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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
April 2016: Issue 113
food labelling Guidelines cowsâ€™ milk allergy Goat milk: an alternative ulcerative Colitis glycogen storage disease
Ancient Grains in the modern diet
THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all. • Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.
REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on ﬁle. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Date of preparation: July 2015 RXANI150143
FROM THE EDITOR
welcome Emma Coates NHD Editor
Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.
It has been an exciting few weeks for Dietetics, with the announcement in February of supplementary prescribing rights for dietitians by George Freeman, Minister for Life Sciences. Advanced and experienced dietitians can manage prescribing for patients without the need for medical staff approval . . . Neil Donnelly discusses this historical development in our Final Helping. However, before you flip from this warm Welcome to Neil’s final tasty morsel, have a look at our sumptuous filling. Maeve Hanan’s first article for NHD explores the forthcoming EU regulations and UK guidelines for food labelling. Maeve guides us through the key points, including alterations to the nutritional declarations on packaging, health claims, allergen and front of pack information. Following on from that, we have an excellent cows’ milk protein allergy (CMPA) feature from Dr Rosan Meyer, Paediatric Allergy Dietitian at GOSH. Rosan looks at the current guidelines for this condition and questions whether they support healthcare professionals in achieving better diagnosis and management of CMPA. CMPA is also touched on by Specialist Paediatric Dietitian Jacqui Lowdon in her article discussing goat milk and the evidence for its use as a cows’ milk alternative feed for infants. Historically, infant formulae based on cows’ milk were the mainstay of infant feeding when breastfeeding was not possible, or breast milk supply was insufficient. Recently goat milk has been approved as an alternative source for infant formulae. Continuing the theme of alternative food options, Gemma Sampson RD offers us a plateful of ancient grains and asks if they are a real alternative to conventional cereals. She takes us through the current thinking about their nutritional properties, health benefits and their position in the modern diet.
I have contributed with a two-part article, which follows a case study of an 18-year-old female with Ulcerative Colitis and discuss its impact on the young woman’s nutritional status and general wellbeing. Part 1 is featured in this issue and you can access Part 2 via the Subscriber’s Zone at www.NHDmag.com. Logon with your password to view Part 2 and a host of other subscriber resources. If you don’t have login details, check whether you are eligible for a free subscription to NHD from our homepage. IMD Watch this month focuses on Glycogen Storage Disease (GSD) type 1, with Freelance Paediatric Dietitian, Rychelle Winstone giving us a valuable overview of the condition, along with its treatment and management. In addition to all of these great features, Ursula Arens asks whether our choice of drinks and beverages has an impact on our eating habits. Does drinking more mean eating more? Alternatively, do some drinks make you eat less? Ursula helps to untangle the complex issue of ‘drinks links’. Finally, our PENG column encourages dietitians to engage in research and audit activities to improve clinically effective practice. Jacklyn Jones, talks us through PENG’s aims and initiatives to support dietitians in taking the first steps into research and audit activities through a recent study day with workshops, mentoring and the availability of small project grants. Enjoy the read - Emma www.NHDmag.com April 2016 - Issue 113
11 COVER STORY
Food labelling guidelines update 3
Welcome . . .
41 Ancient grains
From the NHD Editor
In the modern diet
Latest industry and product updates
46 On behalf of PENG
Does drinking more mean eating more?
Research and audit
17 Cowsâ€™ milk protein allergy Is the message getting through?
49 Web watch Online resources and updates
23 Goat Milk
50 dieteticJOBS Latest career opportunities
An alternative infant feed
50 Events and courses Upcoming dates for your diary
29 IMD watch Glycogen storage disease type I 35 Case study: ulcerative colitis The impact of IBD on an 18-year-old
51 The final helping From Neil Donnelly
All rights reserved. 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 firstname.lastname@example.org 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 Dawson Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst
Advertising Richard Mair Tel 01342 824073 email@example.com Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email firstname.lastname@example.org www.NHDmag.com www.dieteticJOBS.co.uk
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www.NHDmag.com April 2016 - Issue 113
ISSN 1756-9567 (Print)
400 20g Vits & Mins Fibre
50% 0 g RNI
FORTISIP 2kcal A DOSE OF SUNSHINE
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*RNI for males 19–50 years used as a comparator (excluding sodium, potassium, chloride and magnesium). †ƐƏ]b|-lbm r;uƑƏƏlѴ0oѴ;ĺ ‡Ensure TwoCal (3.4 µg) and Fresubin 2kcal (5 µg) Ő1ouu;1|-|ঞl;o=ru;r-u-ঞomőĺ Date of preparation: 03/16
FOOD FOR THOUGHT
Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk email@example.com
Latest on sugar and salt New sugar tax It has been unveiled by George Osborne this month that there will be a sugar tax in the new budget. The levy which targets soft drinks will use proceedings to fund school sports. This is a great step forward but also needs to be supported by new food and beverage labelling schemes. Currently labels use ‘total sugars’ rather than ‘free’ or ‘added’ sugars which can lead to confusion when comparing against the latest Scientific Advisory on Committee sugar guidelines (as we have seen with the Change4Life Sugar Smart app). Alignment of these is fundamental if guidelines are to be translated into public practice. (Turn to page 11 for more on food labelling guidelines). New sodium report The National Diet and Nutrition Survey has also now published results from the Urinary Sodium Survey. This has estimated salt intake in adults aged 19-64 years in adults in England. The report also presents a trend analysis for salt from 2005/6 to 2014. Overall, the latest report shows that mean salt intakes for men and women aged 19 to 64 years are 8.0g and 6.8 grams per day, respectively. So it can be seen that these are 33% and 27% higher than the SACN recommendation - that the average salt intake of the population should be no more than 6.0g per day. So, more work to be done here too, especially amongst males. For more information, see: www.gov.uk/government/statistics/national-diet-and-nutrition-survey-assessmentof-dietary-sodium-in-adults-in-england-2014
Organic food - better nutritionally? Organic food options are when looking at data from all livestock, becoming an increasingly it was found that total PUFA and popular lifestyle choice. Now, omega-3 PUFAs were 23% and 47% two new meta-analysis papers higher in organic meat, respectively. have looked at whether The same team of scientists also organic meat and milk really looked at 170 papers comparing organic are better from a nutritional and conventional cows’ milk. Once stance. again, total PUFA was 7% and omega-3 Scientists’ pooled data from 67 PUFA levels 56% higher in organic milk. separate studies, all looking at the Organic milk also had significantly nutritional composition of organic higher α-tocopherol and iron levels, but and non-organic meats. Meats studied lower amounts of iodine and selenium. included pork, beef, chicken, turkey, Overall, it can be seen that organic lamb, goat or rabbit. Generic searches meat and milk appear to have a more were also carried out using the terms desirable fatty acid composition. This ‘livestock’, ‘meat’ and ‘poultry’. seems to be due to grazing and forage For meat, differences between based diets typically followed under individual fatty acids and micronutrient organic standards. profiles did not produce any meaningful For more information see: Średnicka-Tober D et al results. This was due to the quality of (2016). British Journal of Nutrition Vol 115, no 6; pg studies not being sufficient. However, 994-1011 and pg 1043-60. 6
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Product / Industry News Inositol for NTD prevention? There has been much interest in folic acid (FA) fortification recently, in order to prevent neural tube defect (NTD) occurrence. It is also recognised that vitamin B12 can help reduce NTD risk and now work is looking into the role of inositol, another member of the B vitamin family. The PONTI (Prevention of Neural Tube Defects by Inositol) study randomised 47 women to take a supplement containing inositol +FA in the peri-conceptual period, or a placebo +FA. Overall, 33 pregnancies occurred with one NTD affected pregnancy in the placebo +FA group, but none in the inositol +FA group. There were no adverse pregnancy outcomes in the inositol group. Clearly, this was a small pilot study. That said, mechanistic studies and larger scale interventions focusing on the role of inositol could be worthy of investigation.
Wiltshire Farm Foods launches new range of Free From meals Each of the new 13 delicious dishes in the Free From range are free from the following allergens: gluten, milk (and other related dairy products), egg, nuts, peanuts, fish, crustaceans, lupin, molluscs, sesame, sulphites and celery - meaning your patients can enjoy every meal, whatever their dietary requirements. To order brochures or arrange a free tasting of the NEW Free From range, visit www.wiltshirefarmfoods.com
To book your Company’s product news for the next issue of NHD Magazine call 0845 450 2125
For more information, see: Greene ND et al (2016). British
Journal of Nutrition Vol 115, no 6; pg 974-83.
Capsaicin - satiety due to GI distress? Well, whilst it was beginning to emerge that red chillies could be one way to kick start satiety and lower energy intake, new research pinpoints that there could be other reasons behind this. The research published in The American Journal of Clinical Nutrition studied the effects of a capsaicin (1.5mg pure capsaicin) of placebo infusion fed into the intestine of 13 subjects in a crossover fashion. It was found that the capsaicin infusion significantly increased satiety but also led to more gastrointestinal symptoms, which included burning, nausea and bloating. Satiety scores also correlated with these sensations. Levels of gut hormones were unaffected by the capsaicin infusion. These findings highlight that satiety symptoms reported in past capsaicin studies could be down to the gastrointestinal stresses they cause rather than changes in appetite hormones.
Anthocyanins and lung function While dietary flavonoids have been known to have antioxidative and anti-inflammatory effects, it is largely unknown whether this could help to support lung function. As part of the Veterans Affairs Normative Ageing Study, a follow-through study measured lung function along with flavonoid intakes of 839 elderly adults. This was done regularly over a period of 16 years. It was found that higher anthocyanin intakes were linked to a reduced decline and agerelated lung function. This trend was observed in both current, former and ‘never’ smokers. In particular, eating ≥2 servings of anthocyanin-rich blueberries per week was found to help support lung function. These are interesting findings, indicating that anthocyanins could help to support lung function as we age. Now, more work is needed to look into the mechanisms behind this.
Journal of Clinical Nutrition Vol 103, no 2; pg 305-13.
Journal of Clinician Nutrition Vol 103, no 2; pg 542-50.
For more information see: van Avesaat M et al (2016). American
For more information see: Mehta AJ et al (2016). American
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CHOICE-CHAINS 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 helps guide the NHD features agenda as well as contributing features and reviews Information Sources: An R (2016). Beverage Consumption in Relation to Discretionary Food intake and Diet Quality among US Adults, 2003 to 2012. Journal of the Academy of Nutrition and Dietetics 116, 28-37
Does drinking more mean eating more? Or do some drinks make you eat less? These questions of food and drink choice-chains need statistical uncoupling by measuring the gradients of population diet and drink intake patterns over time. Thank goodness Professor Ruopeng An has both the brains and the stomach to unweave this messy tangle of dietary connections. His excellent analysis of drinks-links is presented in the January issue of The Journal of the Academy of Nutrition and Dietetics (An, 2016). It seems that consumers of diet beverages and sugar-sweetened beverages (SSBs) are different not just in their drinks choices: they also make different food choices. And this is also the case for drinkers of coffee or alcohol. What you drink may couple with what you eat. Of course, coffee-and-cake or beer-andcrisps are matches: drinking coffee with crisps or beer with cake seem bizarre combinations. So would it be reasonable to predict that coffee drinkers consume more cake=sugars and beer-drinkers consume more crisps=salt? Professor An examined beverage choices of more than 22,500 American adults from data collected from the National Health and Nutrition Examination Survey (NHANES), in the years 2003 to 2012. Two non-consecutive day intakes were assessed to give two-day average scores. What do American adults drink? Most (53%) had coffee, which was twice as likely a choice as tea (26%). SSBs were consumed by 43% of the sample, which was twice as likely a choice as diet beverages (21%). Which was very close to the number who had enjoyed one or more alcoholic drinks (22%). Not included within the score system were drink choices of water or milk in any form, or pure fruit juices. The five beverage types
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captured nearly all subjects only 3% reported to be consuming none of these drinks over the two days captured. In contrast, less than 1% of thirsty respondents reported to be consuming all of these drinks categories. The next issue was, if you consumed these beverage types, what were the daily kilocalorie contributions from these choices? Alcoholic drinks (beers, wines, liquors, etc) topped the ratings with more than 380kcals. SSBs also added nearly 300kcals to daily energy intakes. Then much lower down the scale, tea drinks provided nearly 70kcals, and coffee and diet beverages contributed tiny amounts of less than 20kcals. Although tea drinks would be expected to match coffee drinks in the UK diet (so, small amounts of energy contributed by additions of sugar and/ or milk), US tea drinking is often iced, sweetened and lemon flavoured, which makes it a more calorific choice than the classic cuppa. Parallel to data on beverage intake, Professor An assessed intakes of discretionary foods. These are described as energy-dense, nutrientpoor food products that are not listed in the main food groups. They are not a necessary part of the diet, but can add diversity, and may be useful in small amounts by those who are physically active. Alphabetical examples include: cakes, chips, chocolates, cookies, fries, ice cream, muffins pies, popcorn and
Choosing to drink alcohol was again linked to the largest increase in energy intakes by more than 380kcals.
waffles. There are more than 660 individual foods listed in this category in the NHANES survey form and, of course, most people reported consuming some of these foods over two days: on average, more than 480kcals worth daily. Professor An also assessed overall diet quality scores using the Healthy Eating Index score (which matches diet intakes with the US national healthy eating guidelines). The average score was just under 50%, but interesting that weekday scores were 10 points better than weekend scores. This is another of many examples of food survey data showing differences in weekday versus weekend patterns, and the need to include weightings for this in the analysis of data. There were some associations between beverage choices and total daily intakes of energy. Choosing to drink alcohol was again linked to the largest increase in energy intakes by more than 380kcals. SSBs boosted total energy intakes by more than 220kcals per day. Choices of coffee or of diet drinks or tea were linked to energy intakes of just over or 100kcals or less. The most interesting pattern was that choices of alcohol or tea resulted in energy intakes that matched beverage choice. So, for example, people who chose alcohol obtained about 380kcals from this source and total daily energy intakes increased by this amount. In contrast, diet drink or coffee consumers obtained less than 20kcals from their beverage choices and yet their energy intakes increased by 70 and 110kcals respectively. Coffee drinkers appear to consume on average 90kcals
more of other linked foods. Only SSBs showed some substitution effect, so that total energy intakes were slightly lower that those provided directly by SBB consumption. Looking only at energy intakes specifically from discretionary foods (aka ‘junk’ foods), coffeedrinking resulted in the largest increase daily of 60kcals. SSBs were linked to 30kcals daily and alcohol drinking had the lowest boost effect at about 20kcals. Intakes of energy from associated discretionary foods seem to be in almost perfect beautiful symmetry to the energy intakes from beverages. So, most kcals but least discretionary food intakes come with alcohol drinking, whereas least kcals but most discretionary food intakes are linked to coffee drinking, followed by diet beverages. The association between greater intakes of diet-beverage and greater kcal intakes from discretionary foods was highest in obese adults. So, coffee-and-cake seems a stronger match than beer-and-crisps (to put picture to the data). Food and beverage intakes are not a zerosum game and there are compensation and substitution effects. Professor An concludes that healthy eating promotions need to consider the links between beverage choices and other food choices. But the psychology of choice, so that sacrifices demand the balance of reward and compensation, is often observed (“because my latte is skinny, my flapjack can be chocolatecovered”). These and many other aspects of food choice form the daily basis for the wise and supportive advice given by dietitians every day. And Professor An’s research is an excellent contribution to better understanding and supporting those we help. www.NHDmag.com April 2016 - Issue 113
From birth to discharge and beyond, the ESPGHAN-compliant1 Nutriprem range is designed to aid the development of preterm babies. For products that support feeding with breastmilk and contain ingredients to help babies thrive, choose Nutriprem.
Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortiﬁer is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low–birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85–91.
FOOD LABELLING: FORTHCOMING EU REGULATION AND UK GUIDELINES Maeve Hanan RD Stroke Specialist Dietitian, City Hospitals Sunderland, NHS
Maeve works as a Stroke Specialist Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.
Food labels are our main means of understanding what our food actually contains; which is really important in enabling us to make more informed and potentially healthier consumer choices. In order to improve the standard of food labelling consistently across Europe, the EU Provision of Food Information for Consumers Regulation1 was adopted in 2011, with most of these legal requirements having become effective on 13th December 2014. This article examines the implication of this Regulation and, in particular, the ‘nutritional declaration’ aspect which will become mandatory for the majority of food labels from 13th December 2016. This Regulation sets out three fundamental requirements for food labelling:1 1. Food information shall not be misleading. 2. Food information shall be accurate, clear and easy to understand. 3. Food information shall not suggest that the food prevents, treats or cures a human disease. MANDATORY INFORMATION FOR FOOD LABELS: (see example, figure 1 overleaf)
a. The name of the food b. The list of ingredients (generally listed in descending order of weight) c. Allergy information d. The quantity of certain ingredients or categories of ingredients e. The net quantity of the food f. The ‘best before’ or the ‘use by’ date g. Any special storage conditions and/ or conditions of use h. The name or business name and address of the food business operator i. The country of origin or ‘place of provenance’ (i.e. when production involves more than one country, this is the country where the primary ingredient comes from, or where the product underwent its last important stage of manufacturing)
j. Instructions for use (where appropriate) k. The alcoholic strength documented as ‘alcohol’ or ‘alc’ followed by the ‘% vol’ (where beverages contain more than 1.2% by volume of alcohol) l. A nutrition declaration Note: Exemptions apply to specific types of glass bottles (only points (a), (c), (e), (f) and (l) are mandatory) and containers where the largest surface area is <10cm2 (only points (a), (c), (e) and (f) are mandatory); however the list of ingredients must be available via other means or upon request. Additional mandatory labelling requirements exist related to products such as: frozen meat or fish, products containing sweeteners, products with a high caffeine content, dried milk products, products in vending machines and alcoholic drinks. ALLERGEN LABELLING (see example, figure 2 overleaf)
Since 13th December 2014, all products which contain any of the allergenic substances listed below are legally required to clearly specify these in the ingredients list and to highlight these through a typeset distinguished by font, style or colour.1 In cases where there is no ingredients list included, the label must state ‘contains’ followed by the allergens in question; unless the name of the product contains the allergen. www.NHDmag.com April 2016 - Issue 113
PUBLIC HEALTH Figure 1: Example mandatory information Allergenic substances legally required to be clearly specified in the ingredients list • Cereals containing gluten - wheat, oats, barley, rye, spelt, kamut or their hybridised strains • Crustaceans • Celery • Eggs • Mustard • Fish • Sesame seeds • Peanuts • Molluscs • Nuts - almonds, hazelnuts, walnuts, cashews, pecan nuts, Brazil nuts, pistachio nuts, macadamia nuts & Queensland nuts • Sulphur dioxide and sulphites at concentrations of more than 10mg/kg or 10mg/litre • Soybeans • Lupin QUID: Quantitative Ingredient Declarations source: www.food.gov.uk/sites/default/files/fir-guidance2014.pdf
Figure 2: Example allergy information
MANDATORY NUTRITIONAL DECLARATION1
From 13th December 2016 a ‘nutrition declaration’ (also referred to as ‘back of pack’ nutritional information) must be present on all food labels.1 Prior to this date (i.e. between 13th December 2011 and 12th December 2016) companies may include a voluntary nutritional declaration which must also comply with the regulation: 12
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a. The energy value declared in both kJ and kcal. b. The amounts of fat, saturated fat, carbohydrate, sugars, protein and salt declared in grams (although it may be stated if the salt content is due to naturally occurring sodium present in the product).