diagnosis as Dickens’ Fat Joe. Eating is the daily example of the needs of the body winning over the control of the mind, so many religions also present moral barriers to the practice of overeating. Professor Gilman describes how dietary prohibitions set in the Old Testament (not to consume foods from animals without cloven hooves, or cud chewers, or seafood without fins or scales) defined sinful

behaviour; overeating initially was just viewed as the lack of the self-control expected of a real man or a scholar. The slide from poor selfdiscipline to sinful behaviour developed with early Christianity and gluttony was promoted on the list of seven deadly misdemeanours, paired closely to the other sin of sloth. So, obesity and overeating became viewed as a moral sin, but can humans control this? “Not I,” confesses Bishop Augustine (353-430), who reveals, “…in the midst of these temptations I struggle daily against greed for food and drink. This is not an evil which I can decide… to repudiate and never to embrace again, as I was able to do with fornication.” St Thomas Aquinas (1225-74) also has little faith in the weakness of the ever-hungry flesh. The human mind seeks delights, but our bodies lead us to the opposite (“…on earth it is excrement and obesity, hereafter it is fire and the worm.”). Aquinas observes that the bleak state of humans is being trapped by their bodies and defined by natural functions - eating and excreting. Professor Gilman reviews many historical discussions on obesity, but also weaves in themes of debate: the battles between science and morality; the battles between somatic or psychological treatments; the battles between individual or societal solutions. He finishes with a focus on obesity patterns in China and Japan; there are such different developments, and understanding the ‘whys’ of this could help predict and perhaps dampen further obesity booms in other fastdeveloping countries. He concludes the book with thoughtful comments on ‘Globesity’. This tiny 200-page book covers a huge span of history and philosophy on the subject of Obesity. There cannot be a more relevant topic of thought for dietetic practice, and there cannot be a more delightful guide to thinking-about-it, than this book. A very essential read for all dietitians. Thank you very much Professor Gilman.

We have six copies of Obesity; The Biography by Sander L Gilman to give away in a free prize draw. For your chance to win, please email us at Closing date for entries is Friday 4th November 2016. October 2016 - Issue 118



Modules for Dietitians and other Healthcare Professionals • Diabetes I/II (D24D01/D24D02) 12th & 13th January, 15th, 16th, 17th March 2017

• Understanding Behaviour Change (D24UCB ) 8th, 9th & 10th February 2017 • Paediatric Nutrition (D24PAN) 9th & 10th March, 4th & 5th May 2017

For further details please contact Susan Lewis via email: Alternatively, check out the University website at and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’.

The future of healthcare services in Wales - Policy Forum for Wales Keynote Seminar The future of healthcare services in Wales 19th October - Cardiff php?fid=policy_forum_for_wales Latest insights into nutrition and probiotic research 20th October - BMA House, London Multidisciplinary Stroke Educational Programme 2nd November - Conference Centre, Nottingham University Hospital Next steps for policy on obesity - prevention initiatives and the new Government childhood obesity strategy 3rd November - Central London

To place a job ad here and on please call 0845 450 2125 (local rate)

CLINICAL SCIENCE DIETITIAN - FULL-TIME, PERMANENT - LIVERPOOL We are seeking someone who will thrive in a dynamic, innovative environment, who has excellent communication skills, is flexible, self-motivated and enthusiastic. In return, we offer a competitive remuneration package. Full training will be provided but clinical experience, particularly in metabolic disorders would be a definite advantage. Previous industry experience would also be advantageous but not essential. The successful candidate will implement their clinical and nutritional science knowledge and input to the business including the nutritional design of new products, clinical studies and be instrumental in designing guidelines of product use. This role offers a fantastic opportunity to utilize your clinical knowledge and expertise in an innovative new way. This will be a challenging role, providing opportunities to continue your professional development. Please e-mail your CV or post to: Mr Chris Richards, HR advisor, Vitaflo International Ltd, Suite 1.11, South Harrington Building, 182 Sefton Street, Brunswick Business Park, Liverpool L3 4BQ. Salary is negotiable dependent upon experience. Closing Date: 21st October 2016.

50 October 2016 - Issue 118

COMMUNITY EATING DISORDERS SERVICE, (CEDS-CYP & CAMHS) Somerset Partnership NHS Foundation Trust, in collaboration with the Somerset Clinical Commissioning Group (SCCG), is establishing and developing a dedicated team of skilled professionals to work with children and young people presenting with an Eating Disorder, and their families and carers. The service model proposed uses the Maudsley approach as the core intervention. We are looking for enthusiastic senior clinicians to participate in this service from establishment through to ongoing development. The successful candidates would be expected to contribute the design of the service, ensure effective evidence-based and adherent models are implemented, as well as maintain their own caseloads and provide clinical and managerial supervision to the team. As senior clinicians within the service, you’ll bring highly developed knowledge of specialist therapeutic assessment, formulation and intervention skills. You will be able to demonstrate registration with your appropriate governing body. Specific knowledge and expertise in the area of Eating Disorders within this population is a key part of this role. To apply email kerry.allen@ 01823 368368. Closing Date: 31st October 2016.

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 the summer we saw the best athletes in the world competing at the Olympic Games in Brazil. Sport has been watched by millions of people globally and countries have embraced the success of individual athletes. Will this encourage more of us to get out of our chairs and find out how we can take part in a huge variety of activities available on our doorstep? The National Lottery has provided much needed financial support for many of our Olympic and Paralympic athletes to enable them to have the best training facilities and professional advice available. What an opportunity for young people! For me, this is where such a difference could be made to the childhood obesity crisis. The benefits of increased activity are well known and parents and professionals have their part to play.

If we are to show that we really can be effective, we need to make a louder, more productive, more innovative input to the problem that is reducing our NHS to mainly tackling obesityrelated issues. Some years ago, I was given the best visual aid I have ever received. It was a five pound block of bright yellow fat. In fact, it wasnâ&#x20AC;&#x2122;t a block, it was a lump which replicated the colour and feel of that found under the skin of an obese individual. Many of you will have seen this. I also have a one pound lump. The impact of this was enough to make people think just what they were carrying

around with them and the problems they were storing up for the future. To this, I would now like to add a most informative and ground-breaking TV documentary on obesity which was shown recently on BBC Three. Entitled OBESITY: The Post-Mortem, the centrepiece of the programme is a woman, aged 60, who died of heart failure. The 12-hour dissection, condensed to an hour, was undertaken at the Royal College of Surgeons in London and explores how obesity damages the organs, the diseases it causes and why obesity is placing so much stress on our healthcare system. I would recommend that every hospital Trust has it running on a loop at every outpatient obesity clinic. I would also recommend that every secondary school shows it as part of its health promotion programme. It is a challenging documentary to watch, but then obesity is challenging! Dietitians are recognised first and foremost by the public as experts in weight management. The BDA are currently running an online conversation about the future of our profession. If we are to show that we really can be effective, we need to make a more productive, more innovative input to the problem that is reducing our NHS to mainly tackling obesity-related issues. It is never too late for people to take charge of their health and lessen the impact on their bodies. The next generation expects. Watch The Post-Mortem and see how you feel! October 2016 - Issue 118


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Reference 1. Hubbard GP et al. Clin Nutr 2012:31;293–312.

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October 2016

ORGANIC FOOD How healthy is it? asks Gemma Sampson

NUTRITION NEWS with Dr Emma Derbyshire

Web Watch useful resources and updates


Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd Emma is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health.

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.

LATEST ON DIETARY FIBRE There is an abundance of evidence published about links between dietary fibre and health. Whilst fibre was first identified and some mechanisms proposed by the eminent scientists Burkitt and Trowell, a new review takes most recent evidence on board. The review published in the British Journal of Nutrition explains that dietary fibre not only speeds up transit time, but also has other important roles such as increasing the viscosity of the digesta and altering flow and mixing behaviours. It also goes on to explain that a better understanding is needed on how the ‘different’ fibre forms affect rates and extents of starch and lipid digestion. Given that the Scientific Advisory Committee on Nutrition last year concluded that we should officially use the AOAC definition of fibre. More research is needed analysing fibre intakes and underpinning mechanisms aligned with this definition. This includes the UK National Diet and Nutrition Survey which has previously focused on non-starch polysaccharides.

BENEFITS IN PACING PROTEIN INTAKE Previous research has suggested that even protein intakes across meals can help to improve muscle synthesis in young adults compared with ad hoc intakes. Now new work has looked at whether this can lead to long-term muscle preservation in older adults. Data was analysed from the NuAge study (Quebec Longitudinal Study on Nutrition as a Determinant of Successful Aging). This included baseline and two-year follow-up 24-hour food recall and DEXA data from 351 men and 361 women aged 67 to 84 years. Findings showed that men and women with evenly distributed protein intakes and men with higher protein intakes had significantly higher lean muscle mass at follow-up, even when confounders were considered. These findings imply that higher protein intakes and an even distribution across meals helps to preserve lean mass is ageing adults. Continued research with longer periods of follow-up are now needed.

For more information, see: Grundy MM et al (2016).

American Journal of Clinical Nutrition [Epub ahead of

British Journal of Nutrition [Epub ahead of print].


For more information, see: Farsijani S et al (2016).

DON’T ‘PET’ CHILDREN TO AVOID OBESITY An excellent new review has now likened obesity in children to obesity in pets. The paper - very much on topic - discusses the concept of ‘pet-parenting’. This is when obesity (in children and pets) is due to excessive treats and meal amounts withdrawn, or portion sizes are reduced, - a form of doting love and affection. eventually leading to their elimination. Those giving the treats/food then often I tried to avoid introducing them in the get caught up in a cycle of giving these first place; what they haven’t had they treats/foods in order to avoid the ire of don’t know about. The main problem the child or pet. Sound familiar? Begging, then comes when they are given treats by pestering, whimpering, whining - hate to grandparents/wider family which leads say it, but it does to me! to pestering down the line. So perhaps What to do? Well the scientists this theory needs to be extended to wider advise a series of withdrawal techniques circles as well as to the parents! where the problem foods (be it gravy For more information, see: Pretlow RA et al (2016). bones or human biscuits) are gradually British Journal of Nutrition. Vol 116, no 5; pg 944-9. October 2016 - Issue 118



ORGANIC FOOD: IS IT REALLY BETTER FOR US? Gemma Sampson Registered Dietitian, Senior R&D Dietitian, Vitaflo International Gemma has experience as a registered dietitian in a variety of clinical and industry settings, with personal interests in sports nutrition, gluten-related disorders and plant-based lifestyles. She runs the nutrition blog Dietitian without Borders (www.dietitian withoutborders. com/)

For full article references please email info@ networkhealth

‘Organic’ is no longer just associated with fresh fruits and vegetables; these days you can find organic pasta, organic sauces, organic biscuits, cakes and energy bars on our supermarket shelves. You name it, there’s an organic version somewhere trying to convince consumers that it’s healthier choice. For food producers, being able to market their produce as organic taps into a big market. In Europe alone, it is estimated that organic sales will continue to grow by 20% each year.2 While the definition of what is organic can vary, it generally encompasses chemical-free farming practices, but can also be extended to cover other positive food terms including ‘cage free’ or ‘natural’, which can add to the organic confusion.2 Marketing a product as organic attracts consumers and can even convince them to pay a premium price tag because higher prices tend to be associated with better quality. When a product is labelled organic, even if that food is heavily processed as consumers associate ‘organic’ with a healthy diet of food containing superior nutritional qualities. But this may not always be backed up by science.1,3 WHY PEOPLE BUY ORGANIC FOOD

The main priorities that have been identified as influencing people’s choice of organic, are health implications, improved product quality and concerns about the environment.3 Characteristics of people who regularly purchase organic products include values of altruism (relationship with others), sustainable environments, protection of the welfare of people and nature, spirituality and self-direction.1,2 As a result, organic food consumption is often linked to so-called alternative 54 October 2016 - Issue 118


lifestyles including vegetarianism, active environmentalism and alternative medicine.2 However, organic fruit and vegetable purchases do not seem to be habitual for most consumers; one study discovered that 84% of organic sales came from 23% of customers.3 Beyond health implications, one of the most important criteria for consumers who purchase organic food, is because it reportedly tastes better.2 Although blind taste test trials have had mixed results comparing organic to non-organic fruits and vegetables. A gap has been found between perceptions that organic produce is superior and actual purchases, which may be reflected by limited availability and the higher price tag associated with organic. People are more likely to purchase organic foods if they come from a higher socio-economic background and are more affluent.1 HEALTH IMPLICATIONS OF ORGANIC FOOD

Improved health for individuals, as well as their families, as a direct result of eating organic food, is the main reason people choose to buy organic foods.1,2 Many consumers are convinced that organic food is always healthier and more nutritious, despite little conclusive scientific evidence to back up the claims. The Food Standards Agency in the UK concluded that there was ‘no evidence of a health benefit from consuming

organic compared to conventionally produced foodstuffs’.4 Organic foods are typically marketed as more nutritious, containing greater amounts of vitamins, minerals and antioxidants. This has been extensively studied in the literature, yet there is little evidence to justify these claims. Nutritional differences are typically subtle and may have negligible impact on actual dietary intake. Earlier this year a study was released stating that organic milk and meat products contained 50% more omega-3 than conventional produce.5 However, this was primarily found within the fat content of the milk, which typically would not provide large amounts to the diet. Incorporating other dietary sources of omega-3 would provide a better impact on omega-3 status for an individual. Interestingly, organically produced milk was found to be lower in iodine than traditionally farmed milk - something worth considering in a society that has increasing levels of iodine deficiency.6 In the case of milk and meat products, the nutritional differences observed between organic and non-organic produce relates to the animal feed and not necessarily the farming practice. In 2012 a systematic review evaluating the results of 17 human studies and 223 nutrient studies concluded that there “lacked strong evidence that organic foods are significantly more nutritious than conventional foods’.7


Many consumers choose organic products as they believe they will be free from pesticides and chemicals. However, an organic label doesn’t guarantee that no pesticides were used during the farming process. Baranski et al found that organic produce had a 30% lower risk of pesticide contamination compared to conventional fruits and vegetables, but were not necessarily 100% pesticide-free.8 So, while the research supports any claims that organic produce is lower in pesticides, organic fruits and vegetables aren’t necessarily pesticidefree. Some consumers choose organic because they associate it with better animal welfare.2 CONCLUSION

While there are some subtle differences observed between organic and non-organic produce in terms of superior nutritional content and reduced pesticide levels, the evidence is not strong enough to make recommendations that all individuals start purchasing organic produce. Food marketing can often play upon the perceptions that organic is a healthier option. Although in the case of processed foods this may not be true. The hefty price tag that typically accompanies organic produce may be a barrier and it would be more practical to look at improving the overall fruit and vegetable intake of the population by any method before singling out organic over traditionally farmed produce.

Comment from the editor

The organic label does have some credibility and shows that a food has been produced or farmed in a certain way. ‘Organic’ is regulated by the UK Government and the EU. Without official certification, farmers or producers can’t claim that a product is organic. The conversion of conventional farming to organic farming is supported in the UK and farmers and producers can apply for support grants and funding to achieve this. Once the conversion has been made official certification must be obtained for the term ‘organic’ to be used. Information about this can be found at Whilst organic food has an image of being healthier than non-organic food, or even possessing ‘super food’ properties, and because it is marketed as fully natural, pesticide free, ‘as nature intended’ etc, this is not necessarily the case. Organic farming or food production simply means this: • avoiding artificial fertilisers and pesticides; • using crop rotation and other forms of husbandry to maintain soil fertility; • controlling weeds, pesticides and diseases using husbandry techniques and where necessary approved materials to control pests and diseases; • using a limited number of approved products and substances where necessary in the processing of organic food. We plan to look into the nutritional implications of organic food in more detail in a future issue of NHD. October 2016 - Issue 118



WEB WATCH Useful information, research and updates. Visit for full listings. NICE ADVICE [MIB74] STRETTA SYSTEM FOR GASTRO-OESOPHAGEAL REFLUX DISEASE Published July 2016 Gastro-oesophageal reflux disease (GORD) is a common condition, where acid from the stomach leaks up into the oesophagus (gullet). It usually occurs as a result of the ring of muscle at the bottom of the oesophagus becoming weakened. It may just be an occasional nuisance for some people, but for others it can be a severe, lifelong problem. Read more on GORD here: Gastroesophageal-reflux-disease/ Pages/Introduction.aspx; The Stretta System treats GORD

symptoms which cannot be controlled using proton pump inhibitor (PPI) medication therapy, alongside surgery, or before surgery. The Stretta System is a radiofrequency (RF) energy device. During the procedure, known as Stretta Therapy, RF energy is delivered to treatment sites above and below the gastro-oesophageal junction. The manufacturer states that Stretta Therapy is non-ablative because it does not remove or destroy tissue, but regenerates the target tissue by creating hypertrophy that thickens the musculature to improve GORD symptoms. NICE has developed a medtech innovation briefing (MIB) on

NATIONAL DIET AND NUTRITION SURVEY REVEALS THAT CHILDREN ARE STILL CONSUMING TOO MUCH SUGAR On 9th September 2016 the latest National Diet and Nutrition Survey (NDNS) was published by PHE. The results highlighted that poor eating habits are still a problem for children of all ages, with particularly worrying levels of sugar intake continuing to be the norm for teenagers. Despite much hard work from Government initiatives, such as Change for Life and, of course, from dietitians and nutritionists, the results were still poor. Teamed with the Government’s recent ‘weak’ ‘Childhood obesity – a plan for action’, the results from this survey seem to present a bleak picture for the health of our nation. However, PHE remain upbeat and positive in leading on the Government’s programme to reduce sugar available at retailers and to challenge food and drink manufacturers. PHE also call for increased awareness and implementation of the ‘Eatwell Guide’ in order to address excessive intake of calories and to increase fruit and vegetable consumption, as well as oily fish. news/young-children-still-exceeding-sugar-recommendation

56 October 2016 - Issue 118

the Stretta System for gastrooesophageal reflux disease. Read more here: advice/mib74standard 111). NICE QUALITY STANDARD [QS128] EARLY YEARS: PROMOTING HEALTH AND WELLBEING IN UNDER 5s Published August 2016 Covering services including: home visiting, childcare, early intervention services in children’s social care and early education. The standard includes vulnerable children who may need additional support. It does not cover clinical treatment, or the role of child protection services. uk/guidance/qs128

£816 MILLION INVESTMENT IN NHS RESEARCH Twenty NHS and university partnerships across England have been funded to complete all kinds of health research via the National Institute for Health Research (NIHR). Research into cardiovascular disease, mental health, including dementia, diabetes, obesity and nutrition, are all being covered by part of the £816 million investment into NHS research. Previous rounds of funding have led to several medical breakthroughs, including clinical trials of new T-cell treatment for cancer, MRI brain scans to detect early Parkinson’s, detection of the early signs of Alzheimer’s disease and new immunotherapy trial to test cancer vaccine. Visit for a full breakdown of where the funding is going and who is researching what!


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NHD Magazine October 2016