Download Guidelines for Food and Health - Birmingham Community Healthcare

Guidelines for Food and Health
Produced by Birmingham Community Nutrition and Dietetic Department
www.dietetics.bham.nhs.uk
Sections
1. Core Guidelines for Food and Health
2. Nutritional Management of Chronic Diseases
3. Black and Minority Ethnic Communities
4. Maternal Nutrition
5. Under Fives
6. Older People
Fernbank Medical Centre
508-516 Alum Rock Road
Ward End
Birmingham
B8 3HX
St Patricks Centre for Community Health
Frank Street
Highgate
Birmingham
B1 0YA
Springfields Centre
Raddlebarn Road
Selly Oak
Birmingham
B19 6JD
Tel: 0121 465 2785
Fax: 0121 465 2776
Tel: 0121 446 1021
Fax: 0121 446 1020
Tel: 0121 627 1627 ext 51484
Fax: 0121 627 8834
Revised Jan 2009
Core Guidelines for Food and Health
The aim of these guidelines is to provide clear, practical and evidence based nutritional advice and
information to enable health professionals and food providers to inform and support the people of
Birmingham to make beneficial dietary changes.
1.0 THE BIRMINGHAM POPULATION
Birmingham is the second largest city in the United
Kingdom. It has a population of over one million
people which includes some of the country’s most
deprived communities. The population also has one of
the richest cultural, religious and ethnic mixes to be
found anywhere in the country.
2.0 INEQUALITIES IN DIET-RELATED
DISEASES IN BIRMINGHAM
The burden of ill health and early death due to dietrelated diseases is not distributed equally across the
population. It is well established that those living in
more disadvantaged life circumstances are more likely
to die early and suffer ill health than those who are of
a higher socio-economic status.(1) Fig 1.
Examples of diet related inequalities include:
l
l
l
l
l
l
l
Babies with fathers in social classes 4 and 5 have a
birth weight on average 130gms lower than babies
with fathers in social classes 1 and 2.
Dental caries is more prevalent in children from
lower socio-economic groups.
The mortality rate from Coronary Heart Disease
(CHD) is over twice as high in female manual
workers as in female non-manual workers.
Diabetes is one and a half times more likely to
develop at any age in those in the most deprived
20% of the population compared to the average.(2)
The prevalence of obesity in women in social class 5
is twice that of women in Social Class 1. For men
the figure is 50% higher.
Central obesity is more common in adults from
manual social classes than non-manual classes. This
effect is greater in women than in men: the
prevalence of central obesity is 50% higher for
women in social class 5 than in social class 1.
People from deprived backgrounds are more likely
to get certain types of cancer and less likely to
survive. For example, breast cancer and colon
cancer five year survival is 7% and 4% less
respectively in the most deprived groups compared
to the most affluent.
3.0
UNDERLYING BARRIERS TO
HEALTHYEATING
Cost is the main determinant of what food is bought
by people on low incomes(3). However, choice of food
depends on a range of factors, which affect the
availability, and accessibility of buying and preparing
healthy foods, as well as attitudes to and awareness of
healthy eating.
The main barriers to healthy eating on a low income
are:(4)
l
Low income and debt
l
Poor access to affordable, healthy food.
l
Sociocultural factors
l
Lack of opportunities to experiment and develop
cooking skills for healthy meals
l
Lack of accessible and accurate information
l
Food labelling
l
Food marketing
l
Poor literacy and innumeracy.
Qualitative information on the community’s own views
of their needs and on the current barriers to eating
well is vital and can only be obtained by asking the
local community.
Fig 1
THE NATIONAL SOCIO-ECONOMIC
CLASSIFICATION ANALYTIC CLASSES
1 Higher managerial and professional occupations
1.1 Large employers and higher managerial
occupations
1.2 Higher professional occupations
2 Lower managerial and professional occupations
3 Intermediate occupations
4 Small employers and own account workers
5 Lower supervisory and technical occupations
6 Semi-routine occupations
7 Routine occupations
8 Never worked and long-term unemployed
Core Guidelines for Food and Health
3.1 THE EATWELL PLATE
To translate these dietary messages into
practical advice in terms of food, the
Food Standards Agency published The
Eatwell Plate (9) which is an updated
version of “The Balance of Good
Health” (5). This tool is recommended for
use by all health professionals to help
people understand and enjoy healthy
eating and to ensure that everyone
receives consistent messages about the
balance of foods in a healthy diet. The
science behind the plate, and how it
should be used, remain the same.
The Eatwell Plate provides visual and
practical interpretation of the scientific
guidelines in the COMA Report – The
Dietary Reference Values for Food and
Energy Nutrients for the United
Kingdom – 1991(6,7). It emphasises choosing a variety of
foods and making changes towards more vegetables,
fruit, bread, breakfast cereals, potatoes, rice and pasta.
Use the Eatwell plate to help you get the balance right.
It shows how much of what you eat should come from
each food group.
The Eatwell Plate is based on the five food groups,
which are: l
Fruit and Vegetables
l
Bread, rice, potatoes, pasta and other starchy foods
l
Milk and dairy foods
l
Meat, fish, eggs, beans and other non-dairy sources
of protein
l
Foods and drinks high in fat and/or sugar.
3.2 THE FIVE FOOD GROUPS
What’s included
Fruit and
vegetables
Fresh, frozen, canned and dried
fruit and vegetables. A Glass of
fruit juice. Beans and pulses can
be eaten as part of this group
Main nutrients
Fibre
Folate
Carbohydrate
Antioxidants
Vitamins
Message
Eat plenty of
fruit and
vegetables – Aim
for at least 5
portions a day.
Recommendations
Eat a wide variety of fruit and
vegetables
Only 1 medium glass (150ml) of
fruit juice counts towards your 5a-day
However much you eat, beans
and pulses count as a maximum
of one portion a day.
Bread, rice,
potatoes,
pasta
and other
starchy
foods
All varieties of bread including
wholemeal, granary, brown,
seeded, chapatti, pitta bread,
bagel, roti and tortilla. Other
starchy foods include plantain,
yam, sweet potato, dasheen, coco
yam, kenkey, squash, breadfruit,
cassava, breakfast cereals, oats,
noodles, maize, millet, cornmeal,
couscous, bulgar wheat, Quinoa.
Starchy
Carbohydrate
Fibre
B Vitamins
Calcium
Iron
Eat plenty of
bread, rice,
potatoes, pasta
and other
starchy foods –
base your
meals on
starchy foods.
Try to choose wholegrain varieties
whenever you can.
Core Guidelines for Food and Health
THE FIVE FOOD GROUPS continued . . .
What’s included
Milk
and
dairy
foods
Meat, fish,
eggs, beans
and other
non dairy
sources of
protein
Milk, cheese, yoghurt and
fromage frais, soya milk.
Not included are butter, eggs and
cream
Meat, poultry, fish, eggs, nuts,
beans and pulses, TVP (textured
vegetable protein) and quorn.
Beans are in this group as they
are a good source of protein.
Main nutrients
Calcium
Protein
Vitamin B12
Vitamins A and D
Iron
Protein
B Vitamins,
especially B12
Zinc
Magnesium
Fish also includes frozen and
canned
Foods and
drinks high
in fat
and/or
sugar
Foods high in fat: Butter,
margarine, spreading fats, cooking
oils, oil based salad dressings,
mayonnaise, cream, chocolate,
crisps, biscuits, pastries, cakes,
puddings, ice cream, rich sauces
and gravies
Foods high in sugar: soft drinks,
sweets, jam, sugar, cakes,
puddings, biscuits, pastries and ice
cream
Fat
Essential fatty acids
Vitamins A, D, E
and K
Message
Recommendations
Eat or drink
moderate
amounts
Choose lower fat versions
Choose soya milk enriched with
calcium
Eat moderate
amounts
Choose lower fat versions such as
meat with the fat cut off, poultry
without skin and fish without
batter
Aim to eat at
least one portion
of oily fish each
week which
includes:
Sardines
Mackerel
Salmon
Tuna (fresh only)
Kippers
pilchards
Eat foods
containing fat
and sugar
sparingly
Cook these foods without added
fat
Limit intake of processed meat
(eg. bacon, salami, sausages,
beefburgers and pate)
Nuts are high in fat so eat
sparingly and choose unsalted
varieties
Some foods containing fat will be
eaten every day but should be
kept to small amounts
Choose monounsaturated
varieties (eg. olive oil, olive oil
based spreads, rapeseed oil,
groundnut oil)
Choose lower fat varieties where
possible (eg. Low fat mayonnaise,
salad dressings, salad cream)
Foods containing sugar should be
limited and eaten at mealtimes
rather than between meals to
help reduce the risk of tooth
decay.
Alcohol
'please refer to Appendix 10 in
the Nutritional Management of
Chronic Disease chapter for
information on alcohol'.
Core Guidelines for Food and Health
Encourage people to choose a variety of foods from
the first four groups every day. This will help ensure
that they obtain the wide range of nutrients their
bodies need to remain healthy and function properly.
Choosing different foods from within each group adds
to the range of nutrients consumed. Foods in the fifth
group - fatty and sugary foods, are not essential to a
healthy diet but add extra choice and palatability.
The dietary messages within the Eatwell Plate apply to
most people, including vegetarians, people of all ethnic
origins, people who are a healthy weight and those
who are overweight. These recommendations are
not fully applicable for population groups
including pregnant and breastfeeding women,
young children and the elderly recommendations for these groups will be
addressed as separate sections within this
document.
By using the Eatwell Plate as an up-to-date nutrition
education tool we are, as health professionals, in a
position to offer consistent nutrition information and
work towards overcoming the public’s perception that
the dietary recommendations are always changing.
However providing an effective nutrition education tool
is only part of being able to achieve dietary change and
when supporting a client in making dietary change we
need to consider the approach with clients and
consider the client’s perspective.
If professionals believe that their mission is to make
people change, they usually fail.
In order to be effective in helping people change their
eating habits professionals need to consider the client’s
motivation to change.
4.0 THE PROCESS OF CHANGE
The process of change model was originally developed by Prochaska and DiClemente (1986).(7) The diagram shows an
adaptation of the model designed to be applicable to the process of changing behaviours which pose risks to health.
Stable, ‘safer’
lifestyle
Making
Change
Preparing
To change
Thinking
About change
Not interested
in changing
‘risky’ lifestyle
Maintaining
Change
Relapsing
Core Guidelines for Food and Health
4.1 STAGES OF CHANGE
NOT INTERESTED IN CHANGING A RISKY
LIFESTYLE
Many people attending Primary Health Care Services
are not interested in changing their lifestyle, nutrition,
inactivity or overeating. They may not ever have
considered change, or been made aware of the risks
they are running, (Prochaska and DiClemente call this
stage ‘precontemplation’.) The health professional’s
aim is to get patients to the stage of maintaining a
‘safer’ or ‘healthy’ lifestyle, but there are several stages
to go through before that.
THINKING ABOUT CHANGE
Once aware of the potential benefits of change, or the
potential risks of continuing the behaviour, people go
through a stage of thinking about change (Prochaska
and DiClemente call this stage ‘Contemplation’). They
weigh up the costs and benefits of change and seek
information to help them in the decision. This stage
can last only a few minutes but commonly
continues for several years.
MAINTAINING CHANGE
Once the habit is broken the person needs to maintain
the new behaviour. When new habits become well
established, the person is seen as moving out of the
change process into a long-term ‘safer’ lifestyle.
Sometimes maintaining the new behaviour may be
difficult and constant vigilance and support is required
to avoid ‘relapse’.
RELAPSING
When a person is unable to maintain the change, old
habits return. Sometimes this is because the
costs/benefits balance has shifted due to other changes
in the person’s life and the change is no longer
perceived as worthwhile. Sometimes the environment
has changed or support has been withdrawn or
become less effective thus making it seem too difficult
to maintain the change. Relapse is normal and most
people then move, in time, back to wondering whether
to change or not, and so on.
PROGRESSION THROUGH THE STAGE
PREPARING TO CHANGE
When the perceived benefits of change seem to
outweigh the costs, and when the person really begins
to believe change is possible as well as worthwhile,
she/he begins preparing to change - perhaps needing
extra knowledge, skills and support to move into
action.
MAKING CHANGE
The early days of change tend to require positive
decisions to do things differently and some people
need - temporarily if not permanently - to change
other aspects of their lifestyle in order to break away
from habit, (e.g. people cutting down on biscuits stop
buying them as part of weekly shop). A clear goal,
realistic plan, support and rewards are features of
success in this stage.
People move both forwards and backwards round the
cycle of change, and spend varying amounts of time in
each stage. However, people who change successfully
do pass through all stages. The authors of the model
have said:
‘Individuals who successfully leap over stages, such as
from precontemplation (not interested in changing) to
maintenance, may exist, but we have not yet found
any. We have been able to successfully predict that
individuals who leap to action without adequate
contemplation or preparation are a high risk for
relapse’
Core Guidelines for Food and Health
4.2 DIETARY COUNSELLING TO CHANGE
EATING BEHAVIOUR
ASSESSMENT:
Make an assessment of the diet depending on the
health issue in question. When doing this and looking
at specific foods one should establish the frequency of
consumption, the type and the amount. For example,
total fat intake may need to be reduced or the type of
fat could be changed.
Any action plan should be personalised and include
some detail of how a planned change might be
implemented. For example a reduction in the calorie
content of the diet might mean an individual will alter
their cooking methods and/or buy different food
products. They may decide to reduce the portion sizes
of certain foods or to have them less often.
A good action plan will be SMART
S
Specific
What understanding does the person have regarding
the link between food and drink choices and their
health?
M
Measurable
A
Agreed by the individual
Establish how ready a person is to change. If they are
not ready then giving advice is unlikely to be helpful.
Aim to support the individual depending on where
they are in the process of change. Acknowledge
matters which might make it difficult for a person to
change. Goal setting might involve a discussion around
issues which are not directly related to food. (Other
matters may have a higher priority in an individual
person’s life and need addressing first).
R
Realistic
T
Time specific
GOAL SETTING:
Suggestions for change should come from the
individual and not the healthcare professional.
Encourage the use of an ‘action plan’ which can be
reviewed.
Care needs to be taken to make sure that the goals are
specific and not general, for example, someone might
say they will ‘eat more fruit’ – this is only a general
goal. The specific goal might be to ‘eat one extra piece
of fruit each day on at least four days of the week’.
This plan might be implemented by putting extra fresh
fruit on the shopping list or buying some tinned or
frozen fruit to have in a store cupboard.
SUPPORT
Follow up arrangements need to be discussed with the
individual. Support is important for any lifestyle
change.
Core Guidelines for Food and Health
5.0 REFERENCES
1. Benzeval M. Judge K & Whitehead M. Tackling
Inequalities in Health:
An Agenda For Action. King’s Fund Institute 1995
2. Saving Lives. Our Healthier Nation 1999. The
Stationary Office Limited.
3. Nutrition Interventions in Primary Health Care. A
Literature Review. HEA 1995
4. Food & Health. The Experts Agree. Cannon 1992.
ISBN 0 85202 449 5
5. The Balance of Good Health. Food Standards
Agency 2001. FSA/0008/0201 30K.
6. The Dietary Reference Values for Food Energy and
Nutrients. For the United Kingdom. Committee on
Medical Aspects of Food 1991. HMSO.ISBN 0 11
321397 2
7. Prochaska, J.O & Diclemente, CC (1986)
Towards a comprehensive model of change in:
Miller, W R & Heather, N (eds) Treating addictive
behaviours: processes of change. (Plenum, New
York)
8. Prochaska, J O, Diclemente, CC & Norcross J C,
(1992) In search of how people change:
applications to addictive behaviours. American
Psychologist September 1992, 1102-14.
9. The Eatwell Plate.
http://www.eatwell.gov.uk/healthydiet/eatwellplate/
http://food.gov.uk/mulitmedia/pdfs/eatwellplatelarge
.pdf
Nutritional Management
of Chronic Diseases
CONTENTS
1. INTRODUCTION
2. ASSESSMENT
3. OBESITY
3.1
3.2
3.3
3.4
3.5
3.6
3.7
Practical information to discuss with patients – 12 point plan
Evidence based interventions
Very low calorie diets and meal replacements
Pharmocotherapy
Referral to a Dietitian
Obesity – useful organisations and websites
Obesity – resources and useful references
4. CARDIOVASCULAR DISEASE (CVD)
4.1
4.2
4.3
4.3.1
4.3.2
4.4
4.5
Evidence for dietary advice and CVD
What is a cardio protective diet?
Dietary advice for the management of CVD risk factors
Dietary advice to reduce high blood pressure
Dietary advice for those with raised blood lipids
Referral to a Dietitian
CVD Resources
5. DIABETES
5.1
5.2
5.3
Evidence based dietary recommendations
Referral to a Dietitian
Diabetes –resources
6. REFERENCES
Appendices
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
1
2
3
4
5
6
7
8
9
10
National Obesity Forum
Classification of Obesity – waist and BMI
Techniques of Behaviour Modification for Weight Management
Co-morbidities associated with obesity
Benefits of weight loss
Position Paper – Very Low Calories Diets – VLCD
Pharmocotherapy/Drug Treatment of Obesity
Increasing Omega-3 Fat Intake – Sources of Omega-3
Glycaemic Index and Diabetes
Alcohol
1
Nutritional Management
of Chronic Diseases
CHRONIC DISEASES -OBESITY / DIABETES / CVD
1.0 INTRODUCTION
Obesity, Cardiovascular Disease (CVD) and Diabetes are
the biggest causes of mortality and morbidity in the
UK and are also the most common nutritional
disorders in Primary Care.1
The principles for dietary management for all three
conditions are similar, and based on the Eatwell Plate
(see Core Guidelines)
This section describes the nutritional assessment
required for these and outlines the dietary emphasis
needed for each condition. It also refers to the
approach that should be taken when discussing dietary
change with clients.
3.0 OBESITY
It is recommended that the National Obesity Forum
Guidelines2 (NOF) be followed (appendix 1).
In 2006 67% of men and 56% of women were either
overweight or obese(1). The causes of obesity are
complex and multi factorial. (See appendix 2 for
obesity classifications).
l
The first stage in the management of obesity is
to establish the underlying factors that have led
to obesity.
l
Dietary recommendations need to be tailored to
the individual’s need, based on assessment. It is
essential the client accepts responsibility for
changing their eating behaviour, rather than the
health professional.
l
It is essential to be aware of any disordered
eating, as up to 30% of obese people will
suffer from binge eating disorder. These people
should be referred to the dietitian and/or
counsellor. Others may have less severe forms of
disordered eating e.g. erratic eating habits,
comfort eating, boredom eating. (See appendix
3 for techniques that may help support these
clients.)
l
Dietary advice will be based on the Eatwell
Plate, emphasising 3 regular meals, daily, which
are high in starchy carbohydrate and low in fat.
l
‘Calorie controlled diets’ can be useful if used in
conjunction with behavioural therapy. People
need to relearn how to eat and to recognise
hunger. It is unhelpful to think in terms of
‘good’ and ‘bad’ food. There are no bad foods,
only bad diets.
l
The emphasis needs to be on permanent
changes to lifestyle, including adopting new
eating habits and behaviours. Food diaries may
help clients identify where eating patterns and
behaviours can be modified.
l
Increasing physical activity is also important.
Aim for at least 30 minutes a day 5 times a
week. This can be achieved in shorter blocks of
10-15 minutes.
l
See appendix 4 for consequences of obesity.
2.0 ASSESSMENT
It is recommended that local guidelines are drawn up
for each of these conditions. However the following is
a list of generic information to collect and/or consider:
Weight
Height
Body mass index (BMI)
Waist circumference
Associated risk factors e.g. smoking, lack of
physical activity, hypertension, family history of
disease, obesity related morbidity, diabetes, CVD
History of dieting
Weight history
Social, family, occupation details
Eating behaviours (including ‘hard to resist’
foods and ‘trigger’ foods)
Meal pattern, snacks, portion sizes (including
frequency, amount and type of food), shopping
and cooking arrangements
Knowledge of diet and condition
Clients readiness to change, including their
motivation and confidence to change (see Core
Guidelines)
Treatment expectations
Gender
Ethnicity
Socio economic status
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
2
Nutritional Management
of Chronic Diseases
3.1 PRACTICAL INFORMATION TO DISCUSS
WITH PATIENTS -12 POINT PLAN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Aim for a realistic weight loss of 5-10% of
current weight (at a rate of 2-4 kg over a
month)
Reduce intake of high calorie foods, snacks and
drinks, (choose low sugar and low fat foods)
and limit fast foods/takeaways
Eat regular, balanced meals, including breakfast
every day. Have some starchy food at each
meal (based on the Eatwell Plate)
Be active more often. Every day aim for a total
of 30 minutes of physical activity at least 5 times
a week. Use a pedometer and aim for 10,000
steps every day.
Eat more vegetables and fruit (aim for at least 5
portions a day).
Calories do count. Be aware of portion sizes –
aim smaller.
Keep a food and mood diary; find out what,
when, why, and where you eat. Keep a regular
check on your weight.
Plan ahead. Stick to shopping lists and menu
plan for at least 2 – 3 days ahead. Don’t shop
when hungry.
Set yourself personal SMART goals for changing
your habits (specific, measurable, achievable,
realistic, time-specific).
Small changes to your daily habits can lead to
big health benefits.
Think long-term changes that will be
permanent, not a quick fix.
Find your support team. Get family and friends
on board to help you and to join in.
3.2 EVIDENCE BASED INTERVENTIONS
l
l
l
l
l
l
l
5-10% weight loss (see appendix 5).
600kcal deficit/day for 1-2 lb/week weight loss.
An improved quality of diet (based on The Balance
of Good Health).
A change in the whole family’s eating habits
(including shopping, cooking, portion sizes, etc.)
An increase in physical activity – aim for 30
minutes, 5 times a week. The 30-minutes can be
broken down into 10-15 minute episodes. Daily
activities are also very important e.g. use lift instead
of stairs, walk short distances instead of taking the
car.
Use a behavioural approach. (See appendix 3).
Long-term support is essential for weight
maintenance. This support will not necessarily be
provided by a health professional it could come
from a self-help group, friend or relative.
References 4,5,6,7.
3.3 VERY LOW CALORIE DIETS (VLCD) AND
MEAL REPLACEMENTS
Evidence suggests these can be effective if used under
supervision from obesity specialists (see appendix 6).
3.4 PHARMOCOTHERAPY
Orlistat (Xenical) and Sibutramine (Reductil) are the only
drugs licensed for obesity management. It is essential
that the manufacturer’s guidelines are followed with
regard to patient selection, prescribing and monitoring.
Dietary modification is still the cornerstone for
management and the medication is ineffective without
a change in eating habits. It is essential the patient
signs up to the support packages (MAP and Change for
Life, respectively) see appendix 7.
3.5 REFERRAL TO A DIETITIAN
It is appropriate to refer to a Dietitian if:
Grade I Obesity BMI>30kg/m2
Grade II Obesity BMI>35
Grade III Obesity BMI>40
l
BMI > 28 Kg/m2 with significant associated comorbidities (such as Diabetes: CVD; hypertension,
hyperlipidamia etc, see appendix 4)
l
BMI > 25 Kg/m2 who have been supported to lose
weight by other healthcare professionals for > 6
months with no success in weight loss.
* It is assumed the GP/Practice Nurse would have
already followed the NOF guidelines and given
advice and support before referral to a Dietitian.
Specialist Obesity Service
This service is aimed at patients needing more complex
management of their condition.
It is appropriate to refer to this service if:
l
l
l
l
BMI over 40 (or over 37.5 for South Asian)
BMI over 35 with co-morbidities
(over 32.5 for South Asian).
Emotional or comfort eating
Previous attempts to lose weight
3
Nutritional Management
of Chronic Diseases
3.6 OBESITY USEFUL ORGANSATIONS AND
WEBSITES
1. British Dietetic Association Interest Group –
Dietitians in Obesity Management –
www.domuk.org
2. www.bdaweightwise.com
3. National Obesity Forum (NOF) Website
www.nationalobesityforum.org.uk - Free to join
4. Association for the Study of Obesity (ASO) Website
for ASO and for ORIC: www.aso.org.uk
5. Health Education Board Scotland (HEBS0) The
training package can be accessed via the HEBS
website at
www.hebs.scot.nhs.uk/learncentre/obesity
6. National Heart, Lung and Blood Institute (NHSBI)
The Guideline, Executive Summary and Evidence
Report can be accessed via the NHLBI website at
www.nhlbi.nih.gov.index
7. The International Obesity Task Force (IOTF)
www.iotf.org
8. The National Electronic Library for Health (NeLH)
www.nelh.nhs.uk
3.7
OBESITY - RESOURCES
1. Weight Wise Campaign www.bdaweightwise.com
2. NICE (2006) Obesity: Guidance on the prevention,
identification, assessment and management of
overweight and obesity in adults and children
3. The LEARN Programme for Weight Control (lifestyle,
Exercise Attitudes, Relationships, Nutrition) (2000)
by Kelly Brownwell. American Health Publishing
Company ISBN:1-8785 13-24-9
4. Shape-up (2001) A lifestyle programme to manage
your weight by Jane Wardle et al.
Weight Concern: London www.weightconcern.com
5. Trainers Tool Kit (2000) – for Dietitians involved in
the dietary management of chronic disease by
Postgraduate Nutrition and Dietetic Centre in
association with and published by the Scottish Diet
Sheet Project. Available from Banner Business
Supplies Tel: 0131 479 3279
6. Tackling Obesity: A Toolbox for Local Partnership
Action (2000) by Alan Maryon Davis, Roberta Rona,
Alison Giles, The Royal Society of Physicians Faculty
of Public Health Medicine: London – currently being
updated
7. Obesity in Practice Journal. Medical Education
Partnership. New Bridge Street House, 33-44 New
Bridge Street, London, ECV 6BJ. Tel 020 7072 4186
email: [email protected]
4
8. So You Want to Lose Weight. Produced by the
British Heart Foundation. Tel 0171 935 0185 and
ask for Distribution
9. Medical Action Plan Successful Weight
Management Materials. Produced by Roche
Pharmaceuticals in 1998, as part of the support
package for Xenical. Telephone patient support
line which is run by nurses on Tel: 0800 7317138.
10.Change for Life. Weight loss pack produced by
Abbott Laboratories 2003. For those using
Sibutromine. www.changeforlifeonline.com
4.0 CARDIOVASCULAR DISEASE
Cardiovascular disease includes all the diseases of the
heart and blood vessels, including coronary heart
disease (CHD), stroke and heart failure.
4.1 EVIDENCE FOR DIETARY ADVICE
AND CHD
There is good evidence that dietary advice given to
those with CVD can reduce mortality and morbidity as
well as modify risk factors.8 The cardioprotective diet is
first line dietary advice for protecting against CHD. It
can be used in primary or secondary prevention of
CHD and it can be used in conjunction with advice to
manage specific risk factors such as hypertension,
hyperlipidemia and obesity. Cardioprotective dietary
advice should always be set in the context of the
Eatwell Plateh (see Core Guidelines).
Aims of Dietary Advice for CVD
The aims of providing dietary advice to patients are
either to help prevent further cardiovascular events in
people who have existing CVD (secondary prevention),
or to prevent cardiovascular events in those people
who are at high risk of CVD (primary prevention).
These aims can be achieved by providing advice on the
‘Cardio-protective’ diet and management of
cardiovascular risk factors.
Nutritional Management
of Chronic Diseases
See appendix 8 for advice on increasing Omega-3
fat intake via oily fish supplements.
4.2 WHAT IS THE CARDIOPROTECTIVE DIET?
The Cardioprotective diet is the first line of dietary
advice for protection against further CHD events.8 It
emphasises the following key main messages:
See section 4.5 for resources for patients on how
to increase omega-3 intake.
(Leaflet titled – Heart Disease and Omega-3
produced by BDA)
1. Reduce saturated fats and totally or partially replace
with unsaturated fats, particularly monounsaturated
fats
2. Advise on the Mediterranean diet; i.e.
- an increase in fresh foods eg fruit,
vegetables and fish (to the recommended level
for the population: two portions of fish per
week; one of which is oily fish)
- include more whole grains and pulses
- reduce processed foods
Reduce Saturated Fat
Advice should be provided on reducing saturated
fat and total or partial replacement with
unsaturated fats (rapeseed or olive oil).
Advice on Mediterranean Diet
Mediterranean dietary advice should be provided
with an emphasis on increasing fruit and
vegetables, aiming for 5 portions a day.
(Mediterranean advice also includes increasing
omega-3 fats and fresh foods, whilst reducing
saturated fats and processed foods)
Increase in Omega –3 fat intake
Priority should be given to ensuring the patient has
adequate omega-3 fat intake. Advice would differ
depending on whether the patient is classed as
primary or secondary prevention.
The cardioprotective diet affects cardiovascular
disease by altering a wide range of risk factors in a
positive way12. Table 1 presents further information
on food and nutrients proven to have an effect on
the cardiovascular disease process and/or risk
factors. The table has identified nutritional effects
specifically on cholesterol, triglycerides and blood
pressure, as these factors are easily identifiable in
clinical situations. However, diet can affect the
cardiovascular process by other ways which include
reducing arrhythmias, thrombosis, lipid oxidation
and inflammation, homocysteine levels and insulin
resistance, platelet aggregation and clotting
factors.
Advice for primary prevention (Low risk patients
and those patients with risk factors such as
hypertension, hyperlipidaemia and obesity):
Aim for two portions of fish per week one of which
should be oily.
Diabetes guidelines recommend 1-2 portions of oily
fish per week.9
Secondary Prevention (Patients post MI and post MI
with diabetes8,10,11):
Aim for 2 – 3 portions of oily fish per week or take
0.5 – 1.0g omega-3 fish oil supplements
(eicosapetanoic acid and docosahexanoic acid)
per day
Table 1. Table of Nutrients and Foods and their effect on CVD risk factors
The following table gives an indication of the predicted effect of different foods and nutrients on CVD factors. The
priority should be given to the evidence-based cardioprotective dietary advice outlined above rather than focussing on
the effects of individual foods and nutrients.
HDL
×
total
Rapeseed (vegetable oil) oil is the
preferred oil as it contains omega-3
fats and is cheaper.
×
HDL
If polyunsaturated fats are the main fat
used, encourage a good antioxidant
intake.
LDL
LDL
OTHER
×
Sunflower,
Use less polyunsaturated fat
corn, & soya oil and more monounsaturated
& spreads made fat
from these.
total
Effect on
blood
pressure
×
Use these type of fats and
oils more often than other
fats. Choose spreads made
from either olive oil or
rapeseed (pure vegetable oil)
Ý Ý
Rapeseed or
olive oil should
be priority.
(Groundnut,
peanut also).
Effect
Effect
on
on
cholesterol triglyceride
Ý
Poly-unsaturated
fats
RECOMMENDATION
Ý
Monounsaturated fat
FOODS
ÝÝ
NUTRIENT
Excess intakes can increase
atherosclerosis.
5
Nutritional Management
of Chronic Diseases
LDL
HDL
all
OTHER
Saturated fat is converted to
cholesterol by the liver. It also reduces
thrombosis & insulin resistance.
Use lower fat dairy products
Encourage oily fish .
If oily fish not eaten encourage other
sources or fish oil supplements. See
appendix 8
ÝÝ
Oily fish: portions/week
Primary prevention: 1
Secondary prevention: 2-3
Or Fish oil supplement: 0.5 –
1.0g omega-3 per day.
×
Oily fish. See
resource Heart
Disease &
omega-3 (BDA)
for other foods.
total
Effect on
blood
pressure
Ý
Replace saturated fat with
monounsaturated fats.
Reduce all foods containing
saturated fat to a minimum.
×
Cakes, biscuits,
meat products,
Butter, ghee, lard,
cream, coconut
oil, full fat dairy
products.
Effect
Effect
on
on
cholesterol triglyceride
Ý
Omega – 3 oils
RECOMMENDATION
Ý Ý Ý
Ý
Saturated fats
FOODS
×
NUTRIENT
Dietary
cholesterol
Eggs, liver,
prawns,
kidneys.
Do not need to cut down
unless advised by Dietitian.
Saturated fat more
important.
total
HDL
×
Trans fats may be found in
foods that contain
hydrogenated fats, including
some types of biscuits,
cakes, fast food, pastry,
margarine and spreads.
×
Hydrogenated
vegetable oil
and foods
cooked in it.
Ý Ý
Ý
Trans fats
×
ÝÝ
Omega-3 oils also:
arrhythmias and
insulin resistance
thrombosis,
inflammation,
Act the same as saturated fats.
LDL
Dietary cholesterol has only a small
effect on serum cholesterol. Should
only be strictly reduced in familial
hypercholesterolaemia.
Ý
increase;
decrease;
×
×
×
Ý Ý
total
HDL
LDL
Ý
×
×
all
( in
excess)
Ý
Need 25g per day of soy
protein for effect.
HDL
LDL
Many of these nutrients help
reduce atherosclerosis
Higher potassium intakes have been
associated with lower blood
pressures.
( in
excess)
Above 1-2 units daily blood pressure
& triglycerides can be increased.
All alcohol has same effect.
Salt restriction leads to reductions in
blood pressure.
×
Soy containing
foods
(e.g. soya).
total
×
Soy protein
High fibre (soluble & insoluble) diets
have been associated with lower
blood pressures.
×
Minimise use of added salt
to cooking & meals.
Reduce intake of
salty/processed foods (crisps,
gravy, soy sauce, packet
soups, processed meat etc).
×
Table/cooking
salt, rock salt;
processed,
snack &
convenience
foods.
Ý
Salt
(ALL types)
×
1-2 units daily.
Contraindicated in alcohol
addiction, liver disease.
Ý Ý
All alcoholic
drinks..
×
Alcohol
all
× ×
See recommendations for
soluble fibre.
×
Fruit,
vegetables,
pulses,
wholegrain
cereals, nuts.
HDL
Can
LDL
Ý Ý
Anti-oxidants,
potassium, folic
acid, & other
compounds
total
LDL
Ý
Aim for minimum 5 portions
fruit and vegetables/day, &
include more pulses (peas,
beans, lentils etc). Choose
wholegrain cereal products.
HDL
These products are very expensive
and should not be used as a
substitute for other cardio-protective
dietary changes.
Continuing consumption is necessary
in order to maintain the effects.
Ý
Fruit,
vegetables,
pulses, oats,
beans, peas,
chickpeas.
Soluble fibre
total
Ý
20-25g/day needed for
clinical effect.
It is necessary to follow the
manufacturers recommended
serving for these products to
be effective.
Ý
Functional
foods &
margarine e.g.
Flora Pro-Activ,
Benecol.
×
Plant stanols &
sterols
×
No specific guidance for
restriction of egg
consumption exists.
Could be useful for vegetarians – but
very high intake needed for effect.
no significant effect.
LDL (Low Density Lipoprotein) cholesterol is the “bad” cholesterol known to be responsible for atherosclerosis.
HDL (High Density Lipoprotein) cholesterol is a “good” cholesterol which does not cause atherosclerosis.
Triglycerides are another type of fat in the blood which cause atherosclerosis.
There is currently not enough evidence to support making changes to intakes of garlic, caffeine, coffee, red wine and vitamin E. For
this reason these foods or nutrients have not been included in the table.
6
Nutritional Management
of Chronic Diseases
4.3 DIETARY ADVICE FOR THE
MANAGEMENT OF CVD RISK FACTORS
The above advice should be given as priority to all
patients with CVD. Research has shown that giving
the above advice will save more lives than giving
weight loss or lipid lowering dietary advice. For advice
on alcohol see Appendix 10.
4.3.1 DIETARY ADVICE TO REDUCE HIGH
BLOOD PRESSURE
l
Reduce salt intake to appropriate level (< 6g day)
m
m
m
m
Use little or no salt in cooking
Try not to add salt at the table
Cut down on salty, processed foods, ready
meals and takeaways
Check out food labels (look for less that 0.25g
salt per 100g or 0.1g sodium per 100g) and go
for lower salt choices
l
Encourage potassium intake from natural sources
i.e. unprocessed food, especially fruit and
vegetables
l
Reduce weight to appropriate level (this may
decrease dosage requirements for those on
antihypertensive medications – aim for 10% weight
loss)
l
Ensure adequate calcium intake (2-3 portions
calcium/dairy foods per day) See Core Guidelines
on Balance of Good Health
l
Keep alcohol intake within healthy limits
(see Core Guidelines)
4.3.2 DIETARY ADVICE FOR THOSE WITH
RAISED BLOOD LIPIDS
l
Ensure patient receives advice on the
cardioprotective diet prior to lipid lowering advice.
l
Ensure the patient is on a statin. Research shows
that statins are more effective than dietary advice.
l
Replace saturated fats with unsaturated fats
(preferably mono unsaturated fats, rapeseed or
olive oil)
l
Encourage soluble fibre (especially oats, but also
beans, peas, lentils etc)
4.4 REFERRAL TO A DIETITIAN
Referrals received by the Nutrition and Dietetic
Department will be prioritised as follows:
1. Patients with existing CVD i.e. angina, myocardial
infarction, stroke or peripheral vascular disease,
cardiac bypass surgery, angioplasty. Patients who
have had a recent major coronary event should be
part of a cardiac rehabilitation process13 and
therefore should have been included in local
programmes to receive dietary advice. However,
we will accept referrals where patients have not
accessed cardiac rehabilitation programmes or
require further support.
2. Patients with a high risk of CHD – i.e.30% risk of
CHD event (angina or MI) over the next 10 years14
(where first line advice from another Health Care
Professional has been unsuccessful)
Where global risk assessment has not been used,
referrals will be accepted for patients who have
diabetes and other risk factors present such as
hyperlipidaemia, hypertension and obesity.
Patients with raised cholesterol only
Referrals for cholesterol lowering advice with no
other CVD risk factors present (i.e. low risk 10 –
15% CHD risk) will not routinely be offered an
appointment with a Dietitian because dietetic time
is prioritised to those patients with existing CVD
and higher CVD risk. Practice Nurses or other
Health Professionals should provide first line advice.
First Line Advice by Other Health Professionals
It is recommended that first line dietary advice on
the cardioprotective diet is given by Health
Professionals other than dietitians (e.g. Practice
Nurse). This includes patients in need of lipid
lowering advice because research shows statins are
more clinically effective at reducing lipid levels than
dietary advice alone15,16. Dietetic time is prioritised
to those patients at greater risk of developing CVD
and struggling with first line dietary advice.
7
Nutritional Management
of Chronic Diseases
4.5 RESOURCES
Good Heart Food produced by Comic Company and
the BDA. This is the most up to date leaflet and
should be used as priority. www.bda.uk.com or
www.comicompany.co.uk
Heart Disease and Omega-3’s produced by the BDA
www.bda.uk.com. This is to be used to promote the
use of Omega-3 fats for oily fish and other sources if
patients need ideas for eating Omega-3 fats.
Carbohydrate
l
60-70% of the total daily energy intake should
come from these foods in combination with
monounsaturated fatty acids (MUFA).
l
The inclusion of low glycaemic index foods should
be encouraged (see appendix 9).
Fruit and Vegetables
l
A4 sheet ‘Foods for a Healthy Heart’ (available via
intranet). This is useful for Primary Care Nurses and
other Health Professionals.
Cut the Saturated Fat: produced by British Heart
Foundation. This leaflet is useful for those with raised
lipids. www.bhf.org.uk
Fat
l
Saturated and trans-unsaturated fatty acids should
provide less than 10% of the total energy intake.
A lower intake (<8% total energy) may be
beneficial if LDL cholesterol is elevated.
l
Polyunsaturated fatty acids should not exceed 10%
of the total daily energy intake.
l
Increase intake of monounsaturated fatty acids
(MUFA). These, together with carbohydrate should
make up 60-70% of the total daily energy intake.
No fixed amount of MUFA has been stated, rather
that the proportions can depend on individual
preference. Care must be taken not to cause
weight gain by including too much fat.
l
Fish oils and Omega-3 fatty acids
Supplementation is not generally recommended in
diabetes. A moderate intake of oily fish can be
encouraged.
Food Facts: Eating for a healthy heart.
www.bda.uk.com. This is useful for primary
prevention
5.0 DIABETES - SUMMARY OF DIETARY
RECOMMENDATIONS
Diet therapy is regarded by Diabetes UK as the
cornerstone of diabetes management. It is important
that consistent dietary messages are given by all
members of the primary and secondary health care
teams.
The aim of dietary management is to provide patients
with the information required to make appropriate and
informed choices regarding the type and quantity of
food that they eat. The overall goal of such advice is
to achieve and maintain optimal metabolic and
physiological outcomes (e.g. HbA1c, lipids, BMI),
improve quality of life and reduce the risk of
complications in the longer term.
5.1 EVIDENCE BASED DIETARY
RECOMMENDATIONS FOR DIABETES
The principles of dietary management for people with
diabetes are similar to the advice recommended for the
population as a whole. This section outlines the
specific recommendations for people with diabetes.
Summary of the Recommendations of the
Diabetes and Nutrition Study Group (DNSG) of
the European Association for the study of
Diabetes (EASD). 17
8
Foods naturally rich in dietary antioxidants
(tocopherols, carotenoids, vitamin C and flavonoids)
and other water and fat-soluble vitamins should be
encouraged.
Sugar and Sugary Foods
The advice for people with diabetes is no different
from that given for the general population. Less than
10% of the total daily energy intake should be from
sugar. This is approximately 50g sugar in a 2000 Kcal /
day diet.
Protein
Protein intake may provide 10-20% of the total daily
energy intake but should not exceed this level.
Approximately, this means 50-100g of protein / day in
a 2000 Kcal / day diet.
Nutritional Management
of Chronic Diseases
Dietary Fibre
Alcohol
Dietary fibre, or non-starch polysaccharides may be
classified into two broad classes :
Soluble fibre – including gums, gels and pectins
(e.g. pulses, fruits and vegetables)
Insoluble fibre – for example cellulose and lignin
(e.g. bread and cereals)
It has been observed that the benefits of dietary fibre
are most marked when soluble fibre is included with, or
incorporated in foods.
Pharmacological therapy, supplementing meals with
guar and pectin for example, is not recommended.
Please see appendix 10.
‘Special Diabetic Foods’
These should not be encouraged.
Non-alcoholic drinks sweetened artificially may be used
for people with diabetes
Table 2 summarises the practical advice to achieve
these recommendations.
Salt
As in the general population, people with diabetes
should be advised to restrict salt intake to under 6g /
day. There may be value in further restriction for those
with elevated blood pressure but achieving it would be
difficult.
Table 2 Practical Advice for People with Diabetes
See also Core Guidelines, this advice is based around the Eatwell Plate.
Food Type
Fat
Practical Advice
Reduce intake of ‘fats’ generally –
Use less saturated fats such as butter/lard/ghee/coconut
fats, visible fat on meat.
Reduce the intake of processed foods, biscuits, pastries,
pies, cakes etc.,
Reduce intake of fried foods
Use low flat dairy products e.g., reduced/low fat
cheeses, skimmed or semi-skimmed milk.
Use monosaturated fats (MUFA) – olive oil/rapeseed oil
and spreads made from these plant oils.
Nuts are a good source of MUFA but are also high in
energy and protein so only take small amounts.
2g Plant stanols or sterols per day reduces LDL
cholesterol.
Rationale
Helps reduce coronary risk
l
Helps weight management
l
l
l
l
l
l
Sugar and sugary
foods
l
l
l
l
l
l
Reduce the overall intake of these foods
Cut out sugary drinks
Can be eaten occasionally as treats in small amounts
Best included as part of a balanced meal
Check food labels for sugar content
Artificial sweeteners such as aspartame, acesulfame K,
sucralose, saccliarine, and cyclamates are suitable for
people with diabetes.
To assist in achieving good blood glucose control.
Helps weight management.
A high intake of sugary foods contributes to dental caries.
9
Nutritional Management
of Chronic Diseases
Food Type
Meat, fish and
alternatives
Advice
l
l
Dairy Foods
l
Fibre
l
l
Salt
Rationale
Two small portions a day
Have 1 – 2 portions of oily fish each week.
To reduce risk of coronary heart disease
Aim for 2 – 3 portions of low fat dairy foods daily.
Reduces blood pressure therefore reduces cardiovascular risk.
Choose starchy carbohydrates, especially those with a
low glycaemic index e.g., pasta, oats (see appendix 9)
Aim to increase consumption of fruit & vegetables.
Include more pulses (peas, beans and lentils).
These foods increase satiety, so help weight management.
Help to maintain a healthy bowel
Are rich in micronutrients and vitamins
Can help to improve glycaemic control and blood lipids.
People with healthy hearts tend to use more wholegrain
products.
Reduce intake by –
Using less processed foods
Having less salted snacks e.g., crisps/nuts
Using less salt when cooking and trying alternative
flavourings.
Trying not to add salt to food at the table
Reduce blood pressure therefore reduce cardiovascular risk.
l
l
l
l
Alcohol
l
l
l
l
Special Diabetic
Foods
l
l
Can be taken in moderation
Men up to 3 units/day
Women up to 2 units/day
Have at least two alcohol free days
Avoid low carbohydrate beers and lagers which are
often high in alcohol.
Do NOT drink on an empty stomach.
With moderate intake there are cardioprotective benefits.
If recommendations are exceeded weight gain may occur.
There is also a risk of raised blood pressure and raised blood
triglycerides if alcohol is taken.
Some oral hypoglycaemic agents, and insulin cause more risk
of alcohol induced hypoglycaemia.
Avoid foods labelled as special ‘diabetic’ products and
use reduced sugar instead e.g., reduce sugar jams.
Artificial sweeteners can be used in drinks (see ‘sugars
and sugary foods’)
Such foods are unnecessary. They can be expensive and are
often high in calories and fat.
They often contain types of artificial sweeteners that can
have a laxative effect eg. Sorbitol, Xylitol.
5.2 REFERRAL CRITERIA - DIABETES
Referrals for all types of diabetes will be accepted. All
patients with diabetes should be offered structured
education (usually provided in group settings), however
the following criteria indicate when it may be
appropriate to refer patients to see a dietitian in a
clinic setting:
l
l
l
l
l
l
over or underweight
dyslipidaemia, hypertension
poor understanding of healthy eating for diabetes
despite advice from other health care professionals
or attendance at diabetes group education
other concurrent diet-related condition eg. food
allergy, coeliac disease, IBS etc.
change of treatment regimen or planning change
of treatment, eg. progression to oral hypoglycaemic
medication or insulin
patient request.
10
5.3 DIABETES - RESOURCES AND USEFUL
REFERENCES
Useful resources are available from Diabetes UK, ‘The
charity for people with diabetes’. For a catalogue
contact them at: - 10 Queen Ann Street, London,
W1G 9LH.
Telephone
Fax
Email
Website
-
020 7323 1531
020 7637 3644
[email protected]
www.diabetes.org.uk
Eating well with Diabetes (free). Produced by
Diabetes UK
Food and Diabetes: how to get it right
(charged for) Produced by Diabetes UK
Nutritional Management
of Chronic Diseases
Food and Diabetes (yellow booklet with strawberry
on cover) produced by Birmingham Community
Nutrition & Dietetic Service. Contact us for more
information.
Eating well and keeping well with diabetes. (for
elderly people) Produced by the Nutrition Advice for
Elderly Group (NAGE) of the British Dietetic
Association. Phone the BDA Publications Department
and ask for NAGE order form. Tel: 0121 616 4926
Department of Health (2001) National Service
Framework for Diabetes: Standards
Department of Health (2005) Structured Patient
Education in Diabetes: Report from the Patient
Education Working Group
Gray A, Clarke P, Farmer A, Holman R on behalf of the
UKPDS group. Implementing Intensive control of blood
glucose concentration and blood pressure in type 2
diabetes in England: Cost analysis. BMJ 2002 325,
860-863
Nutrition Subcommittee of the Diabetes Care Advisory
Committee of Diabetes UK. The implementation of
nutritional advice for people with diabetes. Diabetic
Medicine 2001 20, 786-807
Rutten, G (2005) Diabetes Patient Education: Time for
a New Era. Diabetic Medicine, 6:671-673
Tasker PRW (1998) The Organisation of Successful
Diabetes Management in Primary Care. Diabetic
Medicine, 15:S58-S60.
Lean MEJ, Powrie JK, Anderson AS, Garthwaite PH.
Obesity, weight loss and prognosis in type 2 diabetes.
Diabetic Med 1989, 7 228-233
Mulvihill C and Quigley R. The management of obesity
and overweight: an analysis or reviews of diet, physical
activity and behavioural approaches. London: HAD
2003
Must A et al. The disease burden Associated with
Overweight and Obesity. JAMA 1999; 282:1523-9
Wing RR, Koeske R, Epstein LH, Norwark MP, Gooding
W, Becker D. Longterm effects of modest weight loss
in type 2 diabetes. Arch Int Med 1987, 147, 17491753
6.0 REFERENCES
1. Statistics on Obesity, Physical Activity and Diet:
England (2008). Published by the Information
Centre.
2. National Obesity Forum (NOF). Website
www.nationalobesityforum.org.uk - Free to join
3. Obesity: Preventing And Managing The Global
Epidemic: Report of the World Health Organisation
Consultantion in Obesity (1997)
4. At Least Five a Week. Evidence of the impact of
physical activity and its relaitionship to health.
(2004) Department of Health. London.
5. The Management of Obesity and Overweight: An
analysis of reviews of diet, physical activity and
behavioural approached. (2003). The Health
Development Agency
6. Systematic Review of Interventions for the
prevention and treatment of obesity and the
maintenance of weight loss (1997). York University
7. Obesity in Scotland (1996) A national clinical
guideline for use in Scotland by the Scottish
Intercollegiate Guidelines Network (SIGN 8). SIGN
Edinburgh. www.sign.ac.uk
8. Hooper L (2004) Dietetic Guidelines: diet in
secondary prevention of cardiovascular disease
(updated, first published June 2003) Journal of
Human Nutrition and Dietetics 17,337-349
9. Nutritional Subcommittee of the Diabetes Care
Advisory Committee of Diabetes UK (2003). The
implementation of nutritional advice for people
with Diabetes. Diabetic Medicine, 20 786-807.
10.Bucher et al. (2002) N-3 polyunsaturated fatty acids
in coronary heart disease: a meta-analysis of
randomised controlled trials. American Journal of
Medicine, 112: 298-304
11.Farmer A, MontoriV, Dinneen S, Clar C. Fish oil in
people with type II diabetes mellitus (Cochrane
Review). In the Cochrane Library, Issues 2,2004.
Chichester, UK: John Wiley & Sons, Ltd.
12.Scottish Intercollegiate Guidelines Network (SIGN)
(1996) Lipids and the primary prevention of
coronary heart disease. SIGN publication no.40
13.Department fo Health (2000). National Service
Framework for Coronary Heart Disease – Chapter 7
Cardiac Rehabilitation. London Department of
Health.
14.Wood D, Durrington P, Poulter N, et al. Joint British
Recommendations on prevention of coronary heart
disease in clinical practice. Heart; 80: S1-S29
15.Department of Health (2000) – National Service
Framework for Coronary Heart Disease – Chapter 2
Preventing Coronary Heart Disease in High Risk
Patients, London: Department of Health.
16.Scottish Intercollegiate Guidelines Network (SIGN)
(1996) Lipids and the primary prevention of
coronary heart disease. SIGN publication no. 40
17.Ha, T. K. K. and Lean, M. E. J. Technical Review:
Recommendations for the Nutritional Management
of Patients with Diabetes Mellitus. European
Journal of Clinical Nutrition (1998) 52, 467 - 481.
11
Nutritional Management
of Chronic Diseases
APPENDIX 1
National Obesity Forum
Guidelines on management of adult obesity and overweight in Primary Care
Obesity and overweight can be managed in Primary Care by a motivated well-informed multi-disciplinary team. The aim of
treatment is to achieve and maintain weight loss by promoting sustainable changes in lifestyle.
Patient selection: Most patients attending diabetic or cardiovascular clinics will automatically be candidates for weight
management. Other patients may be picked up by practice audit, opportunistic screening or self-referral. Posters and leaflets
should be available in the surgery and community for the education of patients.
Treatment groups:
Treatment or advice should be offered to:
l
Patients with BMI >30
l
Patients with BMI >28 with co-morbidities, e.g. COAD, ischaemic heart disease
l
Patients with any degree of overweight coinciding with diabetes, other severe risk factors or serious disease.
l
Patients who self-refer, where appropriate.
l
Parents of families with more than one obese or overweight member may need special consideration and more intensive
support.
l
Prevention advice should be offered to high risk individuals e.g. those with a family history of obesity, smokers, people with
learning disabilities, low income groups.
History: including personal medical history, family history, social history, past history of dieting, readiness to change, barriers to
change and current diet and levels of activity.
Investigations:
To isolate any medical pathology,
Act as a baseline for future measurements,
Exclude any secondary conditions or co-morbidities,
Reassure patients that there is no reason why they cannot lose weight.
Height, weight, BMI ( > 25 overweight, > 30 clinically obese), waist circumference (>102cm for men, >88cm for women lead to
substantially increased health risk), blood pressure, urinalysis and blood tests if appropriate: consider U&Es TFTs, LFTs, fasting
Blood Glucose, fasting lipids, hormone profile including sex hormones and cortisol. Other tests should be carried out as dictated
by co-morbidities, e.g. CXR, ecg, glucose tolerance test, HbA1c, creatinine clearance.
Bio Impedance Analysis: is an indirect measure of fatness and can be unreliable in e.g. children and athletes. Bioelectrical
Impedance Analysis can be used to measure body fat and lean tissue mass; it is reliable and accurate, and can be motivational in
patients who become more active and improve their body composition. It is assessed with an inexpensive stand-on body
composition analyser.
Primary Care Teamwork: After initial assessment, management should involve as many members of the primary care team as
possible, according to availability (including doctors, nurses, dietitian, counsellor etc) to provide support and advice and weight
loss and its long-term maintenance. Information on local facilities for exercise and physical activity, relevant support groups and
weight management groups should be made available. It is essential that each member of the team gives consistent advice, and
has a positive approach.
Treatment: Parents and families; it is important to give special consideration to situations where parents and other family
members are obese or overweight. Parents are important role models for their children, but the child may be the catalyst for
change within the whole family. Successful interventions involve the whole family, and the children and/or adolescents, and
family should be willing and motivated to make lifestyle changes. Weight maintenance should be addressed at the start of any
weight management programme and support for any weight loss achieved should be offered on a long-term basis. Obesity is a
chronic condition and its management should be lifelong.
Goals: Aim for 10% weight loss in 3 months to achieve significant health benefits. 5-10% has also been shown to produce
measurable health outcomes. Any weight loss should be encouraged and for some weight maintenance, rather than weight
gain may be a realistic goal.
12
Nutritional Management
of Chronic Diseases
First line: The aim is to achieve a 600Kcal deficit of energy/day requirements through changes in diet and physical
activity.
l
Support and encouragement e.g. weight management clinics either within primary care or commercially run. Targets,
treatments and expectations should be agreed with patients, eg 0.5kg per week, or 10% maintained weight loss rather than
‘ideal weight’. Advice about co-existing risk factors e.g. alcohol, smoking, hyperlipidaemias. Regular follow-up
appointments with initially monthly, then 1-3 monthly for 1 year, to help maintain weight loss.
l
Permanent sustainable lifestyle changes: some activity every day; less television, computer games and sedentary lifestyles;
more exercise; 30-40 minutes sustained exercise; e.g. brisk walking, swimming or cycling, at least 5 days per week.
l
More exercise during daily routine; use stairs instead of lifts; walk to work, or park the car further away from work place;
take a walk during lunch break. Gardening, washing the car, and activities around the home should be encouraged.
l
Encourage activity as a whole family; e.g. walks or trips to the park for relaxation.
Dietary changes:
l
Establish regular meals, including breakfast & encourage healthy eating for long term weight management.
l
Reduce dietary fat; avoid fried food; encourage grilled, boiled or baked. Buy lean cuts of meat; avoid crisps, pies, cakes,
biscuits. Use semi-skimmed milk and low fat spreads.
l
Encourage healthy snacks e.g. fruit as alternatives to sweets, chocolates or crisps.
l
Provide advice to patients about food labelling.
l
Encourage self-monitoring i.e. food diaries to enable patient to establish areas for change. Suggested changes need to be
tailored to the individual. Giving standard diet sheets is rarely effective.
l
Use locally approved advice sheets to ensure consistency of messages. Contact local dietetic departments for guidance.
Other Dietary Options:
l
Meal Replacements provide a suitable option for some patients. These are structured diet plans normally involving the
consumption of two meal replacement drinks per day, plus a self prepared evening meal, fruit and vegetables, totalling
approximately 1200-1400kcal daily. They are purchased from supermarkets and pharmacies.
l
VLCDs (diets containing less than 800 kcals) should only be used under close medical and dietetic supervision.
Success of the first line treatment is gauged after 3-6 months by reduction of BMI, weight reduction (e.g. 5-10% or waist
reduction 5-10cm), improvement of symptoms, or reduced markers of co-morbidity (e.g. exercise tolerance or blood sugar). if these
criteria are not achieved, second line treatment should be considered:
Drug treatment:
l
The pancreatic lipase inhibitor Orlistat may be used in conjunction with a low fat diet to achieve more rapid and greater
weight loss. Patients must lose 2.5 kg prior to treatment and demonstrate a 5% reduction in weight in 3 months and 10%
in 6 months to comply with licensing and NICE guidelines. It is not absorbed from the gut, and is therefore free from
systemic side effects however patients eating inappropriate high amounts of dietary fat may experiences oily bowel motions,
flatulence or leakage.
l
Sibutamine inhibits reuptake of seretonin and noradrenaline, which control food intake. It has been shown to be an effective
aid to weight reduction and maintenance. It helps patients feel satisfied with smaller portions of food, so that they eat less.
It is contraindicated in patients with high or poorly controlled blood pressure (>145/90) or significant cardiovascular disease.
BP must be checked initially at 2 weekly intervals for 3 months. Patients must show 2 kg loss at 4 weeks and 5% at 3
months in order to continue treatment.
l
According to their licenses and the NICE guidelines, Sibutramine and Orlistat are indicated for the promotion of weight loss
as an adjunctive therapy within a weight management programme for patients with nutritional obesity and a BMI of
30Kg/m2 or higher, or for patients with BMI of 28Kg/m2 or higher (27Kg/m2 for Sibutramine), if other obesity related risk
factors are present.
Other therapies:
l
Behavioural therapy. Alternative treatments, including acupuncture and hypnotherapy.
l
Referral to hospital obesity clinic when insufficient weight loss achieved, particular when BMI>40, or >35 + co-morbidities,
or in presence of uncontrolled complications.
l
Bariatric Surgery can be extremely successful, but is only indicated in the severely obese; someone who is >100% above
their ideal weight; has a BMI>40 or is at immediate risk of serious medical complications. An increasingly common
procedure is the adjustable laparoscopic gastric band. By this method the functional capacity of the stomach is permanently
reduced by the partitioning off of a small segment of the body of the stomach, in order to reduce food intake. Older
methods, including the ‘Roux-en-Y’ technique, surgically bypass the stomach, thereby combining malabsorption of food
with restriction of the capacity of the stomach.
13
Nutritional Management
of Chronic Diseases
APPENDIX 2
WAIST AND BMI
Measurement of Obesity
Obesity is classified using the Body Mass Index (BMI), a simple index of weight for height. The index is measured
by the formula:
BMI = weight (in kg) divided by height (in m2).
Classification*
BMI (kg/m2)
Asian-Pacific*
BMI (kg/m2)
Caucasian
Risk of co-morbidities
Underweight
<18.5kg/m2
<18.5 kg/m2
Low (but risk of other
clinical problems increased)
Normal Weight
18.5-22.9 kg/m2
18.5-24.9kg/m2
Average
Overweight
23.0-24.9 kg/m2
25-29.9kg/m2
Mildly increased
Obese class l
25.0-29.9 kg/m2
30-34.9kg/m2
Moderate
Obese class ll
> 30.0 kg/m2
35-39.9kg/m2
Severe
Obese class lll
> 35.0 kg/m2
>40kg/m2
Very severe
Adapted from International Diabetes Institute
13
*classification is under review by WHO. Suggested further public health action points along the continuum of BMI 14.
Interpretation of BMI is limited because it does not account for differences in size of body frame, proportion of
lean mass, gender, and ethnicity and age (University of York, 1997). WHO are preparing evidence to redefine BMI
for different ethnic groups.
Fat Distribution and Waist Measurement
The waist-hip ratio has been the traditional method of identifying people with increased risk due to the
accumulation of excess intra-abdominal fat. Research suggests that the measurement of waist circumference
alone is preferable and best reflects the intra-abdominal fat mass without any need to adjust for height. The
waist circumference is measured at the halfway point between the superior iliac crest and the rib cage in the
midaxillary line.9 Women are at equivalent absolute risk to men of coronary heart disease, at the same value
waist-hip ratio.
The following levels are sex-specific and indicate enhanced relative risk:
Gender /ethnicity
Increased Risk
Substantial Risk
Non - Asian Men
= 37inches)
à 94 cm ( ö
= 40 inches)
à 102 cm ( ö
(ö
= 36 inches)
à 90 cm
= 32 inches)
à 80 cm ( ö
à 88 cm
à 80 cm
Asian Men
Non - Asian Women
Asian Women
(ö
= 35 inches)
= 32inches)
(ö
(From: SIGN Guidelines, 1996)9
Excess fat that is found in the stomach region is often associated with heart disease, diabetes and some types of
cancer. Individuals with this type of fat distribution are commonly referred to as being ‘apple shape’. Excess fat
which is found under the skin, around buttocks, hips and thighs is generally accepted to be less harmful to health
and these individuals are said to have a ‘pear shape’ (Ashwell, 2000). Therefore BMI should be used as a broad
indicator and waist circumference used to give measurement of cardio-vascular disease risk.
14
Nutritional Management
of Chronic Diseases
APPENDIX 3
Techniques of behaviour modification for weight management (adapted from Brownell 1997)
1.
STIMULUS CONTROL
Shopping:
Shop for food only on a full stomach
Shop from a list
Only buy appropriate foods
Avoid ready-to-eat foods
Only carry the amount of cash needed for foods on the
shopping list
3.
Slow rate of eating
Take one small bite at a time.
Chew food thoroughly before swallowing
Put fork down between mouthfuls
4.
Plans:
Plan to limit food intake
Pre-plan meals and snacks
Substitute exercise for snacking
Eat meals and snacks at scheduled times
Do not accept food offered by others.
Activities:
Use graphs, cartoons, pictures, etc., to remind yourself to
eat properly.
Make nutritionally acceptable foods as attractive as possible
in preparation and presentation.
Remove inappropriate foods from the house
Store problem foods out of sight
Keep healthier foods visible
Eat all food in the same place
Remove food from inappropriate storage areas in the house.
5.
PHYSICAL ACTIVITY
Lifestyle activity:
Increase lifestyle activity
Increase use of stairs
Walk where you would normally use a bus or a car
Keep a record of frequency, intensity and duration of time
walking each day
Exercise:
Start a mild exercise programme
Keep a record of daily exercise
Increase the amount of exercise very gradually
7.
COGNITIVE RESTRUCTURING
Develop realistic expectations for weight loss
Set reasonable, realistic weight-loss and behaviour change
goals
Focus on progress, not shortcomings
Avoid imperatives such as ‘always’ or ‘never’
Keep a record of thoughts about self and weight
Challenge and counter self-defeating thoughts with positive
thoughts
SELF-MONITORING
Keep a dietary diary that includes:
Time and place of eating
Type and amount of food
Who else (if anyone) is present
How you felt before eating
Activities that you are doing at the same-time
Calorie or/and fat content of foods
Examines patterns in your eating
NUTRITION EDUCATION
Use self-monitoring diary to identify problem areas
Make small changes that can be continued
Eat a well-balanced diet according to the Balance of Good
Health
Learn nutrition values of foods
Decrease fat intake, increase complex carbohydrate intake
6.
2.
REWARDS
Solicit help from family and friends
Ask family and friends to provide this help in the form of
praise and material rewards
Clearly define behaviours to be rewarded
Use of self-monitoring records as basis for rewards
Plan specific rewards for specific behaviours
Gradually make rewards more difficult to achieve
Serving Food:
Keep serving dishes off the table
Use smaller dishes and utensils
Avoid being the food server
Serve and eat one portion at a time
Leave the table immediately after eating
Save leftovers for another meal instead of finishing what is
on your plate.
Holidays and parties:
Prepare in advance what you will do
Drink fewer alcoholic beverages
Plan eating habits before parties
Eat a low-calorie snack before parties
Practice polite ways to decline food
Do not be discouraged by an occasional setback
EATING BEHAVIOUR
8.
RELAPSE
Learn to see lapses as opportunities to learn more about
behaviour change
Identify triggers for lapsing
Plan in advance how to prevent lapses
Generate a list of coping strategies in high-risk situations
Distinguish hunger from cravings
Make a list of activities to do which make it impossible to
give in to cravings
Confront or ignore cravings
Outlast urges to eat
15
Nutritional Management
of Chronic Diseases
APPENDIX 4
SIGNIFICANT CO MORBIDITIES ASSOCIATED WITH OBESITY
Being overweight is associated with a number of co-morbidities caused by metabolic complications and/or the
excess weight itself
Complications of excess weight are:
hyperlipidaemia (and low HDL)
type 2 diabetes
metabolic syndrome
increased blood pressure
coronary heart disease
breathlessness, respiratory disease, sleep apnoea
stroke
gout
weight-related muscoskeletal disorders and arthritis (especially weight bearing joints)
cancers : postmenopausal breast, endometrial, ovarian, gallbladder, prostate and colon cancers
menstrual abnormalities (PCOS) and hirtuism
gallstones (especially in women, and non-alcoholic staetohepatitis(fatty liver))
pregnancy complications: increased risk of neural defects, perinatal mortality, hypertension, toxaemia,
gestational diabetes, preterm labour, caesarean, hospitalisation.
stress incontinence
psychological :social isolation, low self esteem, depression, binge eating, night eating, and reduced
employment prospects
disability
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
Relative risks
Greatly Increased
Moderately Increased
Slightly Increased
(Relative Risk >>3)
(Relative Risk 2-3)
(Relative Risk 1-2)
Dyslipidaemia
Coronary Heart Disease
Cancer
Metabolic Syndrome
Hypertension
Impaired Fertility
Breathlessness
Osteoarthritis (hips/knees)
Low back pain
Sleep apnoea
Gout
Reproductive hormone
Type 2 Diabetes
16
Imbalance
Nutritional Management
of Chronic Diseases
APPENDIX 5
Benefits of 10 kg weight loss in a 100 kg subject (Jung 1997)
Mortality
20 - 25 % decrease in premature mortality
Blood Pressure
10 mmHg decrease in systolic pressure
20 mmHg decrease in diastolic pressure
Lipids
10% decrease in total cholesterol
15% decrease in LDL - cholesterol
8% increase in HDL - cholesterol
30% decrease in triglycerides
Diabetes
Reduces risk of developing type 2 diabetes by 50%
30 - 50% decrease in elevated blood glucose
15% decrease in HbA1C
LDL: low density lipoprotein: HDL: high-density lipoprotein: HbA1C:- glycosylated haemoglobin
17
Nutritional Management
of Chronic Diseases
APPENDIX 6
VERY LOW CALORIE DIETS (VLCD) AND MEAL REPLACEMENTS
For additional information see position paper on Dietitians in Obesity Management Website. www.domuk.org
Meal Replacements
What is a Meal Replacement approach?
There have been various interpretations of what is meant by ‘meal replacements’. A recently devised working
definition states that meal replacements are ‘portion controlled products which are vitamin and mineral fortified
and replace one or two meals in the day allowing one low calorie meal using standard foods [and snacks]. This
combination of food-based meals and portion controlled liquid shakes, bars or other replacement products is
sometimes referred to as a partial meal replacement plan.
This approach provides an energy intake of approximately 1200-1600kcal/day and should not be confused with
very low calorie diets that provide less than 800 kcal/day and are designed to be the sole source of complete
nutrition.
Recommendations for use
Current research evidence does support the inclusion of meal replacement approaches as one of a range of
possible dietary treatments for overweight and obesity. It is recognised that little is known about the value of
unsupported, ‘off the shelf’ use of meal replacements products as most of the research has evaluated this approach
as part of comprehensive programmes with health professional support.
Meal replacements have been found to as effective as traditional dietary treatments in the short term with long
term follow up suggesting this approach may encourage weight maintenance. None of the research published to
date suggests any adverse effect of using this treatment. The commonly held belief that meal replacements are
only helpful in the short term does not seem to be supported by current research.
Who does this type of dietary treatment suit?
At present it isn’t possible to predict who does best with this kind of approach. However, it might be an option to
suggest if a patient:
l
l
l
Has tried and failed to lose weight using more traditional dietary treatments
or
Have difficulty trying to prepare meals
or
Struggle to control or understand portion sizes
Very Low Calorie Diets
What is a very low calorie diet VLCD?
l
800 kcal/day
l
Fortified liquid meals, sole source of nutrition, used fro 8 – 16 weeks in morbidly obese clients who have not
responded to other more conventional approaches.
Recommendations for use
The evidence suggests VLCD can be effective for short term use if used under close supervision of obesity
specialists and a comprehensive behavioural and lifestyle approach is used along side them. Long term follow up
and support is essential.
Who does this type of dietary treatment suit?
VLCDs are generally reserved for use by those with morbid obesity for who rapid weight loss is required.
There clearly is a strong need for education and support on healthy food choices at times when replacement
products are not being used, and for ongoing weight loss maintenance.
Based on DOM UK position statement March 2005
18
Nutritional Management
of Chronic Diseases
APPENDIX 7
PHARMOCOTHERAPY / DRUG TREATMENT OF OBESITY
Orlistat (Xenical)
l
Pancreatic lipase inhibitor to be used in conjunction with a low fat diet. Reduces the amount of fat absorbed
by approximately 30% with a dose of 120mg, to be taken 3 times a day with meals.
l
Licensed BMI>30 or BMI> 28 with co morbidities.
l
As the drug is not absorbed from the gut there are no systemic side effects, although some patients
experience oily bowel motions, flatulence and leakage.
l
Patients should be followed up monthly by GP or practice nurse, and encouraged to use the company’s
support package (MAP).
l
Should demonstrate a 5% reduction in weight within 3 months and 10% within 6 months, otherwise
treatment may be discontinued.
l
However it is recognised that treatment may need to be continued in the long term for weight maintenance,
as rebound weight gain usually occurs on discontinuation.
Reductil (Sibutramine)
l
Inhibits re-uptake of serotonin and noradrenaline which controls food intake/appetite.
l
Centrally acting satiety enhancer with doses of 10/15mg o.d (increased to 15mg if less than 2kg wt loss at 4
weeks).
l
Licensed BMI>30 or BMI> 27 with co morbidites.
l
Use in conjunction with calorie controlled diet, so encourage use of company support package (Change for
Life).
l
Patients should lose 2.5 kg at 4 weeks prior, but not essential.
l
Patients must lose 5% at 3 months, otherwise treatment should be discontinued.
l
Contraindicated in patients with high blood pressure 145/90 or significant cardiovascular disease.
l
Follow up at 2 weekly intervals for 3 months, to check BP.
l
Currently licensed for 2 years.
Rimonabant
l
Recommended as an adjunct to diet and exercise for adults who are obese or overweight and who have had
an inadequate response to, are intolerant of or are contraindicated to Orlistat and Sibutramine.
l
Treatment should be continued beyond 6 months only if the person has lost 5% of their initial body weight
since starting treatment.
l
Should be discontinued if a person returns to original weight whilst on Rimonabant treatment.
l
Should not be continued for longer than 2 years without a formal clinical assessment and discussion of the
individual risks and benefits with the receiving patient.
l
In 2008 NICE temporarily withdrew it's guidance on the use of Rimonabant for the treatment of overweight
and obese patients as a result of the European Medicines Agency's (EMA) recommendation to suspend
marketing authorisation for Rimonabant.
19
Nutritional Management
of Chronic Diseases
APPENDIX 8
INCREASING OMEGA-3 FAT INTAKE:
EVIDENCE FOR DIFFERENT SOURCES
l
Please refer to resource (Heart Disease and omega-3’s) produced by the BDA.
l
Oily fish should be first advice for increasing omega-3 intake.
l
If oily fish not taken, the next best evidence for omega-3’s is fish oil supplements (0.5-1.0g omega-3
DHA/EPA per day).
l
If patients do not want to or will not take fish oil supplements, then suggest patients use rapeseed oil in
cooking and a rapeseed/olive margarine as a spread and suggest plant based omega-3 fat sources.
l
Plant based omega-3 sources (and or vegetarian supplements) should be recommended for vegetarians and
vegans. Although their effectiveness is unclear and the scientific evidence for reducing mortality is not the
same as for fish oil supplements.
20
Nutritional Management
of Chronic Diseases
APPENDIX 9
GLYCAEMIC INDEX AND DIABETES
Starchy carbohydrate foods should be included at each meal as part of your balanced diet. Carbohydrate foods are
sugars and starches and these foods affect blood glucose levels in different ways.
Some foods can cause a sharp rise, whilst other produce a slow, more gentle rise in blood glucose levels. This is
called the Glycaemic Index (GI) of a food.
Foods with low GI have a better effect on overall blood glucose levels, so including these foods in the diet regularly
can help to improve the control of your blood glucose.
Use the following list to choose carbohydrate foods that produce a slow rise in blood glucose levels. Remember all
starchy carbohydrate foods are good, but some are better than other.
NB - the GI should not be used alone but as part of an overall healthy balanced diet.
GOOD
BETTER
BEST
Breads
High fibre white breads
e.g. Champion White bread
Bagel
Crumpets
Pitta bread
Wholemeal bread
Coarse mixed grain breads
Granary bread
Fruit/raisin bread
Rye bread
Pumpernickel
Cereal Foods
Rice Krispies
Cornflakes
Puffed wheat
Cheerios
Bran flakes
Instant oats
Weetabix
Shredded wheat
Mini wheats
Untoasted muesli, no added sugar
Porridge
Rolled oats
All bran
Toasted muesli
Sultana Bran
Special K
All types of pasta and noodles
White rice
Brown rice
Old potato - baked, boiled
mashed, instant, wedges
Biscuits
Morning coffee
Water biscuits
Rice cakes
Crisp bread
Vegetables
Parsnip
Swede
Coucous
Taco shells
Semolina
Basmati rice
Gnocchi
New potato, boiled
Sweet potato - boiled yam
Digestives*
Arrowroot biscuits
Ryvita
Oatmeal biscuits*
Rich tea biscuits
Oatcakes
Ritz
Beetroot
Sweet corn, broccoli, cabbage,
cauliflower, green beans,
green peas, tomato
Pulses/legumes, baked beans,
lima beans, chick peas, split peas,
lentils, haricot beans, kidney
beans, soya beans, pearl barley.
21
Nutritional Management
of Chronic Diseases
GOOD
Fruit
Watermelon
BETTER
BEST
Banana (over ripe), cantaloupe
melon, sultanas, pineapple, papaya,
fresh apricots, mango juice
(unsweetened)
Banana (firm/just ripe), apple,
cherries, grapes, grapefruit, kiwi
fruit, mango, oranges, pear,
peaches, plums, dried apricots,
dried apple, small glass of apple
juice, pineapple juice, grapefruit
juice
Tea cakes*
Sponge cake*
Low fat milk shake, yoghurt (low
sugar/diet). Fruit from the ‘best’
column above
Banana cake*
Oatmeal biscuits*, rich tea, potato
crisps*, peanuts*, low fat popcorn.
Snack Foods
Those foods marked with an asterisk (*) can be high in fat and should only be eaten in small
amounts if you are overweight.
APPENDIX 10
ALCOHOL
Alcohol is high in calories and is therefore associated with weight gain. It is also a risk factor for cardiovascular
disease and increases the risks of developing certain cancers. Advice for the general population is to limit alcohol
consumption to no more than 2-3 units a day for women and 3-4 units a day for men (with 1-2 alcohol-free days
each week).
People with diabetes are advised to limit alcohol consumption. The following recommendations apply specifically
to people with diabetes:
1-2 units a day for women
2-3 units a day for men
With 1-2 alcohol-free days each week
Examples of the alcohol unit contents of difference drinks are shown below:
125ml glass of wine (12% ABV)
1.5 units
175ml glass of wine (12% ABV)
2 units
1 pint of ordinary strength beer, lager or cider (3.5%)
2 units
1 pint of strong beer or lager (5%)
3 units
30ml measure of spirits (40%)
1.2 units
The website www.drinkaware.co.uk has detailed information about the alcohol content of different drinks
together with advice and guidance.
22
Black and Minority
Ethnic Communities
CONTENTS
1. INTRODUCTION
1.1
1.2
Minority Ethnic Communities in Birmingham
Diet-related Inequality
2. SOUTH ASIAN COMMUNITIES
2.1
2.2
2.3
2.4
Religion and Culture
Food Preferences
Hot and Cold Foods
Key Dietary Messages
3. AFRICAN - CARIBBEAN COMMUNITIES
3.1
3.2
Food Preferences
Infant Feeding Practices
4. CHINESE COMMUNITIES
4.1
4.2
Food preferences
Yin and Yang Foods
5. JEWISH COMMUNITIES
5.1
Food preferences
6. OTHERS
7. REFERENCES
8. USEFUL WEBSITES
1
Black and Minority
Ethnic Communities
1.
INTRODUCTION
The nutritional recommendations detailed in other
sections of these Food and Health Guidelines also
apply to people from black and minority ethnic groups.
It is acknowledged that people from black and
minority ethnic backgrounds are a disadvantaged
group of the population in terms of health
(Department of Health, 1992; Balarajan and Raleigh
1995). Overall, the prevalence of disorders such as
heart disease, diabetes, hypertension, stroke and
mental illness tends to be high but, despite these
increased health needs, uptake of healthcare services
tends to be low. Health problems are often
compounded by factors such as poverty,
unemployment, poor housing, communication
difficulties and social isolation, particularly for women.
Many of these problems have nutritional implications.
There is enormous diversity in culture, traditions and
food habits both between and within different ethnic
groups and even within a single family. It is vital that
health professionals understand and are familiar with
these factors when offering dietary guidance. About
half of those of minority ethnic origin in the UK were
born in this country and as a result, western influences
on diet have affected traditional eating patterns to a
considerable extent. Some people eat a diet which is
no different from that of their indigenous peers.
Others, particularly older people, or those who have
recently immigrated, may still retain their traditional
eating practices.
30% of the Birmingham population is made up of
people from black and minority ethnic communities
based on the census of 2001. This is shown in the
diagram below:-
1.1 BLACK AND MINORITY ETHNIC GROUPS IN BIRMINGHAM - 2001
(National Statistics Website: www.statistics.gov.uk)
1.2
THERE IS CONSIDERABLE INFORMATION THAT SUGGESTS THAT SOME MINORITY ETHNIC
COMMUNITIES ARE PROPORTIONALLY OVER-AFFECTED BY HEALTH INEQUALITIES INCLUDING THOSE
RELATED TO DIETARY INTAKE.
For example:
l
l
2
Coronary Heart Disease (CHD) mortality is 46%
higher for men and 51% higher for women in
South Asians living in the UK than the average in
England and Wales.
West African and Black-Caribbean men and
women living in England and Wales have lower
l
l
CHD mortality rates than the average (half the rates
in men and two-thirds in women).
Stroke mortality rates are higher in South Asians,
West African and Black Caribbean men and women
than the average in England and Wales.
Babies whose mothers were born in the Indian subcontinent are on average 200gms lighter at birth
than those whose mothers were born in the UK.
Black and Minority
Ethnic Communities
Differences in eating habits, both cultural and religious,
can contribute to diet-related disease. For example:l
Bangladeshi men and women are more likely to eat
both red meat and fatty foods and less likely to eat
fruit than any other minority ethnic group. Pakistani
men and women have the lowest vegetable
consumption of minority ethnic groups. Chinese
men and women eat the most fruit and vegetables.
MUSLIMS
Islam is a major world religion. It lays down detailed
rules about social and religious behaviour. Muslims
believe in one God, Allah, and that Mohammed was
the last and greatest of his prophets. There are five
main duties of Islam:
l
l
l
The practice of adding salt to cooking is almost
universal between South Asian and Chinese groups
and is more common in Black Caribbean adults than
the general population.
l
l
l
Information in the following sections is intended to give
only general guidance about the general eating
patterns and food preferences of people from the most
common minority ethnic groups and religions.
Remember, when giving advice to an individual or
family about food and nutrition, it is important to tailor
the advice on their individual diet and preferences.
2.0 SOUTH ASIAN COMMUNITIES
RELIGION AND CULTURE
Name of religion:
Hinduism
Islam
Sikhism
Followers:
Hindus
Muslims
Sikhs
HINDUS
Hindus believe that all life is a continuous process, and
that all things are subject to reincarnation, birth, death
and rebirth. A person is born into his caste – the
division of society into different social levels, linked to
traditional occupations and to each person’s duty in
society. There are four main castes and within each
caste there are many sub-castes. For social, religious
and economic reasons people generally marry within
their own caste.
Although there are Hindu temples, most worship is
private. Worship is mostly performed at home, often at
a family shrine, which may be a special room that has
been set aside for prayer and devotion.
Belief in one God
Prayer five times a day
Giving two and a half percent of annual income to
charity
Fasting from sunrise to sunset during the month of
Ramzan (known as Ramadan)
Pilgrimage to Mecca
Strict Muslims will pray five times a day. Before praying
a Muslim will wash and there is a ritual procedure laid
down for this. Friday is the Muslim holy day. When
men and women attend the mosque together they do
not sit together.
The Muslim holy book is called the Koran/Quran and
must be treated with respect. Religious festivals include
Ramadan which takes place annually, Eids, of which
there are four or five a year, and other festivals.
SIKHS
Sikhism is a reformist sect of Hinduism, so Sikhs share
many of their beliefs and ideas with Hindus. However,
unlike the Hindus, they believe in one God. The caste
system is rejected as a matter of principle. Emphasis is
placed on the importance of actions and beliefs rather
than ritual. Every Sikh has a duty to play a practical
and useful role in society and to care for his or her
family.
Sikhs worship in a temple called a Gurdwara.
Communal worship is very important in Sikhism and the
Gurdwara is a focus of religious and community activity
Langar (free meal) is offered to everyone. Devout Sikh
families in Britain try to go to the Gurdwara on a
Sunday. The Sikh holy scriptures are called the Guru
Granth Sahib Ji; this is treated with great reverence and
is placed on a raised platform in the Gurudwara.
There are two important festivals: Holi, which is in
February/March and lasts three days, and Diwali in
October/November.
When a Hindu is dying, the priest will usually be asked
to perform the full rites by reading from the holy
Sanskrit scriptures.
3
Black and Minority
Ethnic Communities
The most important festivals are:
(1) Vaisakhi – Sikh New Year – this is celebrated by
prayer.
(2) The birthday of Guru Nanak Devji.
(3) Diwali – this is celebrated by prayer.
The five signs of Sikhism which unite and identify Sikhs
are
Kesh – uncut hair including the beard
Kangha – a wooden comb.
Kara – iron, steel or gold bangle
Kirpan – a small symbolic dagger religious
symbolic knife
Kaccha – special undershorts
the Indian Sub-Continent they or their family
originated from.
Most of the Asians in Birmingham will speak one of
the following languages:
INDIANS may speak either Gujarati, Punjabi or Hindi
PAKISTANIS may speak either Punjabi or a dialect of
Punjabi called Mirpuri, Urdu
BANGLADESHIS will speak Bengali, Hindi
What languages do South Asians speak?
There are several different languages spoken; the
language which is spoken depends on which part of
2.2 FOOD PREFERENCES
The table below gives specific details of the foods consumed by the main South Asian groups in Britain.
Country
Pakistan
Bangladesh
India
Punjab
Gujerat
Religion
Islam
Sikhism
Hinduism
Fasting
Ramadan
Sunrise to sunset. One lunar month
Variable
Birthday of deities up
to three days per week
Pork, non-‘halal’ meat and meat products
Alcohol
A matter of
personal choice
but sometimes
abstinence from
alcohol and beef
Beef, often all
meat is excluded
by choice. Sometimes
fish, often eggs
for women
Wheat as chapati
or paratha
Wheat sometimes
maize flour as
chapatti, paratha
or puri
Wheat, maize or
millet flour as
chapatti, paratha
or puri
Foods to be
avoided
Diet:
Main staple cereal
Meat, fish and
eggs
Pulses
Main fats
Predominantly lamb
or chicken, some
beef or goat,
occasionally liver
Dahl, often with
spinach, occasional use
of gram flour
Rice, generally
polished
Fish including
Predominantly lamb
Predominantly
shell fish, or chicken or chicken, sometimes
vegetables
or lamb, less
pork or fish.
meat; less
frequently offal
Eggs occasionally (not
frequently, chicken,
Eggs – fried,
eaten by strict
goat or lamb, and fish.
vegetarians)
hardboiled or omelette
Occasionally
Butter, ghee or oil
Dahl eaten regularly
Pulse mixtures
More general use of gram flour
Butter, oil or
margarine
Ghee or oil,
occasionally magarine
Fruit & vegetables
Less frequently
Turnip, swede, parsnips used often
Dairy products
Milk, yoghurt
Milk, yoghurt, curd cheese (paneer)
4
Black and Minority
Ethnic Communities
An example of what might constitute an evening meal
for a South Asian family is dahl, a meat or vegetable
dish, chapattis and/or rice, side salad, natural yoghurt,
pickle and fresh fruit.
Family structures could include the nuclear family, an
extended family or a joint family including the wives
and children of several of the sons of the family. In
their country of origin a South Asian family would
place great emphasis on getting together for a meal,
whether it be lunch or dinner. However, on settling in
the UK, lack of time and the availability of convenience
foods has meant that family meals are becoming less
common as in the indigenous population.
ASIAN FOOD - SUGGESTIONS FOR
HEALTHY EATING
Food or Method of Cooking
2.3 HOT AND COLD FOODS
In many communities around the world it is believed
that certain foods are “hot” whilst others are “cold”.
The hot or cold nature of foods bear no relation to the
temperature or the spiciness of the dish. It is believed
to be an inherent property of the food giving rise to
physical effects in the body. The belief in “hot “ and
“cold” foods is held to varying degrees by South
Asians.
Hot foods are said to excite the emotions, raise body
temperature and promote activity. These foods are
therefore used when someone has a ‘cold’ condition
such as depression or low blood pressure. Cold foods
are said to reduce body temperature and impart
cheerfulness and strength. Pregnancy is a hot
condition and therefore cold foods are eaten to
balance this.
Advice Suggested
STARCHY STAPLES
Chapattis
Flours used for chapatti
Medium-brown to wholemeal
Fat added to dough (oil/butter)
Try not to add any. Keep Chapattis soft by covering with a tea cloth
Butter/margarine/ghee – (clarified butter)
Spread onto surface of chapatti
Paratha eaten
Chapatti flour with butter inside,
folded and fried
Deep fried chapatti (puri)
Have dry chapattis or reduce amount of spread/butter
Reduce amount of fat in preparation, and try not to add any
after cooking
Very high in fat. Try not to have often
Limit to special occasions
Rice
White
Brown rice. Brown basmati is also available
Pilau rice (fried rice)
Very high in fat. Advise boiled more often
Biriyani
Very high in fat. Try to use low fat cooking methods
Potato
Cook with skins on when added to curry
PROTEINS
Meat/chicken
Try to cut all visible fat before cooking. Use low fat cooking
methods. Lamb keema (mince and peas) Skim fat from
surface when dish is made. If eaten daily try to
encourage to reduce frequency and substitute some days
with dahl/veg curry
Masala fish (fried) marinade
Try not to fry, bake in oven
Paneer (curd cheese)
Try not to fry. Put into low fat curries either scrambled or
just cut into cubes with frying. Make paneer with
semi-skimmed milk
5
Black and Minority
Ethnic Communities
PROTEINS
Eggs
Have boiled, poached or scrambled. Cut down on oil when
cooking in a curry and do not fry.
Dahl, chickpeas and channa
Use 1-2 tablespoons of oil. Try low fat cooking methods. Avoid
adding any butter at the table before eating. If vegetarian, try to have
dahl every day for iron. Vitamin C will help iron absorption; have
pure fruit juice or fruit after meal
Milk
Do not use gold top (Jersey) milk. If overweight advise to
have semi-skimmed or skimmed milk. Mention milk tastes thinner
but still full of the goodness
Yoghurt
Encourage to buy low fat or make at home with semi-skimmed milk.
Do not add fried gramflour balls (boondi). Add cucumber (raita)
and tomato instead
FRUIT AND VEGETABLES
Fruit
Generally recommend to contribute towards 5 a day and
spread these out. Where possible, eat with the skins
Fruit juice
1 glass of pure fruit juice = 1 portion of your 5 portions a day
Vegetables
Encourage low fat vegetable curry (subzee); try not to overcook
(this reduces nutrients) especially spinach (saag).
Encourage salad with meals
SNACK FOODS
Biscuits, cakes, pastry
Avoid sweet Pakistani rusks. Try to reduce frequency of biscuits
in general
Crisps, bhajis, pakoras, samosas,
chevra (Bombay mix)
Cut down, as these are very high in fat and salt. Best to have fresh
fruit. Limit fried foods. If frying, shallow-fry instead of deep-fat frying
and remove excess fat, using kitchen roll, or bake samosas in the
oven. Keep for special occasions. Try tea cakes, toast, crumpets and
malt loaf instead.
SUGARY FOODS
Asian sweets (barfi, jalebi and ladoo)
Try to avoid Asian sweets – save these only for special occasions.
If not overweight, can have puddings made with low fat milk and
artificial sweetener
Puddings; sevia, kheer, halva
Kheer – use semi-skimmed milk. Use sweetener for taste or dried fruit,
sultanas and raisins. In puddings – try margarine instead of ghee and
reduce the quantity. Save for special occasions
Squash/pop/cordial
Diet or low-cal, even if only having occasionally – try sugar-free drinks
Sweet paan
Avoid. Have savoury version instead
Sugar, honey, gurr (jaggary),
in sweet or savoury foods
Try to cut down on, or use artificial sweetener
e.g. Canderel, Sweetex
6
Black and Minority
Ethnic Communities
FATS USED
Butter, ghee (clarified butter), margarine
Use pure vegetable, sunflower or olive oil instead
of ghee or butter. Reduce the quantity used. Aim for 1-2 tablespoons
for a 4 person dish
Tea/coffee
Check the amount and type of milk used. Advise low fat milk.
Check if sugar, gurr or honey is added.
If necessary use artificial sweetener
Take-aways, weddings, parties, relatives
(weekends); Temple/place of worship.
Check type of food eaten and how often involved, and advise
accordingly
Pickle
Drain oil before eating
Examples of Hot and Cold Foods
l
Hot Foods
Ginger, garlic, nuts, almonds, ginger wine, brandy,
Gur/honey, coffee, grapes, karela, (a bitter gourd)
aubergine, lady fingers (okra), radish, spinach,
green chillies, fish, chicken, pork, meat, eggs, pigs
trotters, certain lentils (masoor dal), chocolate
l
Cold Foods
Orange juice, cucumber, rice, lassi, lentils, lemon,
sugar cane, kheer, cold water, chick peas, beans,
onion, spinach, banana
Weaning: good weaning practices may be
compromised by social disadvantage and the varying
quality, expense and availability of familiar Asian foods.
Late weaning and prolonged breastfeeding are
commonly practised with infants who have only been
in the UK for a short time. In the UK, late weaning
may be partly due to the poor availability of suitable
foods and lack of adequate and appropriate advice.
There is a tendency for Asian infants to be weaned on
sweet proprietary weaning foods, which are low in
protein and iron. For Muslims, this may be due to a
limited availability of halal baby food.
l
Mothers should be encouraged to cook savoury
weaning foods at home. Spices can be used but
should be limited to a small amount. Salt should be
avoided.
l
The practice of sweetening milk and adding foods
such as rusk, honey, Weetabix and baby rice to
bottles is common and should be discouraged.
Health professionals need to be aware that if they
recommend foods which people believe will be too hot
or cold for them, they are unlikely to follow advice.
2.4 INFANT FEEDING PRACTICES IN ASIAN
POPULATIONS
Breast Feeding: The incidence of breastfeeding is
much greater in the Indian Sub Continent than in
South Asian communities in the UK. There are several
reasons for low numbers of Asian mothers
breastfeeding.
l
Verbal communication is the basis for support,
hence non-English speaking mothers may be
denied this help, except in areas well supplied with
interpreters.
l
A mother in the UK may have to cope with
housework, shopping, cooking and other
responsibilities without the lying in period she
would have had in her country of origin.
l
Breastfeeding is not usually carried out in the
presence of men. Not all British homes are big
enough to provide separate rooms for men and
women in order to obtain the necessary privacy.
Therefore the mother may have to leave the living
room and retreat to her bedroom every time the
baby wants to feed.
7
Black and Minority
Ethnic Communities
3.0 AFRICAN-CARIBBEAN COMMUNITIES
The name African-Caribbean collectively refers to
people of African descent who come from the many
Caribbean islands.
The majority of people from the Caribbean moved to
the UK during the 1950’s and 1960’s, notably from
Jamaica.
Although African-Caribbean people are generally
Christian, there are many faiths in the Caribbean.
Main religions
which affect
dietary
practices
include
Seventh
Day
Adventism,
Rastafarianism
and Islam.
Seventh Day
Adventists –
became a separate
body after the expected
Second Coming of Christ
failed to be realised in 1844.
They believe that Christ’s coming is
imminent and observe Saturday
instead of Sunday as their Sabbath. Followers
are often vegetarian. If meat and fish are eaten,
pork is
avoided, as are fish without scales and fins.
Alcohol and other stimulants are avoided.
Dietary restrictions will depend upon the
individual.
Rastafarian - members are
originally of a Jamaican religion
that regards Ras Tafari, the former
emperor of Ethiopia, (Haile
Selassie), as God. Many are vegetarian
or vegan. The majority of followers will only
eat ‘ITAL’ foods, which are foods considered to be
in a whole and natural state. Processed or preserved
foods are excluded. Specific foods not consumed are
pork, fish without fins and scales, fruit of the vine and
stimulants. The degree of dietary restriction depends
upon the individual.
8
3.1
FOOD PREFERENCES OF AFRICAN CARIBBEAN COMMUNITIES
When discussing the Caribbean diet, it is important to
remember that the people of the Caribbean are
not a homogeneous group. Dietary practices of each
island have been influenced by different historical,
political, social and geographical factors. For example,
development of the sugar colonies
brought many cultures to the Caribbean. Hence dietary
practices will vary considerably and dishes with similar
or the same name can contain different ingredients.
An example of what might constitute a meal for an
African-Caribbean family is meat or fish, some type of
starchy root or green banana or both with 2 – 3
vegetables, chicken with rice/red peas and fried
plantain, and salad. Dumplings may be added
in addition, e.g. beef stew with vegetables
and dumplings. Usually there is no
dessert - maybe a fruit.
People tend to have one main meal a
day. Where the job allows, this is at
about 3 or 4pm, otherwise
at 6 - 7pm.
Black and Minority
Ethnic Communities
REGIONAL DIETS OF MAIN AFRICAN-CARIBBEAN GROUPS IN BRITAIN
FOOD AND DESCRIPTION
COOKING METHOD
USAGE
BREAD - often dense, hard dough bread
With or without spreading fat
Breakfast/lunch/snacks
CREAM CRACKERS
Snack eaten with cheese and spreading fat
BUN - flat round cake contains molasses
Snack eaten with cheese and spreading fat
ROTI - flat pancake made from
flour and water
Cooked on a hot
plate
Parties/festive occasions / everyday
Served with curry
FRITTERS - batter mixture often
contains saltfish
Deep fried
Breakfast/snack
May be taken with bread
DUMPLINGS - made with flour, salt or
sugar, baking powder and water.
Cornmeal may be added
Boiled or fried
Eaten with fish/meat/vegetables
Fried: used as snack
Boiled: used in one pot meals
MACARONI - may have sauce or milk,
cheese, eggs, onions, flour and fat
Boiled/baked in the oven Macaroni cheese. Usually eaten in
combination with a rice dish
YELLOW CORNFLOUR - made from ground
corn. Fine or coarse texture.
Boiled with water.
‘Turned’ cornmeal
(boiled with water,
seasoning, pepper,
onion etc.until
thickened). Used with
wheat flour to make
dumplings
Weaning food or porridge
Eaten with meat or vegetables
RICE - white or brown , polished, par-boiled Boiled
Large amounts taken, sometimes with
added butter, margarine, coconut cream,
beans
STARCHY ROOT VEGETABLES (can also be
called provisions) - Yams, eddoe, sweet
potato, potato, cassava, tannia, dasheen
Boiled, baked, roasted,
mashed or creamed
Usually the main part of meal. Eaten with
protein foods and vegetables. More than
one usually taken at a meal. Added to soup
(one-pot meals). Made into puddings,
e.g. sweet potato pudding
STARCHY FRUITS - green banana, plantain,
and breadfruit.
Boiled, baked. Plantain
sometimes fried
Main part of a meal
Plantain sometimes used for breakfast,
soups, and stews
Boiled/steamed
VEGETABLES - callaloo, karela, kale,
spinach, dasheen leaves, pumpkin, pak choi, / stir fried
okra, eggplant, christophene (chocho)
Fresh vegetables preferred. Used in soups
and stews. Carrots may be grated and juice
combined with water and condensed
milk to make a drink known as carrot juice
PULSES (usually dried) - pigeon/gungo peas, Soaked as necessary.
cowpeas, lima, or sugar beans, chick peas, Boiled
split peas, red kidney beans.
Added to soups and stews. May be eaten
in combination with rice when described as
‘rice and peas’
9
Black and Minority
Ethnic Communities
FOOD AND DESCRIPTION
COOKING METHOD
USAGE
FRUIT - bananas, mango, melon, orange,
paw paw, limes, sugar apple (sweetsop)
star apple, otaheite, avocado, and ackee.
Usually eaten fresh.
Can be used to make ice cream, pudding,
juices, punches, jams and jellies. Some are
imported and therefore very expensive.
Avocados and ackee are fruits commonly
used as vegetables. Avocado sometimes
called pear. Ackee served with salt fish.
MEAT - Pork, beef, lamb, mutton, goat,
rabbit. All cuts of meat may be consumed.
Many traditional dishes use offal, tails,
hides, feet and heads.
Meat is usually marinated Eaten with cereals or staple
or seasoned before
starches, particularly rice.
cooking. Stewed, curried,
roasted, steamed, fried
and very occasionally
grilled. Often browned
by frying or with the
use of burnt sugar.
POULTRY - Mainly chicken
As above
As above
FISH - All types eaten, i.e. Snappers,
Fried, steamed, stewed
mackerel, flying fish, coley, mullet, salted fish salad and baked.
Fish served with vegetables and
staple starches.
Salt fish eaten with ackee or dumplings
DAIRY PRODUCTS - Milk: fresh or tinned
(evaporated, condensed).
Cheese: natural or processed.
Dairy products are not used in large amounts.
Used in drinks and puddings, condensed
used in preference to fresh milk.
Cheese often used as a snack with cream
crackers, bread or bun.
FATS AND OILS - Vegetable, coconut, olive,
\red palm oil, lard, butter, margarine.
Used for frying, steaming and roasting etc.
Red palm oil is often used to give flavouring
and colouring to particular foods.
EGGS
Fried, scrambled, boiled, Cakes, puddings, salads, garnishes,
occasionally as an
macaroni based dishes, fritters etc.
omelette.
NUTS - Cashew, peanut, almond, red palm,
coconut (and coconut cream)
Snacks
Coconut cream added to soups, rice and
peas, cornmeal puddings etc.
SEEDS - Pumpkin, watermelon,
sesame, guinea.
Added to curries.
Eaten as snacks.
DRINKS - Fruit juices e.g. orange, mango,
and pineapple. Herbal teas - sweetened.
Malted drinks or hot chocolate.
Milk - based energy drinks. Non alcoholic
malt drinks. Glucose energy drinks. Home
made juices, i.e. lime juice sweetened with
sugar. Carrot juice punch (carrot, tinned
milk, nutmeg, sugar). ‘Punch’ (Stout,
tinned milk, sugar, nutmeg, raw egg).
10
Black and Minority
Ethnic Communities
3.2 INFANT FEEDING PRACTICES IN THE
AFRICAN-CARIBBEAN POPULATION
l
Breast-feeding: in the Caribbean 90% of women
breast feed their babies initially, however this is
often short lived and exclusive breast-feeding is
rare. The large-scale marketing of infant formula
and the early return of women to work are
implicated in early cessation.
l
Weaning: infants are traditionally weaned as early
as 1 month of age and 45% are reported to be
receiving food by 3 months. In contrast late
weaning is commonly observed in the orthodox
Rastafarian population. Common weaning foods
include high starch foods such as cornmeal, oat or
rice porridge. Infants then need to move onto a
variety of foods. - See Under Fives section.
4.0
4.0 CHINESE COMMUNITIES
CHINESE COMMUNITIES
4.1
4.2
‘yang’ (hot).
‘Yin’ and ‘Yang’ foods
Diet plays an important role in helping
individuals maintain a normal healthy balance in
their body and to correct imbalances. Some
foods have ‘heating’ (yang) properties and
others have ‘cooling’ (yin) properties. Other
foods are considered neutral. It must be
remembered that the ‘hot’/yang and ‘cold’/yin
terminology is independent of actual
temperature of the food when it is eaten, or
thermal heating properties. A typical meal
consists of rice, some meat or fish, vegetables
and soup. Soups can be part of the main course
or eaten on their own. People tend to have
breakfast and two main meals.
All dishes are served together. Eggs, meat, fish
and vegetable dishes, or their combinations are
served in individual dishes, for people to serve
themselves. Rice is served in individual rice
bowls.
Most of the Chinese in Britain originate from
Hong Kong (rural and urban areas) and others
come from South China. Many Chinese people
came to Britain during the 1950’s, but most
Chinese immigrants came after 1962 to work in
the catering trade.
In traditional Chinese medicine, good health
depends on maintaining a balance in the body
of two opposite elements ‘yin’ (cold) and
Hot Foods (‘Yang’)
Neutral Foods (‘Yin Yang’)
Cold Foods (‘Yin’)
Meat
Oily fish
Herbs
Alcoholic drinks
Ginger
Pepper
Spices
Oils and fats
Foods which produce ‘yang’ energies
tend to be spicy, high calorie, oily,
fried or foods strong in flavour
Mangoes
Pineapples
White fish
Rice
Bread
Some vegetables
Beancurd
Papaya
Orange
Some fruits and vegetables.
Foods which produce ‘yin’ energies
are usually thin, bland, watery
or low in calories
(Most fruits, barley water and
some herbal teas)
11
Black and Minority
Ethnic Communities
5.0 JEWISH COMMUNITIES
5.1 FOOD PREFERENCES
7.0 REFERENCES
Acheson D (1998) Independent Inquiry into Inequalities
in Health Report. London Stationary Office.
Judaism is an ancient religion. Many people of the
Jewish faith have been born in Britain of families which
have been here for several generations.
Balarajan R, Raleigh V,S. (1995).Ethnicity and Health in
England HMSO London.
Most have come from Europe and some from the
Middle East.
Department of Health (1992). Health of the Nation.
A Strategy for Health in England. HMSO London.
Dietary laws are fundamental to the Jewish religion.
Orthodox Jewish people follow strictly the dietary laws
and customs of Kasrut.
British Heart Foundation (1997). A Taste of Low Fat
Asian Foods, Healthy Recipes for a Healthy Heart.
A basic law of Kasrut is that meat and milk foods must
be kept apart in cooking and eating.
All utensils used in the preparation, cooking and
serving of either product must be washed and kept
separate. e.g. crockery, cupboards, ovens, tablecloths,
tea towels etc.
Only Kosher meat, bought from a Kosher butcher
should be eaten.
Thomas B. (2001). Manual of Dietetic Practice.
Blackwell Science Ltd. Oxford.
BRENT HEALTH EDUCATION 1986 A Guide to Religious
and Cultural Beliefs.
HENLEY A Asians in Britain Introduction
(Produced for the DHSS and the King Edward’s
Hospital Fund for London)
8.0 USEFUL WEBSITES
A meal consists of either Kosher meat or fish and
potatoes or rice, vegetables and fruit.
www.lutonpct,nhs.uk/cookclub.htm.
Also cheese, egg or herring with salad or bread are
considered a meal.
www.soundhealth.nhs.uk
People tend to have 3 meals a day: breakfast, lunch
and dinner.
www.healthyliving .gov.uk
www.leicnhs.uk/leaflets/index.html
www.birmingham.gov.uk
www.hearts.nhs.uk/hp/health-topics/nutrition/asian
www.bhf.org.uk
Meals are usually served in courses.
6.0 OTHERS
Birmingham has a constantly changing population and
there are various other minority ethnic groups which
have not been covered in this section. If you require
any further information or assistance please contact
The Birmingham Community Nutrition & Dietetic
Service.
12
Black and Minority
Ethnic Communities
APPENDIX 1
Changes to Diabetic Treatment
DIABETES AND RAMADAN
DIET ONLY
Guidelines for Fasting Safely During The Holy
Month
Fasting during Ramadan is one of the five pillars of
Islam.
Fasting is obligatory for all healthy adult Muslims.
Exemption from fasting is granted to certain people,
including children under twelve, the sick, the elderly,
pregnant and breast-feeding women and travellers.
However they are expected to do the fast later on
their own and many prefer to do it with others at
Ramadan.
During Ramadan the treatment for diabetes may
change because of fasting.
Patients will need to speak with their diabetes team
before changing medication or insulin doses.
Changes to Diet
People who do not take any medication may fast
safely.
DIET AND TABLETS
People who take tablets to help blood glucose control
may usually fast, but timing of tablets will change.
Because there are many different tablets it is difficult
to give general advice. Patients must see their diabetes
team for tailored advice during this time.
DIET AND INSULIN
Insulin treatment exempts people with diabetes from
fasting, although some people still wish to fast. If this
is the case, insulin doses often need large adjustments
and this must be discussed prior to Ramadan with the
diabetes team.
The diet should normally be based on the following
guidelines:
l
Regular meals based on starchy foods e.g. rice,
chapatti, bread, cereals
l
Avoid adding sugar to foods
l
Choose sugar-free drinks
l
Lower fat intake
l
Five servings of fruits and vegetables each day
Insulin must never be stopped completely, even
when fasting.
During Ramadan dietary habits change. Only 2 meals
a day are eaten, Sehri (early morning meal) and Iftar
(break of fast after sunset). There are longer gaps
between meals and greater amounts of foods and
different types of foods are eaten. In Ramadan people
may experience large swings in blood glucose levels.
Low blood glucose: e.g. weakness, sweating, shaking,
hunger, tingling.
High blood glucose: e.g. thirst, tiredness, need to pass
urine.
During Ramadan, follow these dietary guidelines
to help control blood glucose:
l
l
l
l
l
l
l
Avoid sweet foods taken at Iftar such as ladoo,
jalebi, barfi. You can break your fast with dates or
other dried fruits.
Fill up on starchy foods such as basmati rice and
chapatti.
Include fruits, vegetables, dahl and yoghurt in
meals at Sehri and Iftar.
Try and have the meal at Sehri just before sunrise,
not at midnight. This will spread out energy intake
more evenly.
All drinks should be sugar-free. Choose sugar-free
types of fizzy drinks and cordials. Do not add
sugar to drinks, use a sweetener where needed e.g
Canderel/Sweetex.
Have 1 small glass of fruit juice/day, which will
count as one of your 5 a day portions. Drink 8
glasses of fluid/day.
Limit fried foods such as paratha, samosas, chevda
and bombay mix. Measure and reduce the amount
of oil used in cooking (ideally aim for 1-2
tablespoons for a 4 person dish).
EXTRA NOTES
During Ramadan, people usually find that blood
glucose levels vary. It is important that patients know
the usual symptoms of high and low blood glucose:
If possible, patients should monitor blood glucose
levels. If this goes below 4mmol/l, the fast must be
broken by taking glucose followed by a starchy food
(e.g. biscuit or a piece of fruit).
If blood glucose falls below 4mmol/l, or rises to above
10mmol/l on 2 or more occasions during fasting,
patients should seek further advice for their diabetes
team.
13
Maternal Nutrition
CONTENTS
1. KEY DIETARY MESSAGES AND INTRODUCTION
2. GOOD NUTRITION IN PREGNANCY
2.2 Healthy Start
3. NUTRIENTS FOR SPECIAL CONSIDERATION
Energy
Calcium and Vitamin D
Folate/Folic Acid
Iron and Vitamin C
Omega 3 Fatty Acids
Women nutritionally at risk
Summary Table
4. WEIGHT GAIN DURING PREGNANCY
5. VEGETARIAN AND VEGAN DIETS
Vegetarian
Vegan
6. ASIAN WOMEN AND NUTRITION IN PREGNANCY
7. MINOR DISORDERS OF PREGNANCY
Nausea and Vomiting
Indigestion and Heartburn
Constipation
Cravings & Pica
8. FOOD SAFETY IN PREGNANCY
Vitamin A
Listeriosis
Salmonellosis
Toxoplasmosis
Campylobacteriosis
Milk
Alcohol
Peanuts
Fish and mercury/pollutants
Caffeine
9. Appendices
Appendix
Appendix
Appendix
Appendix
Appendix
Appendix
1
2
3
4
5
6
Healthy eating checklist for pregnancy
Additional energy requirements for Lactation
Dietary sources of Calcium and Vitamin D
Dietary sources of Folate
Dietary sources of Iron
Alcohol Units
10. References
1
Maternal Nutrition
KEY DIETARY MESSAGES FOR MATERNAL NUTRITION
1. Take the recommended folic acid supplement
before conception and up until the 12th week of
pregnancy. After 12 weeks continue with a diet
rich in folic acid
2. Eat a good variety of foods daily to include:
5 portions fruit and vegetables
2 – 3 portions protein foods
plenty of starchy foods, preferably wholegrain
3. Include iron-rich foods every day. Take vitamin C
rich foods at each meal and avoid tea/coffee at
mealtimes
5. Eat 1 portion of oily fish per week (not exceeding
maximum of 2 portions per week) or alternative
omega 3 fatty acid sources
6. Alcohol should be avoided, but if alcohol is taken
have no more than 1 – 2 units of alcohol once or
twice a week. Do not get drunk
7. Follow the latest DOH food safety advice for
pregnancy. (Up to date information can be found
on www.eatwell.gov.uk)
8. Promote the Healthy Start scheme
(www.healthystart.nhs.uk)
4. Include calcium rich foods daily aiming for 3 dairy
portions a day. Take a Vitamin D (10mcg)
supplement daily such as Healthy Start Vitamins
for Women
1.
INTRODUCTION
The outcomes of pregnancy such as fertility, fetal
growth and development, risk of birth defects and
maternal health, can be directly affected by the
nutritional status of the mother before and during
pregnancy.
It has been suggested that poor nutrition during
pregnancy can affect the child’s risk of chronic diseases
such as coronary heart disease and diabetes later in life
(Barker, 1995)1. More research is needed to
substantiate this claim.
Good nutritional status is most crucial prior to
conception and during the first trimester. This is the
time of most rapid cell differentiation and
establishment of embryonic systems and organs.
Many women may not be aware that they are
pregnant during this vulnerable stage. This highlights
the need for education on healthy eating habits for all
women of child bearing age, but also during
pregnancy in preparation for future pregnancies. The
diets of childbearing women are often inadequate
(National Diet & Nutrition Survey, 2003)2.
A well balanced diet remains important throughout
pregnancy and lactation to ensure appropriate energy
intake, maintenance of maternal calcium and iron
stores and adequate intake of vitamins and protein.
During pregnancy women may be more receptive to
nutritional messages. If healthy eating habits can be
established during pregnancy, and reinforced during
subsequent pregnancies, they may continue
throughout life and benefit the whole family.
2
2.
GOOD NUTRITION IN PREGNANCY
To ensure an adequate intake of all the nutrients
required during pregnancy a varied, balanced diet is
essential. Information about diet should be given that
is practical and tailored to the woman as early as
possible in the pregnancy (NICE, 2008)3. The Healthy
Eating Checklist for Pregnancy (Appendix 1) can be
used.
The healthy eating recommendations described in the
Eatwell Plate are appropriate for pregnant women
assuming that care is taken with respect to particular
nutrients, described later.
Adopting a diet lower in fat, containing more fibre-rich
starchy foods, more fruit and vegetables and less sugar,
has the following benefits during pregnancy:
Weight Gain Excessive weight gain can be avoided by
limiting fatty, sugary foods and satisfying
appetite with fibre-rich starchy foods
and fruits and vegetables.
Constipation Increasing the fibre content of the diet
by choosing wholegrain varieties of
breads, cereals etc and eating more fruit
and vegetables will relieve constipation.
This needs to be accompanied by
increased fluid intake.
Heartburn
This may be aggravated by fatty foods.
Maternal Nutrition
2.1 A GUIDE TO A HEALTHY BALANCED
DIET - DURING PREGNANCY
FOOD GROUP
FRUIT AND
VEGETABLES
5 servings
(at least)
per day
FOODS
All
All
-
Fruit
fresh
stewed
tinned
vegetables
fresh
frozen
tinned
SERVINGS
1 serving is:1 piece of fruit
3 tbsp. vegetables
Bowl of salad
3 tbsp. stewed/
tinned fruit
Medium glass (150ml)
fruit juice
NUTRIENTS
PROVIDED
HEALTHY
EATING TIPS
Fibre
Vitamin C
Folic acid
Iron
Potassium
Plenty should be
eaten. The skins of
vegetables and fruit
should be eaten
where possible.
Vegetables should
not be overcooked
or valuable vitamins
will be lost
Bread, flour, chapatis, Serving size to
breakfast cereals,
appetite
potatoes, yams, sweet
potatoes, rice, pasta
Carbohydrate
Fibre
B vitamins
(niacin, thiamin)
Calcium
Protein
Starchy foods should
be the main part of
each meal. Starchy
foods are low in
fat and filling.
Wholemeal varieties
should be chosen
for more fibre
Milk
Yoghurt
cheese
1 serving is:200 ml milk
150 ml carton yoghurt
35g cheddar type cheese
180 ml milk pudding
200-250g cottage cheese
Calcium
Protein
B Vitamins
Vitamin A
Zinc
Iodine
Magnesium
Low fat varieties
should be chosen e.g.
semi-skimmed or
skimmed milk, low fat
yoghurt, reduced fat
cheddar. Low fat
varieties contain as
much calcium as
higher fat varieties
75g meat, chicken, fish
2 eggs
150g pulses (cooked)
50g nuts or nut products
e.g. peanut butter *
200g tofu
100g quorn
Protein
B Vitamins
Iron
Zinc
Vitamin A
Fibre (from pulses)
Choose lean meat
Less fat should
be used in cooking
Encourage low fat
cooking methods e.g.
grill, poach, steam,
stew.
STARCHY FOODS
With each meal
(at least)
MILK AND MILK
PRODUCTS
3 servings per day
MEAT, FISH, POULTRY
AND ALTERNATIVES
Beef, lamb, pork,
ham, chicken, turkey,
2 servings per day
fish, tinned fish
e.g. tuna, sardines*
eggs (well cooked)
pulses baked beans, dahl,
kidney beans etc
nuts*
tofu, quorn, soya
*avoid peanuts only if
there is a family
history of Atopic
disease
* See Food Safety section 8
3
Maternal Nutrition
2.2 HEALTHY START
Healthy Start has replaced the Welfare Food Scheme
(milk tokens). Healthy Start provides vouchers which
can be exchanged for fresh fruit and vegetables, liquid
cows milk or infant formula milk. It also provides free
vitamin supplements.
Entitlement and application process
The scheme, which is means tested, is open to
pregnant women from 10 weeks of pregnancy and
children under 4 years old. All pregnant women under
18 years are also entitled. Asylum seekers are not
entitled as they have separate arrangements through
the Home Office.
To apply for the scheme an application form needs to
be completed and signed by either a midwife or GP to
verify the pregnancy. This should be done as early as
possible in the pregnancy (NICE, 2008)3.
The vouchers
Pregnant women and children aged under 4 years
receive one voucher per week for each child and
pregnancy. Children under 1 year receive two vouchers
per week.
The vouchers can be used at any participating retailer.
These can be found at www.healthystart.nhs.uk using
the ‘shop locator’.
The vouchers can be used for:
l Plain liquid cows milk (whole, semi-skimmed,
skimmed and must be pasteurised, UHT or heat
treated)
l Infant formula (based on cows milk) only
suitable for use from birth
l Fresh fruit and vegetables. These can be whole,
chopped, loose or packaged.
Pre-cooked, canned, frozen or dried versions are
not included. Fruit juice and smoothies are not
included
Healthy Start vitamin supplements
Under the scheme, free vitamin supplements are
available for:
l Children from 6 months to 4 years (see Under
5’s section)
l Pregnant women and mothers of children under
one year old.
The Healthy Start Vitamins for Women are in tablet
form and the dose is 1 tablet per day.
One tablet contains:
400mcg folic acid
10mcg vitamin D3
70mg vitamin C
They are suitable for vegetarians. One pot contains 56
tablets (8 weeks supply).
4
For beneficiaries, these are available from health
centres. In HOB tPCT area they are free to all
pregnant women and mothers of children under one
year old as part of the Vitamin D policy to prevent
rickets.
3.
NUTRIENTS FOR SPECIAL
CONSIDERATION
3.1 ENERGY INTAKE
It is recommended that pregnant women with
abnormal body mass index (< 18 or > 30) have
additional antenatal care (NICE, 2008)4.
Low body mass index
Body fat content has an important influence on female
fertility. The average body fat content of post pubertal
women is 28% of body weight. At least 22% of body
weight needs to be fat for the maintenance of
ovulatory cycles (Frisch & McArthur,1974)5. Women
who diet excessively or have eating disorders can have
irregular menstrual cycles (Goldberg, 2002)6.
Conception can occur in women who are well below
average or ideal weight and has been reported in
women with a body mass index (BMI) as low as 14.9
(Treasure & Russell, 1988)7. However the infants of
women who are low weight (BMI<18) at the time of
conception are more likely to be of low birth weight
and/or premature and to have significantly increased
morbidity (Edwards et al 1979)8. The likelihood of
producing healthy offspring is increased if the diet of
such mothers is adequate throughout pregnancy and
weight is gained appropriately (see section 4).
High body mass index (Obesity)
Women with a high BMI (>30) can have reduced
fertility and an increased risk of late pregnancy
complications, perinatal mortality and even death
(CEMACH, 2007)9. Women should be informed of
these risks (NICE, 2008)3. However, low energy diets
should be avoided during pregnancy as there is no
evidence that they are safe for the fetus. It is preferable
for weight to be reduced to the desired level at least 34 months prior to conception to prevent nutrient
deficiencies which may affect the fetus. See section 4
for management of obesity in pregnancy.
Requirements during pregnancy
The DH (1991)10 have set the requirement for energy
during the last trimester of pregnancy at only 200
kcal/day above the pre-pregnancy energy requirement.
In the first two trimesters there is no significant
increased energy need. Women who are underweight
at the beginning of pregnancy and women who
maintain their activity levels may need more. The
Maternal Nutrition
majority of women do not need to eat more. Pregnant
women should be advised to eat enough to satisfy
their appetite from the four main food groups (see
section 2.1) to achieve appropriate weight gain.
Energy requirements during lactation
The energy cost of milk production is high (see
Appendix 2). However, usually the mother experiences
increased appetite and increases her food intake to
meet her requirements.
3.2. CALCIUM AND VITAMIN D
Pregnancy
It is important that there is enough calcium and vitamin
D available as they are essential for the mineralisation
of the fetal skeleton. In the presence of adequate
Vitamin D, the increased requirements for calcium are
met by increased absorption (Misra & Anderson,
1990)11. Demand is greatest in the last 10 weeks of
pregnancy when the bulk of fetal mineralisation takes
place.
The recommended intake of calcium during pregnancy
is 700mg/day for women aged 19-50 years and
800mg/day for those aged 15-18 years (DH, 1991)10.
The average UK calcium intake of 0.8 – 1.0 g/day will
meet these needs. However, there are some subgroups
who are at risk of calcium inadequacy:
-
-
-
women who consume little or no milk or dairy
products eg those with an intolerance,
African/Caribbean women
teenage mothers whose own calcium requirements
are high as they have not yet achieved peak bone
mass
Asian women who may consume a high phytate
diet which additionally compromises calcium
absorption.
change to diet is not possible. To ensure adequate
calcium absorption all pregnant women should be
advised to take a daily 10 mcg Vitamin D supplement
(NICE, 2008)3. The Healthy Start vitamins for women
contain this. All pregnant women living in HOB tPCT
can have these free of charge.
See Appendix 3 for sources of calcium and Vitamin D.
Lactation
Most lactating women increase their food intake and
hence calcium intake, thus providing the additional
calcium required for milk production. Groups at risk of
deficiency are as stated above.
Poor Vitamin D status in pregnancy will lead to low
levels of Vitamin D in breast milk. This can result in
low Vitamin D status in the infant causing rickets (see
under 5’s chapter).
A daily Vitamin D supplement of 10 mcg is
recommended for all lactating women (NICE, 2008)3.
The Healthy Start vitamins for women contain this. All
postnatal women living in HOB tPCT can have these
free of charge.
3.3 FOLATE/FOLIC ACID
Folic acid is essential in early pregnancy to help protect
against neural tube defects (NTDs) (DH,2000)12.
It is impossible to obtain from dietary sources the
additional 400mcg/day that is needed in addition to
the recommended 200mcg/day from food.
The Department of Health (DH 2000)12 recommends
that to prevent the first occurrence of NTDs, all
women planning a pregnancy should:
-
Supplement their diet with 0.4mg (400mcg) folic
acid daily until the 12th week of pregnancy. (This is
available on prescription but, except for those on a
low income and exempt from prescription charges,
pre-conceptually it is cheaper to buy it over the
counter rather than to pay the standard prescription
charge).
-
Choose foods such as bread and breakfast cereals
which are fortified with folic acid.
-
Consume more folate-rich foods, which should not
be overcooked – see Appendix 4.
Those most at risk of Vitamin D deficiency are those
who have limited skin exposure to sunlight, or who are
of south Asian, African, Caribbean or Middle Eastern
descent or who are obese (NICE, 2008)4.
Low calcium intake and/or inadequate Vitamin D
during pregnancy can lead to low calcium stores in
newborns, resulting in hypocalcaemic fits when a few
weeks old.
It is important that such women are offered
appropriate dietary guidance to increase calcium
intake, or a daily 500mg calcium supplement if a
Women who have not been supplementing their diet
with folic acid and become pregnant should
immediately start supplementation and continue until
the 12th week of pregnancy.
5
Maternal Nutrition
To prevent recurrence of neural tube defects in the
off-spring of women or men with a history of a
previous child with NTD, women who wish to become
pregnant, or are at risk of becoming pregnant, should
take a daily supplement of 5 mg folic acid (available on
prescription only) and supplementation should
continue until the 12th week of pregnancy.
Women with diabetes (Type 1 or Type 2), are also
advised to take this higher dose of 5mg folic acid daily
pre-conceptually and up to the 12th week of
pregnancy (NICE, 2008)13.
Women with epilepsy. Note some antiepileptic drugs
interact with folic acid, and the higher dose may need
to be prescribed.
3.4 IRON AND VITAMIN C
Prior to conception
Many women of childbearing age in the UK have low
iron stores (Buttriss et al, 2001)14. In those women who
start pregnancy without adequate iron stores, low
reserves in conjunction with low iron intake, may result
in iron deficiency. Ideally iron deficiency should be
corrected before conception.
During pregnancy
The DRV (DH, 1991)10 for iron in adult women is
14.8mg/day with no recommended increase during
pregnancy. In women where iron intake is adequate,
increased requirements are met by increased dietary
absorption, cessation of menstrual losses and
mobilisation of maternal stores.
Women with low iron stores and low intakes are at risk
of iron deficiency and may need supplementation.
Asian women have a high incidence of iron deficiency
anaemia (See Section 6).
Advice to include iron rich foods in the diet, especially
those containing haem iron,is sufficient for women
without evidence or history of anaemia (See Appendix
5). Ensuring the diet is rich in vitamin C will improve
absorption of non-haem iron. This is particularly
important for vegetarian women.
Tea and coffee with meals can inhibit the
absorption of iron (Hurrell, 1997)15. They
should be taken at least 1/2 to 1 hour
before or after the meal.
6
Iron supplements should only be prescribed if there is
clear haematological evidence of iron deficiency
anaemia (NICE, 2008)4. Note, as pregnancy progresses,
haemodilution can make interpretation of serum
ferritin levels difficult.
The iron tablets should be taken with a vitamin C rich
drink such as pure orange, tomato or grapefruit juice
to maximise the absorption of the iron.
Iron supplements should not be taken at the same time
as calcium supplements as absorption of both may be
decreased.
Postnatal period
Women who have had iron deficiency anaemia in
pregnancy should have their haematology checked
again postnatally and be supplemented appropriately.
Maternal Nutrition
3.5 OMEGA 3 FATTY ACIDS
As well as maternal protection from heart disease, it is
thought these may be important for the development
of the central nervous system in babies before, and
after, they are born. It is recommended that all child
bearing women including pregnant and breastfeeding
women eat at least 1 portion of oily fish per week but
do not exceed 2 portions weekly due to possible
pollutants (see Section 8).
Examples of oily fish are: salmon, trout, kipper,
mackerel, herring, sardines, fresh tuna, pilchards,
sprats, whitebait.
Vegetarian sources are soya and soya oil, walnut oil
and walnuts, linseed oil and linseeds, rapeseed oil,
flaxseed oil and Columban eggs.
3.6 WOMEN NUTRITIONALLY AT RISK
The women most likely to be nutritionally at risk in
pregnancy are those:
l
l
l
l
l
l
l
Fish liver oil supplements must not be taken in
pregnancy due to their Vitamin A content (see Section
8). There is currently inadequate evidence to
recommend taking specific omega 3 supplements.
l
l
young girls who conceive within 2 years of the
menarche
from ethnic minority groups especially if recently
arrived in the UK or have English language
difficulties
from a low income group
restricting their food intake eg allergies, eating
disorders, slimming,
that have alcohol or drug problems
that have closely spaced pregnancies
that have pre-existing medical disease eg
gastrointestinal problems
vegans and vegetarians who follow an
inadequate diet
with abnormal BMI
SUMMARY TABLE
The following should be checked, ideally pre-conceptually or at antenatal booking at the latest.
The use of the Healthy Eating Checklist for Pregnancy (Appendix 1) will assist this process.
NUTRIENT
ACTION
Energy
Check BMI and follow guidelines stated in sections 3.1 and 4.0
Calcium
Check intake is adequate and advise accordingly (see appendix 3)
Vitamin D
If pre-conceptual, check exposure to sunlight (See Appendix 3). If likely to be
deficient, request GP prescribe vitamin D.
If pregnant, advise to take a Vitamin D (10mcg)
supplement (available on prescription if not eligible for Healthy Start vitamins for
women). If live in HOB tPCT area signpost to the free Healthy Start supplements for
women available to all pregnant women.
Folate/Folic Acid
Check taking recommended supplement. Check dietary sources meet the daily
200 mcg from food required (Appendix 4)
Iron and Vitamin C
Pre-conceptually correct iron deficiency.
Check intake of rich sources of iron and advise accordingly (Appendix 5)
If vegetarian, encourage rich non-haem sources and high vitamin C food/drink
with each meal
Omega 3 fatty acids
Check intake using section 3.5 and advise accordingly.
In addition, ensure the woman is informed about Healthy Start to assess eligibility.
7
Maternal Nutrition
4.
WEIGHT GAIN DURING PREGNANCY
There are no official UK recommendations for weight
gain during pregnancy. The Food Standards Agency
states 10 – 12 kg (www.eatwell.gov.uk). The US
Institute of Medicine (IOM, 1990)16 has
recommendations based on pre-pregnancy body mass
index (BMI).
Body Mass Index can be calculated as shown below:
BMI = Weight (kg)
Height (m)2
Categories
BMI < 19.8
Recommended
total weight
gain (kg)
Underweight
12.5 – 18
BMI 19.8 – 26.0 Healthy weight 11.5 – 16
BMI 26 – 29
Overweight
7.0 – 11.5
BMI > 29
Obese
at least 7kg
l
l
l
Young adolescents and black women should aim
for the upper end of the range.
Short women (<1.57m) should aim for the lower
end of range
Weight gain will be slightly more with multiple
pregnancy
(IOM, 1990)16
Some feel these IOM recommendations are too high
and suggest for those with a BMI in the healthy weight
range to aim for 6.8 – 11.4 kg (Feig & Naylor, 1998)17.
Excessive weight gain predisposes to large babies,
difficult deliveries and may lead to maternal obesity.
Conversely, the risk of having a low birth weight infant
is higher in women of normal weight or who are
underweight if they gain too little weight in pregnancy
(Goldberg, 2002)6.
Women are no longer weighed routinely at antenatal
follow-up examinations (NICE, 2008)4. However, if the
woman consents, underweight or obese women
should have their weight monitored and be advised
accordingly.
Weight Gain in Obese Women
Obese women at the start of pregnancy have an
increased risk of complications as listed in section 3.1.
Women with a BMI > 30 should be referred to a
dietitian for assessment and advice (NICE, 2008)3.
It is not recommended that overweight or obese
women lose weight during pregnancy (NICE, 2008)3
because it is essential that a balanced diet is
maintained. The effects of deliberately restricting
energy intake on the fetus are unknown.
Until there is further guidance it would seem prudent
to ensure that overweight and obese women aim to
minimise weight gain to at least 7kg over the whole
pregnancy. This will result in no addition to the
woman’s BMI after birth. Dietary advice should
concentrate on eating to appetite from the 4 main
food groups (section 2.1) but reducing foods high in
fat and sugar. Moderate safe exercise daily is also
beneficial and safe (NICE, 2008)4. For more information
on exercise in pregnancy visit www.rcog.org.uk (Patient
Information and Statements).
It is best for obese women to reduce their weight
either before or after pregnancy (NICE, 2008)3.
The 6 week GP postnatal check is a good opportunity
to consider weight management options. For those
that are breastfeeding, losing weight by eating
healthily and taking regular exercise will not affect the
quantity and quality of the milk (NICE, 2008)3.
5.
VEGETARIAN AND VEGAN DIETS
VEGETARIAN
The principles of good nutrition in pregnancy
previously described apply to women who follow a
vegetarian diet.
The term “vegetarian” generally refers to an individual
who does not eat meat, poultry, fish or products made
from these but who does eat milk, milk products and
eggs. The food a vegetarian is prepared to eat does
vary and it is advisable to check which foods are eaten.
A vegetarian still needs to eat foods from each food
group daily as shown in section 2.1. Meat, poultry and
fish are sources of protein, iron and B vitamins.
Alternative sources of these nutrients are:
Protein
Pulses e.g. baked beans, dahls, kidney beans, lentils
Nuts*
Tofu,
Quorn
Cheese
Eggs
Milk
Yoghurt
Soya based products
* See Food Safety section 8
8
Maternal Nutrition
To ensure an adequate intake of high biological value
protein, vegetable sources of protein (pulses, nuts*,
tofu) should be eaten with a cereal based food (bread,
chapati, rice, pasta)
e.g. baked beans on toast; dahl and rice or chapatti;
mixed bean casserole and pasta; peanut butter*
sandwich; hummus and pitta bread.
Iron
Pulses e.g. baked beans dahls, kidney beans, lentils,
Peas
Eggs
Tahini
Fortified breakfast cereals
Apricots
Dried Fruit
Dark green vegetables
eg kale, spinach, broccoli
To ensure an adequate intake of iron, 3 - 4 iron
containing foods from the table above should be taken
every day
To enhance the utilisation of iron include a food rich in
vitamin C at the same meal e.g. citrus fruit (oranges,
grapefruit, satsuma etc), citrus fruit juices, tomatoes,
peppers, fresh pineapple, guava, mangoes,
strawberries, kiwi.
See Section 3.4 regarding tea and coffee.
Vitamin B12
Vitamin B12 is unique amongst vitamins in that it is not
found in any plants. Vegan diets must contain Vitamin
B12 fortified foods daily e.g yeast extracts such as
Marmite or Vegemite, fortified soya milk, fortified
breakfast cereals. Vitamin B12 supplements will be
required if these foods are not eaten daily.
Calcium and Vitamin D
Vegans do not consume any dairy produce.
Consequently their dietary intake of calcium is limited.
Foods such as bread and flour products and some dark
green vegetables, nuts and seeds provide some calcium
in the diet.
Some vegans may use soya milk on cereals or in drinks.
Encourage the use of calcium fortified soya milks and
yogurts as ordinary soya milk contains no calcium.
If dietary intake of calcium is inadequate a daily
calcium supplement will be required.
A daily 10mcg Vitamin D supplement should be taken.
See section 3.2 for more information.
Protein and Iron
B Vitamins
Wholegrain breads
Cereals
Rice
Beans and pulses
Yeast extract, e.g. Marmite
Nutrients for particular consideration include: -
Nuts*
Green vegetables
Milk
Eggs
See advice on protein and iron earlier in this section.
These are all good sources. Some should be included
every day.
* Avoid peanuts only if family history, on either side, of
atopic disease
VEGANS
The term “vegan” generally refers to an individual who
does not eat meat, poultry, fish, eggs, milk or milk
products or any animal products.
Achieving an adequate nutritional intake on a vegan
diet requires careful planning and consideration. To
ensure the nutritional adequacy of a vegan diet during
pregnancy, referral to a dietitian for assessment and
advice is recommended. Vegan women would benefit
from making any necessary dietary changes prior to
conception.
9
Maternal Nutrition
6.
ASIAN WOMEN AND NUTRITION IN
PREGNANCY
Within Birmingham and Solihull Asian women
originate from a number of different countries in the
Indian sub-continent and their religion may be Islam,
Hinduism or Sikhism.
The foods traditionally eaten will vary depending on
the country of origin, religion, how long the family has
been in the UK, how much they are influenced by the
UK diet and many other factors.
Meat, poultry, fish, eggs and alternatives
l
Red meat is an excellent source of iron and should
be encouraged, especially in women with low iron
stores.
l
Dahls are also good for iron and should be
encouraged.
l
Women may go off meat and chicken during
pregnancy. Alternative high protein and iron foods
need to be encouraged (see section 5)
A varied, balanced diet
Hot and cold foods
The traditional diets taken by families from the Indian
sub-continent are balanced and varied. However,
during pregnancy the traditional balance may be upset
due to customary dietary restrictions such as hot and
cold foods, or because of problems such as nausea. In
addition, as previously explained, there are greater
requirements for some nutrients.
Most Asian food beliefs relate to the idea of hot and
cold foods and the need to balance these to maintain
physical and emotional equilibrium. Hot foods are
believed to raise the body temperature, excite the
emotions and increase activity. Cold foods are believed
to cool the body temperature. Hot and cold has
nothing to do with the actual temperature of the food.
Too many of either can unbalance the body and the
emotions and cause problems.
Be aware of the following points:
Fruits and vegetables
l
l
l
A variety of fruits and vegetables need to be
consumed to meet requirements for vitamins and
minerals
Green vegetables are good sources of folate,
Overcooking vegetables will reduce the amount of
folate and vitamin C in them.
Starchy foods
l
l
Wholemeal varieties should be encouraged.
Chapatis are not leavened. Consequently their
phytate content is higher than in leavened bread
and the phytate makes it harder to absorb the iron
and calcium from foods.
Milk and milk products
l
l
l
These products might only be consumed in small
amounts. Suggest ways of incorporating more into
the diet to ensure an adequate intake of calcium.
If in any doubt about a woman’s intake of calcium
a calcium supplement should be considered.
The calcium can only be utilised in the presence of
vitamin D. A daily 10 mcg Vitamin D supplement
must be advised. See section 3.2 for more
information.
10
Views vary between communities and between
families. Foods that are high in animal protein are
generally considered hot. Usually people eat a variety
of foods which balance each other in the heating and
cooling action, possibly eating more cold foods in the
summer and hot foods in the winter.
At certain times the effects of hot and cold foods
become particularly significant.
Pregnancy is considered to heat the body and so hot
foods could cause a further rise in the temperature and
a miscarriage. Some non-vegetarian women may cut
down on meat and eggs when they are pregnant.
During lactation, a cold condition, cold foods may be
avoided in case they give the baby a cold or a cough or
catarrh.
For a list of hot and cold foods see the Black and
Minority Ethnic Communities Chapter.
Nausea and loss of appetite
Nausea, often experienced during the early stages of
pregnancy, may be worse in Asian women. They may
therefore need extra encouragement to eat a balanced
diet (see Section 7).
Maternal Nutrition
7.
MINOR DISORDERS OF PREGNANCY
Introduction
During pregnancy hormone changes occur which may
cause minor problems that may require nutritional
advice.
The problems that may occur are: 1.
2.
3.
4.
Nausea and vomiting
Indigestion and heartburn
Constipation
Cravings and pica
1. Nausea and vomiting
Nausea may occur on its own but may lead to
vomiting. It is generally known as “morning sickness”
but can occur at any time during the day. It occurs
mainly during the early stages of pregnancy and
usually ceases by 16 weeks, but occasionally persists
throughout pregnancy. Food preparation, strong
cooking smells, car travel may exacerbate it as will
dehydration, an empty stomach and low blood glucose
levels
Advice
Prevent dehydration
l
Drink little and often throughout the day aiming for
6- 8 glasses of fluid (1.5 – 2 litres) daily
l
Keep food and drinks separate
l
Avoid caffeine containing drinks as they act as a
diuretic
l
It is important to try to drink even if vomiting is
severe. Sip a few mouthfuls of drink every 15-20
minutes
Eat little and often
l
Eat at least 6 times a day (small plateful, avoid large
meals)
l
If only able to eat small amounts (one mouthful of
food) eat every 20-30 minutes
l
Keep crackers, dry cereal or biscuits by the bed and
eat some before getting up
l
It is important to try to eat even if still vomiting
Eat mainly carbohydrate (starchy) foods
l
Choose plain starchy foods eg bread, breadsticks,
dry breakfast cereal, potatoes, pasta, rice, chapatti,
crackers, biscuits. Have them dry and on their own
if sickness is severe.
l
If these cannot be eaten, try glucose sweets (avoid
if diabetes)
Other tips
l
Ginger may help eg ginger tea, stem ginger18
l
Get plenty of rest and fresh air
l
Try cold food instead of hot food
l
Try drinking with a straw
l
Avoid the smell of cooking
l
Try travel acupressure bands
l
Avoid fried and fatty foods
N.B. Excessive vomiting in pregnancy is known as
hyperemesis gravidarum and should be urgently
referred to the maternity unit.
2. Indigestion and Heartburn
During pregnancy there is an increase in the production
of hydrochloric acid in the stomach and a relaxation of
the cardiac sphincter resulting in acid regurgitation into
the oesophagus.
Advice
The aim is to neutralise the acid and minimise
regurgitation.
1. Avoid lying down immediately after eating
2. Frequent small meals
3. Avoid highly spiced and fried foods
4. Raise the head of the bed with bricks or use
3 pillows.
5. Appropriate antacids can be prescribed via the GP.
3. Constipation
The lowered muscle tone to the gut, the pressure from
the growing uterus and the intake of iron supplements
may all cause constipation in pregnancy.
Advice
1) Diet should include plenty of fibre through eating
wholemeal bread, wholegrain cereals, fruits and
vegetables.
2. Increase fluid intake. Aim for 2 litres daily including
a hot drink in the morning
3. Take regular suitable exercise to increase muscle
tone eg walking
4. Consider changing the iron supplements but check
folic acid not combined with these.
4. Cravings and pica
Cravings for particular foods are a common occurrence
and there is no evidence that they adversely affect the
nutritional intake.
Pica, which is more rare, is the craving for and
ingestion of inedible substances such as ice, clay, rock
and laundry starch. If there are concerns regarding the
possible toxicity of substances ingested ensure the
midwife or named consultant is informed.
8.
FOOD SAFETY IN PREGNANCY
During recent years much publicity has been generated
regarding food safety and the pregnant woman.
It is the responsibility of individual health professionals
to be fully conversant with the current advice to ensure
safety of both the mother and her unborn baby.
11
Maternal Nutrition
Current guidelines for health professionals when
providing advice regarding food safety and pregnancy
are outlined overleaf. For up to date advice, check with
the Food Standards Agency (www.eatwell.gov.uk).
Food safety, pre-conceptually and during pregnancy is
concerned with the avoidance of certain foods and
with basic food hygiene rules. Food should be acquired
from orderly, clean shops, where food has been
correctly stored according to manufacturers’
instructions. ‘Sell by’ dates should be checked and
damaged packs avoided.
Frozen and perishable foods should be placed and
stored in the appropriate refrigerator or freezer, and
maintained at the correct temperature:
Refrigerators below 5LC or 41LF
Freezers -18LC or 0LF
Cleanliness and care in all food preparation is
important, with hands, utensils and work surfaces
being thoroughly clean.
When cooking prepared food, manufacturers’
instructions must be carefully followed.
Health professionals need to ensure that pregnant
women are aware of food safety advice, yet this should
be balanced with a need to avoid unnecessary anxiety.
Listeriosis
In its mild form, this illness resembles influenza (flu).
Although it is a rare disease it is important for
pregnant women to take special precautions to avoid
listeriosis because even the mild form of the illness in
the mother can result in miscarriage, stillbirth or severe
illness in the newborn baby (DH, 1996)20.
Unlike most food-borne organisms, Listeria
Monocytogenes is able to multiply at temperatures as
low as 3LC and therefore may be found in refrigerated
food, Current advice for pregnant women should be to
avoid:
l
soft, ripened cheeses such as Brie, Camembert, blue
vein, goats and sheep cheeses
l
Paté
The counts of Listeriosis monocytogenes that have
been found in other foods e.g. cook-chilled meals, and
ready to eat poultry, have usually been low, but it
would be prudent for pregnant women to be advised
to reheat these types of food until they are piping hot.
Salmonellosis
Salmonellosis is caused by Salmonella bacteria and is
one of the commonest causes of food poisoning,
giving rise to sickness and diarrhoea.
It can trigger miscarriage or premature labour if it is
severe.
Vitamin A
Prior to conception and during pregnancy
In pregnancy there is an increased requirement for
Vitamin A. The UK Reference Nutrient intake for
Vitamin A is:
Dishes with uncooked egg should be avoided including
home made mayonnaise or chocolate mousse. Eggs
should be well cooked. All poultry should be cooked
thoroughly. Avoid raw shellfish.
Campylobacter
600mcg adult women
700mcg pregnant women
950mcg lactating women (DH, 1991)10
However there is evidence, which suggests that an
excessive intake of Vitamin A (retinol) immediately
before or during pregnancy may increase the risk of
birth defects (DH, 1990)19.
It is recommended that all women likely to become
pregnant or who are pregnant to avoid liver, liver
products, fish liver oils, and vitamin A containing
supplements (containing > 700mcg daily) (NICE,
2008)4.
Women who eat a well balanced diet will get adequate
amounts of vitamin A in their diet without these
particular sources.
12
Campylobacter pathogens are a common cause of
food poisoning, resulting in abdominal pain and
diarrhoea.
This infection during pregnancy has been associated
with prematurity, spontaneous abortion and stillbirth.
The risk of infection is reduced by observing good food
and personal hygiene practices.
Toxoplasmosis
Toxoplasmosis is caused by infection with an organism
called Toxoplasma gondii found in raw meat and cat
faeces. It can affect a pregnant woman and in rare
instances, can also seriously affect the unborn infant. It
is usually unnoticed in the mother, but it can
sometimes cause a mild flu-like illness.
Maternal Nutrition
Advice to pregnant women should be to:
l
avoid eating any raw or undercooked meat, with
thorough handwashing after handling any of the
above.
l
All vegetables, salads and herbs should be washed
carefully to remove any soil and dirt that may have
been contaminated by cats fouling.
l
Wear disposable gloves when gardening and
handling cat litter trays
Milk
To avoid any milk-borne infections milk needs to be
pasteurised, sterilised or ultra heat-treated before being
consumed by pregnant women. Cheeses made from
unpasteurised milk should also be avoided.
Alcohol
Alcohol passes through the placenta to the fetus.
Excess drinking in pregnancy can cause foetal alcohol
syndrome. Women that drink excessive amounts of
alcohol will require specific counselling and treatment.
There is inconsistent evidence about the effect of
moderate and occasional alcohol consumption. The
current recommendation is for pregnant women and
women trying to conceive to avoid alcohol, particularly
for the first 3 months of pregnancy. If women choose
to drink they should have no more than 1 or 2 units of
alcohol once or twice a week and they should not get
drunk (NICE, 2008)4.
See Appendix 6 for alcohol units.
Fish and mercury/pollutants
Some large fish contain unsafe levels of methyl
mercury for the developing fetus. Shark, swordfish and
marlin should be avoided. Tuna should be limited to
two fresh steaks (cooked weight 140g each) or four
medium sized cans of tuna (140g drained weight each)
a week.
Oily fish can contain pollutants such as dioxins and
PCBs. More than two portions of oily fish a week
should be avoided by all women of childbearing age
including during pregnancy (See Section 3.5 for list of
oily fish).
Caffeine
The Food Standards Agency recommends that
pregnant women should limit their caffeine intake to
less than 200mg/day. This follows suggestions that
caffeine intakes in excess of 200mg/day may be
associated with low birth weight and miscarriage.
(CARE Study Group, 2008)22.
Guide to the quantity of caffeine in commonly
consumed food and drink:
l
l
l
l
l
l
Peanuts
l
l
The incidence of peanut allergy in children is increasing
and, because of its severity, is of concern. The risk of
peanut allergy is greatly increased in children from
atopic families and it may be possible that intrauterine
exposure to peanut allergens may increase the risk of
subsequent allergy in such children.
l
1
1
1
1
1
1
1
1
1
mug of instant coffee
cup of instant coffee
mug of filter coffee
mug of tea
cup of tea
can of cola
can of ‘energy’ drink
(50g) bar plain chocolate
(50g) bar milk chocolate
100mg
75mg
140mg
75mg
50mg
up to 40mg
up to 80mg
up to 50mg
up to 25mg
Caffeine is also found in certain cold and flu
remedies. Women should always check with their
GP or other health professional before taking any of
these.
The Department of Health21 has therefore
recommended a pregnant women with diagnosed
allergic disorder, or if the father or another child in the
family has such a disorder, may wish to avoid peanuts
and peanut containing products during pregnancy.
There is no evidence that women from non-atopic
families would benefit from doing so.
13
Maternal Nutrition
QUICK CHECKLIST
Health professionals should advise clients to: Employ basic food
hygiene rules when:
Purchasing
Storing
Preparing all food
l
l
l
AVOID!
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l
l
l
l
l
l
l
l
l
l
Raw shellfish
Shark, sword fish, marlin and excessive tuna.
More than 2 x 140g portions oily fish a week
Liver, Liver Products, cod liver oil, vitamin A supplements
Patés
Soft ripened cheeses, e.g. Brie, Camembert, Blue cheeses
Raw Eggs
Cook-chilled meals and ready-to-eat poultry unless reheated until piping hot.
Raw or undercooked meat
Unpasteurised milk
Excessive caffeine
Alcohol
APPENDIX 1
HEALTHY EATING CHECKLIST FOR PREGNANCY
This checklist is to help you to think about the foods you eat. It is important for the baby, and you, that you
eat a healthy diet in pregnancy.
Please complete the following questions. For each section look in the advice box. You may be prompted to
take a leaflet for more advice. These are available in the waiting area or from the midwife.
When you have finished show the form to the Midwife or Support Worker.
NB If your present food intake is affected by feeling sick or vomiting then use your food intake from before the
sickness started.
Advice/Suggestions
Diet at present
About You
How many weeks pregnant are you?
Are you taking/did you take
folic acid tablets?
9
About Healthy Eating
How many times a day do you eat?
_________ Meals _________ Snacks
______________ weeks
How many portions of fruit do you
eat in a day?
None
(1 portion is a piece of fruit, glass of
juice, helping of tinned or cooked fruit)
How many portions of vegetables
do you eat in a day?
(1 portion is 3 tablespoons.
Do not include potatoes)
14
9
Yes
None
If No, and you are less than 12 weeks
pregnant, ask your GP for a prescription
Look for the ‘Healthy Start’ leaflet
No
1
2
3
4
5
1
2
3
4
5
Try to eat at least 3 times a day
(meals or large snacks). Pick up the
leaflet ‘Eating While You Are Pregnant’
You need to eat at least 5 portions of
fruit or vegetables every day.
If your total sum of fruit and
vegetables is less than 5 portions a day
then take the 5 A Day leaflet for
some ideas
Maternal Nutrition
Diet at present
About Calcium
How many dairy portions a day do
you eat?
(1 portion =
- 1 glass of milk (include that on
cereal, in drinks, puddings)
- Matchbox size piece of cheese
- small carton yoghurt
About Iron
Are you taking iron tablets?
None
1
2
3 or more
Advice/Suggestions
If you eat less than 3 dairy portions a
day then pick up the leaflet Calcium
& Vitamin D.
If you rarely go outdoors, or most of
your skin is covered up when outside:
- take the leaflet ‘Calcium & Vitamin D’
- ask your GP to prescribe Vitamin D.
9
Yes
Every day
How often do you eat any of the
following meat or meat products?
beef, lamb, pork, burgers, sausages, Once or twice
corned beef or any foods made
a week
with these such as meat pies.
9
No
If No, you will be prescribed these if
you need them. If Yes, take the
leaflet ‘Iron’
Most days
If never or just once or twice a week
your diet could be low in iron.
Take the ‘Iron’ leaflet.
Never or
rarely
About Fluids
How many drinks do you have in a day? ___________________ drinks
Include water, tea, coffee, pop, squash
and juice.
You need to drink at least 8 drinks a
day (112 - 2 litres) to prevent
constipation
If you have any further concerns about your diet, mention to your midwife or GP.
Produced by Birmingham Community Nutrition & Dietetic Department, www.dietetics.bham.nhs.uk
APPENDIX 2
ADDITIONAL ENERGY REQUIREMENTS FOR LACTATION
MONTH
All breast feeding
0-1
1-2
2-3
Group 1
3-6
6 onwards
Group 2
3-6
6 onwards
Group 1
Group 2
ENERGY
COST
Kcal/day
ALLOWANCE FOR
WEIGHT LOSS
(Kcal/day)
TOTAL ADDITIONAL
ENERGY REQUIREMENT
(Kcal/day)
570
650
690
120
120
120
450
530
570
700
300
590
250
120
Nil
480
240
750
650
630
540
60
Nil
570
550
MILK VOLUME
ml/day
women
680
780
820
Women who practice exclusive or almost exclusive breastfeeding until the baby is 4 months old and then
progressively introduces weaning foods as part of an active weaning process which often lasts only a few
months.
Women who introduce only limited complementary feeds after 3-4 months and whose intention is that
breast milk should provide the primary source of nourishment for 6 months or more.
15
Maternal Nutrition
APPENDIX 3
SOURCES OF DIETARY CALCIUM AND VITAMIN D
Calcium
A daily intake of 700mg is required.
Approximately 250 mg of calcium is provided from the
following:
200ml (1/3 pint) milk (whole, semi-skimmed or
skimmed)
35g (11/4 oz) cheddar cheese
150g (5oz) carton of yoghurt
28g (1 dtsp) dried skimmed milk powder
200g (1/3 pint) milk pudding
56g (2oz) sardines or similar soft boned fish.
Vitamin D
The main source of Vitamin D to the body is the
action of sunlight on the skin. This only occurs
between April and October and some will be stored
to last the winter months.
Dietary sources of Vitamin D are limited to:
Oily fish (see Section 3.5)
Fortified margarine
Canned tuna (see Section 8)
Fortified breakfast cereals
Eggs
If soya milk and products are taken ensure they are
fortified with calcium.
Dietary sources can only provide 10% of the daily
Vitamin D requirement.
Other calcium sources are tofu, green vegetables,
beans, sesame seed, tahini paste, dried figs, oranges,
almonds, brazil nuts, white flour products.
All pregnant and lactating women should take a daily
10mcg Vitamin D supplement.
APPENDIX 4
DIETARY SOURCES OF FOLATE FOR PREGNANCY
RICH SOURCES
Good Sources
(More than 100 micrograms per serving*)
Brussels Sprouts, Asparagus, Spinach, Kale
Cooked black eye beans
Fortified breakfast cereal
(50 - 100 micrograms per serving*)
Broccoli, Spring Greens, Cabbage, Green Beans
Cauliflower, Peas, Bean Sprouts, Okra, Iceberg
Lettuce
Parsnips, Cooked Soya Beans and Chick Peas
Kidneys, Yeast and Beef Extracts, Oranges
Some fortified breakfast cereals
-
fresh, raw,
frozen or cooked**
-
fresh, raw
frozen or cooked **
Moderate Sources
(15 - 50 micrograms per serving)
Potatoes, most other fresh and cooked vegetables
Most fruits, Most nuts, Tahini, Bread (100g serving)
Brown Rice, Wholegrain pasta, Oats, Bran, Orange juice
Fortified breakfast cereals, Cheese, Yoghurt
Milk (1 pint), Eggs, Salmon, Beef, Game.
Poor Sources
(0 - 15 micrograms per serving)
Most other breakfast cereals, Alcoholic Drinks,
Soft Drinks, Sugar, Most Pastries, Cakes,
Most other Meats and fish
*
**
16
Minimum recommended portion sizes 100g of these vegetables. Larger (150 - 200g) portions of broccoli,
cauliflower and spring greens will supply more than 100 micrograms.
Based on vegetables boiled for 10- 20 minutes. Steamed, stir-fried and microwave vegetables cooked for a
shorter time will lose less.
(DOH 1992)
Maternal Nutrition
APPENDIX 5
DIETARY SOURCES OF IRON
Iron is found in both animal and plant foods.
Iron is better absorbed in the form of haem iron as found in meat and fish, than from the non-haem iron found in
cereals and vegetables. Some dietary constituents facilitate absorption eg animal protein, Vitamin C. Some dietary
constituents inhibit absorption eg tannins, polyphenols and phytate.
Liver and liver products are major iron sources but consumption cannot be recommended in pregnancy due to
Vitamin A toxicity (see Food Safety section).
Iron rich foods for pregnancy:
GOOD SOURCES OF IRON (Haem iron)
AVERAGE SOURCES OF IRON (Non-haem iron)
Red meat eg lamb, mutton, goat, beef, kidney, pork
Corned beef, black pudding, tongue
Leg and thigh meat of poultry
Oily fish eg sardines, pilchards*
Fortified breakfast cereal
Eggs
Pulses eg peas, beans, lentils, dahls, baked beans
Dark green vegetables eg peas, cabbage, spinach
Dried fruit eg dates, figs, apricots
Sesame seeds, sunflower seeds, tahini
Hummus, tofu
Pistachios, cashews, almonds
Besan flour
* Oily fish – no more than 2 portions/week
APPENDIX 6
ALCOHOL UNITS
Drink
Low Alcohol Drinks
Beer, Lager, & Cider at 2%
Beer, Lager & Cider
4%
5%
6%
Super-strength drinks
Beer, Lager & Cider at 9%
Alcopops (5%)
Spirits (38 – 40%)
Gin, rum, vodka & whisky
Shots (38 – 40%)
Tequila, Sambucca
Amount
Bottle (330ml)
0.7 units
Can (440ml)
0.9 units
Pint (568ml)
1.1 units
Litre
2 units
1.3 units
1.7 units
2 units
1.8 units
2.2 units
2.6 units
2.3 units
2.8 units
3.4 units
4 units
5 units
6 units
3 units
Bottle (275ml)
1.4 units
Small measure
(25ml)
1 unit
Small measure (25ml)
1 unit
4 units
5.1 units
9 units
Large measure
(35ml)
1.3 – 1.4 units
Small double
Large double
measure (50ml)
measure (70ml)
1.9 – 2 units
2.7 – 2.8 units
Large measure (35ml)
1.3 – 1.4 units
If they are liqueurs they can vary considerably in strength and can be stronger or weaker than this example
Wine & Champagne
10%
11%
12%
13%
14%
Fortified wine (17.5 – 20%)
Sherry & Port
Small glass (125ml)
Standard glass (175ml)
1.75 units
1.25 units
1.4 units
1.9 units
1.5 units
2.1 units
1.6 units
2.3 units
1.75 units
2.5 units
Standard measure (50ml)
0.9 - 1 unit
Taken from www.nhs.uk/units
Large glass (250ml)
2.5 units
2.8 units
3 units
3.3 units
3.5 units
Bottle (750ml)
7.5 units
8.3 units
9 units
9.8 units
10.5 units
17
Maternal Nutrition
REFERENCES
1. Barker DJP. Foetal origins of coronary heart disease.
British Medical Journal 1995; 311: 171-174
17.Feig DS, Naylor CD. Eating for two: are guidelines
for weight gain during pregnancy too liberal?
Lancet 1998; 351: 1054-1055
2. National Diet & Nutrition Survey 2003. Ages 19-64,
Volume 3. www.food.gov.uk/science/dietarysurveys
18.Jewel D, Young G. Interventions for nausea and
vomiting in early pregnancy. The Cochrane
Database of systematic reviews reviews. Issue 4.
2003
3. Maternal & Child Nutrition, Improving the nutrition
of pregnant and breastfeeding mothers and
children in low-income households. NICE Public
Health Guidance 11,2008 www.nice.org.uk
19.Department of Health (DH). Vitamin A and
Pregnancy. PL/CMO (90) 11, PL/CNO (90), London:
HMSO, 1990.
4. Antenatal Care; Routine Care for the healthy
pregnant woman. NICE Clinical Guideline 2008
www.nice.org.uk
20.Department of Health (DH). While you are
Pregnant: Safe eating and how to avoid infection
from food and animals. London. DH 1996
5. Frisch RE, McArthur JW. Menstrual cycles: fatness
as a determinant of minimum weight for height
necessary for their maintenance and onset. Science
1974; 185:949-951
21.Department of Health Committee on Toxicity of
Chemicals in Food, Consumer Products and the
Environment. Peanut Allergy. London: DH 1998.
6. Goldberg G. Nutrition in Pregnancy and Lactation.
In Shetty P (ed) Nutrition through the Life Cycle.
Leatherhead. Leatherhead Publishing, 2002
7. Treasure JL, Russell GFM. Intrauterine growth and
neonatal weight gain in babies of women with
anorexia nervosa. British Medical Journal 1988;
296:1038
8. Edwards LE, Alton IR, Barrada MI, Hakanson EY.
Pregnancy in the underweight woman. American
Journal of Obstetrics & Gynaecology 1979; 135:
297-302
9. Saving Mothers Lives 2003 – 2005, CEMACH 2007
www.cemach.org.uk
10.Department of Health (DH). Dietary Reference
Values for Food Energy and Nutrients in the UK.
Report on Health and Social Subjects 41. London:
HMSO, 1991.
11.Misra R, Anderson DC. Providing the fetus with
calcium. British Medical Journal 1990; 30: 12201221
12.Department of Health (DH). Folic Acid and the
Prevention of Disease. Report on Health and Social
Subjects 50. London: The Stationery Office, 2000
13.Diabetes in pregnancy. NICE Clinical Guideline 63,
2008 www.nice.org.uk
14.Buttriss J, Wynne A, Stanner S. Nutrition: A
Handbook for Community Nurses. London. Whurr
Publishers. 2001
15.Hurrell RF. Bioavailability of iron. European Journal
of Clinical Nutrition 1997; 51 (suppl 1): S4-S8
16.Institute of Medicine. Nutrition During Pregnancy.
Washington DC, National Academic Press, 1990.
18
22.CARE Study Group. Maternal caffeine intake during
pregnancy and risk of fetal growth restriction: A
large prospective observational study. British
Medical Journal 2008; 337: a2332
USEFUL CONTACTS
NHS Breast feeding information
Tel: 0844 2090920 (National Breastfeeding helpline)
www.breastfeeding.nhs.uk
National Childbirth Trust
Tel: 0300 330 0770
www.nct.org.uk
La Leche League
0845 456 1855
www.laleche.org.uk
Food Standards Agency
www.food.gov.uk
www.eatwell.gov.uk
The Centre for Pregnancy Nutrition,
Sheffield University
www.eatingforpregnancy.org.uk
(funded by Wellbeing of Women)
Healthy Start Scheme
www.healthystart.nhs.uk
Royal College of Obstetricians & Gynaecologists
www.rcog.org.uk
NHS Pregnancy Care Planner
www.nhs.uk/pregnancy
The Under Fives
INTRODUCTION
Feed Preparation
1. FEEDING THE UNDER ONES
(i) Hygiene
(ii) Making up Feeds
(iii) Water for Feed Preparation
(iv) Storage of prepared feeds
(v) Warming Up Feeds
(vi) Thickening of Feeds
(vii) Transporting of feeds
Summary
1.1
Breastfeeding
(i) Incidence of breastfeeding
(ii) Benefits of breastfeeding
Nutritional advantages
Health Benefits
Benefits to society
(iii) Disadvantages of artificial feeding
(iv) Management of breastfeeding
Baby-led feeding
Avoiding nipple confusion
Expressing breastmilk
Going back to work
Stopping breastfeeding
Hypoglycaemia
Jaundice
Gastroenteritis
Stools
Sore nipples
Milk engorgement
Mastitis
Slow weight gain/failure to thrive
(v) Breastfeeding and drugs
(vi) Breastfeeding and HIV
(vii) Breastfeeding and the Pre-term Infant.
(viii) Education and support
Summary
1.2
1.3
Fluids other than milk for infants under 6
months
1.4
Weaning
Aims of Weaning
When to Wean
Stages of Weaning
6-9 months
●
9-12 months
●
Weaning prior to 6 months
Home prepared weaning foods
●
Commercial foods
Milk and other fluids
Summary
1.5
Iron and the Weaning Diet
Vitamin D and rickets
Prevention of iron deficiency anaemia
and vitamin D deficiency
Vitamins and the weaning diet.
Infant Formulae
Nutritional composition
Types of Infant Formulae
(i) Standard formulae
(ii) Soya formulae
(iii) Lactose free, cow’s milk based formulae
(iv) Protein hydrosylates
(v) Elemental formulae
(vi) Follow-on formulae
(vii) Low birthweight formulae
(viii) Follow-on low birthweight formulae
(ix)
(x)
(xi)
(xii)
Other formulae
High energy formulae
Goat’s and sheep’s formulae
Goat’s and sheep’s milk
Further Considerations
1.6
Vegetarian and Vegan Weaning
Vegetarian weaning
Vegan weaning
Summary
1.7
Dental Health
Dental Care
Fluoridation
Sugar and Sugary Foods
Summary
1
The Under Fives
2. FEEDING THE ONE TO FIVE
YEAR OLDS
2.1
Healthy Eating for the One to Fives
Fat
Sugar
Dietary Fibre or ‘non starch
Polysaccharides’
Fruit and Vegetables
Salt
Vitamins
4. CONSTIPATION
5. OBESITY
APPENDICES
Appendix A: Policy in Support of the Unicef Baby
Friendly Community Initiative Seven Point Plan –
Birmingham East and North Primary Care Trust.
Appendix B: Breastfeeding Positioning
2.2
Food Fads
Appendix C: Dietary sources of iron and Vitamin C.
Summary
Appendix D: Good Dietary Sources of Vitamin D
3. FOOD ALLERGY AND
INTOLERANCE
Appendix E: Bottlefeeding – a practical guide
Appendix E: Handling mealtimes
3.1
Cow’s Milk Protein Intolerance/Lactose
Intolerance.
3.2
Coeliac Disease
3.3
Peanut Allergy
3.4
Hyperactivity
3.5
Gastroenteritis
3.6
Acute Diarrhoea
Appendix F: Bottle-feeding – a practical guide
Appendix G: Infant Feeding Recommendation –
Department of Health
References / Resources
List of useful Addresses/Contacts
Summary
2
The Under Fives
INTRODUCTION
Children are an extremely important target group of
the population for nutritional advice. Poor dietary
habits can adversely affect their development and
predispose them to many diseases e.g. coronary heart
disease.
Nutritional advice which is accurate, up-to-date,
consistent and delivered in a positive manner, could
improve the long term health of the population by
facilitating the development of good eating habits early
on in life and the prevention of ill health in adulthood.
The promotion of a healthy diet and lifestyle is a
worthwhile preventative health objective.
This supplement to the core guidelines for food and
health supports professionals who are in a position to
give advice in relation to the dietary needs and feeding
practices of children, from birth to five years of age. It
is important to consider the needs of the individual
child when using these recommendations. The
guidelines apply to healthy full term infants – pre-term
infants require special consideration, depending on the
degree of prematurity.
The aim of these guidelines is to ensure health
professionals provide parents, or carers, with accurate,
up-to-date, consistent information and advice, thereby
promoting appropriate feeding practices for the under
5’s.
discussed with the parents or carers prior to the birth,
by health professionals involved in the care of the
mother. Advice should be consistent, accurate and
impartial, and delivered in a positive way to give
parents the opportunity to make an informed decision.
Continued support and advice is essential post-natally
to promote successful feeding practices.
1.1 BREASTFEEDING
Breastfeeding gives babies the optimal start in life,
providing everything babies need for a healthy,
nutritious and balanced diet. Breast milk and Breast
feeding protects against illness, specific diseases and
offers developmental advantages. For these reasons
breastfeeding offers long term benefits to the health of
the nation and is cost-effective for the NHS.
The UK Baby Friendly Hospital Initiative The Ten Steps
to Successful Breastfeeding and the Seven Point Plan in
the Community for the protection, promotion and
support of breastfeeding offers best practice standards
and has been demonstrated to improve breastfeeding
rates.
Appendix A offers further information regarding these
initiatives, and details the policy for Birmingham East
and North PCT staff in support of these. For Heart of
Birmingham and South Birmingham PCT staff, please
refer to their policy.
(i)
INCIDENCE OF BREASTFEEDING
Through production and implementation of these
guidelines the following objectives will be achieved: (a) To improve the health of women and children in
Birmingham by promoting and facilitating successful
breastfeeding.
(b) Provision of information, advice and support on the
chosen feeding method for parents or carers.
(c) Adoption of appropriate weaning practices at a
suitable age taking into account the family’s cultural
and religious background.
(d) Appropriate use of vitamin supplements.
(e) Encouragement of good eating habits in childhood,
which will form the basis of a healthy and varied
diet in later life.
1.
FEEDING THE UNDER ONES
Milk, either as breast milk or as an infant formula, is
the sole source of nutrition from birth until the infant is
weaned onto solids at 6 months. Thereafter it remains
an important contribution to the nutritional intake of
the pre-school child.
The choice between breast or bottle feeding should be
Incidence of breastfeeding (ONS 2005)1
Population Group
% Starting
Breastfeeding
% Who Continue At:
6 Weeks
6 Months
Asian brit
94
66
37
Black
97
87
57
Mixed
84
54
40
White
74
46
23
All mothers
70
49
26
Chinese and other
85
65
40
73% of the West Midlands (Strategic Health Authority)
mothers initially breast fed.
*Reference 1 www.ic.nhs.uk/webfiles/publications
The 2005 ONS survey1 highlighted certain factors
associated with a lower incidence of breastfeeding:l
l
l
l
Low social class.
Having discontinued education before 18 years
of age.
Younger mother.
Second or subsequent babies.
3
The Under Fives
Almost half of the mothers that start breastfeeding
have stopped within six weeks due to a number of
reasons including difficulties which could be overcome
with skilled, sensitive encouragement and support.
NHS staff are uniquely placed to provide this assistance
and so promote breastfeeding.
Although it is widely accepted that breastfeeding is the
healthy option, it is important to recognise that not all
mothers choose to breastfeed. This decision should be
supported provided they have received research based
information and are supported to make an informed
choice.
(ii)
BENEFITS OF BREASTFEEDING
Nutritional Advantages
Breast milk is the perfect food for human infants. Its
composition is ideally suited to the needs of each
particular baby so varies from one child to another,
even with the same mother. There is also a change in
milk composition during each feed, the foremilk (milk
which is first drawn during a feeding) having a higher
water content to quench thirst, and the hind milk (the
milk which follows foremilk during a feeding) being
higher in fat. Breast milk composition varies according
to the infant’s size and age2.
The protein in breast milk is predominantly whey which
is easily digested and readily absorbed. The protein and
mineral content are lower than in infant formulae,
giving a lower renal solute load. This is important
because of the immaturity of infants’ kidneys2.
Provided the mother is not malnourished the vitamin
and mineral content of breast milk is adequate. Iron is
present in small quantities but in such a bio-available
form that it is virtually completely absorbed. If
maternal nutritional status is in question, consideration
should be given to the vitamin intake of the infant.
This should ideally be addressed through improvement
of the mother’s diet. Breastfeeding mothers in receipt
of income support, income-based jobseeker’s
allowance or child tax credit (with an income of
£15,575 a year or less 2008/09) are entitled to free
vitamin supplements and vouchers to obtain fruit and
vegetables as well as milk under the Healthy Start
Scheme. The Healthy Start Scheme replaced the
Welfare Food Scheme in November 2006.
4
Health benefits for Babies and Children
Breast milk, unlike formula milk, contains anti-infective
factors, for example immunoglobins which increase the
infant’s resistance to infection. The milk produced in
the first few days after birth, known as colostrum,
contains the highest concentration of these.
Breastfed babies are at a reduced risk of developing
gastroenteritis3. They are also significantly less
susceptible to infections of the respiratory4 and
urinary tract5 and to otitis media (middle ear
infection)6. Children who were breastfed have
considerably lower rates of malocclusion
(misalignment of teeth). Other studies suggest that
breastfeeding offers protection against Sudden Infant
Death Syndrome. There is recent evidence that
exposure to bovine serum albumen in artificial milk
may trigger the autoimmune process which leads to
juvenile onset diabetes8. Also, lower mean blood
pressure and total cholesterol in those who were
breastfed and lower prevalence of
overweight/obesity and type 2 diabetes among
those who were breastfed35.
In pre-term babies breastfeeding reduces the risk of
necrotising enterocolitis9 and promotes optimal
neurological development10. Many studies have
indicated that full term breastfed infants are also at an
advantage.
Breastfeeding may reduce the incidence of allergic
response amongst infants who have a family history of
atopy4 (e.g. hayfever, asthma, eczema).
Health Benefits for the Mother
Mothers who breastfeed are at a reduced risk of breast
cancer11 and some forms of ovarian cancer12. It has
been estimated that 400 deaths of young women per
year could be prevented by breastfeeding.
Breastfeeding also offers the convenience of having
milk always readily available for the baby and the
benefit of supporting weight loss for the mother as fat
laid down in pregnancy is used by the body to make
breast milk.
Breastfeeding helps to maintain the unique contact
between mother and baby and so promotes bonding
and attachment behaviour.
The Under Fives
Benefits to Society
Baby-led feeding and increasing milk supply
The main cost savings to the NHS comes immediately
in the form of reduced hospital admissions for
gastroenteritis. The admission rate for bottle fed
babies is five times greater than for breastfed babies,
regardless of socioeconomic conditions. If all babies
were breastfed there would be a saving to the NHS of
£35 million per annum13.
Allowing the baby to decide how often to feed and for
how long has, in the past, been called demand
feeding. Baby-led feeding probably best describes this
process. All babies are different, and the mother’s milk
production responds to these differences. A mother
does not have to wait until her baby is upset and
crying to offer the breast. She learns to respond to the
signs her baby gives, for example rooting, which means
the baby is ready for a feed. A mother should let her
baby finish feeding on the first breast, then offer the
second, which her baby may not want. If a baby
receives high volumes of foremilk and never gets to the
hind milk he/she will not have received as much energy
and so will get hungry again soon, exhibit unsettled
and unsatisfied behaviour and prolonged feeding
episodes. On the other hand a thirsty baby who is not
very hungry may require just the more watery milk and
so will only need to suckle briefly.
(iii)
DISADVANTAGES OF ARTIFICIAL FEEDING
Formula milk, unlike breast milk, does not contain: cells
(leucocytes), thyroid and epithelial growth hormones,
enzymes and prostaglandins developing immune
systems and neurodevelopment.
(iv)
MANAGEMENT OF BREASTFEEDING
As soon as possible after birth it is important that
mother and child are together with “skin to skin”
contact to facilitate a first feed taking place. This
should be offered to all women irrespective of feeding
choice. Babies should be encouraged to breast feed as
soon as possible after the birth. Failure to promote this
can cause early cessation of breast feeding.
The second feed: Correct positioning and attachment
at the breast is crucial, see Appendix B. If the mother
experiences correct attachment at the early feeds, it is
likely that she will not tolerate incorrect attachment at
later feeds. The father can be involved in the advice
given, to enable him to continue to support his partner.
Even if the mother is exhausted, or has had a
caesarean section, she can be helped to feed whilst
lying in bed.
The mother should be taught to express breast milk by
hand, in case the baby is having difficulties with
breastfeeding, the baby is unable to take full feeds, to
augment milk drainage, reducing mastitis.
Night feeds provide the baby with significant
proportion of his/her total intake. Additionally, milk
production will be increased more by night feeding
than by day, because the prolactin release in response
to suckling is greater at night. To facilitate night
feeding, mothers should be encouraged to have their
babies with them or in easy reach as is practically
possible.
At first babies may need to feed as often as hourly but
the frequency of feeds will decrease as the milk volume
increases and production meets individual babies
appetite according to baby’s growth and development.
At certain times a baby may be experiencing a growth
spurt and so require more breast milk. The mother
may need reassurance at this time that her milk supply
is not diminishing and that it will increase to meet the
baby’s needs. Milk production is determined by
frequency of suckling and effective emptying, so
it is important to allow the baby to suckle as and
when necessary to increase milk
supply.
It is the responsibility of health professionals to support
breastfeeding by providing timely information in a
confident, informed manner. Protocols for the support
of breastfeeding in special situations and the
management of common complications exist in the
Breastfeeding Factfile (details under additional reading).
5
The Under Fives
Any interference with natural frequency of suckling
and effective attachment will inevitably lead to a
reduction in milk supply. Examples of interference
include: Extra fluids other than breastmilk.
Supplementary feeds/top ups.
Dummies/pacifiers.
Using nipple shields.
Restricting feeding to a schedule.
Baby sleeping through the night too early.
l
l
l
l
l
l
If a woman’s milk supply has decreased it is important
to:
l
Check that the position of mother
and baby is correct.
} See Appendix B
l
Check that the baby is attached
on the breast properly.
} See Appendix B
l
Ensure that the hind milk is being obtained by fully
feeding from one breast before progressing to the
other.
l
Ensure baby-led feeding unless advice provided by
Paediatrician and/or Dietitian when there are
concerns regarding poor growth.
Increasing a depleted milk supply will usually take 3648 hours. The mother should be encouraged to feed
the baby as often as possible including at least one
night time feed, as the hormone levels are highest
between 2.00am and 6.00am and this will boost milk
production for the following day. The mother should
be encouraged to rest while she is trying to increase
her milk supply, to eat a healthy diet and drink as her
thirst dictates. There is no evidence to suggest that
overeating or drinking large volumes of fluid, will
improve milk production.
Avoiding Nipple Confusion
The mechanism of suckling from the breast is so
different from sucking on a teat that giving a bottle
can lead to breast refusal and poor suckling technique.
Cup feeding offers an alternative method of feeding
for the mother or baby who cannot breastfeed in the
initial period after birth. Cup feeding is useful because
it enables the baby to control his/her own intake and
does not interfere with suckling at the breast as no
teat is taken into the mouth and the process is entirely
baby led.
Dummies are generally not recommended for breastfed
babies. Use of dummies during the establishment of
breastfeeding may disrupt the baby’s oral-motor coordination interfering with baby-led feeding and lead
to breast refusal, overly hungry baby and infection. If a
breastfed baby seems unsettled, it is more important to
examine the mother’s feeding technique and seek an
improvement in management. In older babies where
breastfeeding is established, if the baby continues to
be unsettled, other sources of problem or comfort
should be explored.
Expressing Breastmilk
The expression of breastmilk can be useful for a variety
of reasons, these include: l
l
l
l
l
Women need a lot of reassurance when they are
increasing their milk production, that the steps
discussed will work, and that they will be able to fully
breastfeed their babies. They also need practical help
so that they can rest and not neglect their own, as well
as their baby’s needs.
Supplementary Feeding
The nutritional requirements of a baby aged up to 6
months can be met entirely from breast milk.22 If a
baby seems hungry he or she should be put to the
breast more often to stimulate increased milk
production. There is no scientific basis for giving
any other fluid or food to a baby before 6 months
of age. However, there is room for flexibility regarding
this advice for individual babies (see section 1.4
Weaning)
6
General breast care.
Relief and prevention of potentially serious breast
conditions, such as mastitis.
Stimulation of the milk supply.
Maintaining milk supply.
Maintenance of lifestyle.
All health care workers who care for breastfeeding
mothers should be able to teach the skills of both
manual and mechanical expression of breastmilk.
The reason a mother may need to express her
breastmilk may vary a great deal. It is important that
women understand the mechanics of breastmilk
expression and have access to appropriate support.
Freshly expressed breastmilk can be stored in a
refrigerator for up to 24 hours.14 It may be stored
frozen for about 3 months. Frozen breastmilk can be
defrosted slowly in a fridge or at room temperature.
Research indicates that breastmilk can be kept at room
temperature for up to 8 hours.
The Under Fives
Going Back To Work
Returning to work seems to be associated with a
reduction in the length of breastfeeding. Economic
constraints force a large number of mothers to return
to work whilst still breastfeeding their infants. The
ability to express milk for later feeding when away
from the infant might strongly influence the mother’s
decision to continue breastfeeding even after they have
returned to work.
If a woman is unable to express a sufficient quantity of
breastmilk she could be referred to a lay or professional
breastfeeding specialist where her concerns can be
explored and experienced support offered. Her success
will depend on her choice to continue to offer breast
milk and her circumstances which affect supply,
collection and storage. If the problem continues,
despite receiving adequate advice and support, she
should be encouraged to mix breastfeeding with infant
formula.
Maximising the Beneficial Effect of Breastfeeding
It is advisable that breastfeeding should continue for at
least the first 6 months to maximise the health benefits
previously identified. Breastfeeding as part of a mixed
weaning diet should ideally continue into the second
year of life, as recommended by the WHO.15
Storage of breast milk
The Department of Health recommends breast milk can
be stored for 24 hours in a fridge between 2-4°C.
It can be stored frozen for up to 6 months36.
The researched guidelines from the Breastfeeding
Network recommend if defrosted in the fridge breast
milk to be used within 12 hours, if defrosted out of the
fridge use immediately and can be stored at room
temperature for 6 hours37.
Stopping Breastfeeding
Mothers should be encouraged to continue
breastfeeding for as long as they wish or until the child
naturally stops breast feeding.
If breastfeeding is stopped before the child is one year
of age then fresh cow’s milk should not be given as the
main drink until the child is one year old. Therefore
until age one, formula milk should be used.
When the mother does decide to halt her lactation, it is
safer to both mother and child and more comfortable
to wean the baby off the breast gradually. As the milk
volume decreases, protective factors in the milk
increase.
Hypoglycaemia
The lack of an agreed definition of hypoglycaemia in
the NORMAL neonate has contributed to difficulties in
the provision of guidelines which has lead to
inappropriate medical intervention and the
jeopardisation of breastfeeding, either initiation or
maintenance. New research is soon to be published in
this area.
It is normal in the first hour after birth for baby’s blood
glucose level to fall, but then begin to rise, even if the
baby has not been fed. Glucose is vital as the major
source of energy, however, uniquely in humans, healthy
full term babies use alternative fuels for energy such
as ketone bodies and other metabolic substrates.
These are generated from body fat when glucose is not
readily available.
There is common concern amongst staff about
hypoglycaemia but acceptable levels of blood glucose
concentrations vary greatly. There is no widely
accepted cut off level below which hypoglycaemia is
indicated. The BM Stix were designed to detect high
glucose levels in people with diabetes. They are
imprecise between 0 and 3mmol/l which is the critical
range to assess newborns16.
Jaundice
Jaundice occurs in 9 out 10 newborn babies. It results
from a build up of (yellow coloured) bilirubin in the
blood stream. Newborn babies have a greater number
of red blood cells which are destroyed after birth. This
destruction releases bilirubin which is normally
metabolised by the liver. In jaundiced babies the liver
process takes a few days to start working efficiently
causing the jaundice.
The colostrum has a purgative effect which helps to
prevent jaundice, so early and frequent breastfeeding is
essential.
Appropriate advice:
l
l
l
Breastfeed soon after delivery.
Frequent and unrestricted breastfeeding.
No supplementary feeds e.g. glucose, water or
artificial milk.
7
The Under Fives
Breastmilk jaundice appears after 7 days. More serious
illness must be excluded by blood tests. If breastmilk
jaundice is the cause, breastfeeding should continue
and it will resolve itself. Mum will need reassurance.
Management of Gastroenteritis
If a baby develops vomiting and diarrhoea, it is
advisable to continue breastfeeding (section 3.5
Gastroenteritis).
when mothers feed babies “on demand”. Correct
positioning is also essential. If a mother does have milk
engorgement, check she is not trying to regulate the
frequency or duration of feeds and that positioning at
the breast is correct. Gentle expressing prior to
feeding to soften the breast will usually be sufficient to
relieve engorgement. If breasts are inflamed it may
also be necessary to express milk gently after feeding
until engorgement has subsided.
Mastitis
Stools
The initial stool passed by all healthy babies is the black
sticky meconium. This is passed on day one to two
after birth.
The breast fed baby’s stool gradually changes to
black/green on day three, green/brown on day 4 and
between day 4-5 it is yellow and seedy with a cottage
cheese consistency. If there is a delay, this may be due
to a problem of milk access or transfer or both.
Initially breastfed babies may have bowel motions very
frequently (sometimes at every nappy change). This
will gradually change. Some established older breastfed
babies will not pass a normal yellow stool for several
days (up to a week). This is normal, and reflects the
lack of waste in breast milk. This is not an indication
for medical intervention and breastfeeding mothers
may need reassurance that this is normal.
Sore Nipples
Sore nipples are always an indication of poor
attachment, therefore the remedy is to improve
attachment.
Re-positioning and optimal attachment of the baby at
the breast will produce nipple healing and is the most
effective remedy to achieving pain-free successful
lactation. Resting and expressing breast milk may
make it difficult to maintain milk production during the
healing process. The use of a nipple shield is not
routinely recommended. Teaching correct positioning
and attachment is essential.
There is no scientific basis for the use of creams,
sprays, lotions or ointments in healing nipples.
Milk Engorgement
Milk engorgement is when milk store in the breast isn’t
removed sufficiently, volume becomes too much for the
breast to store comfortably and breast become firm
and painful to touch. Milk engorgement rarely occurs
This is sometimes confused with engorgement, but
mastitis only affects part of the breast. However, if
engorgement is not treated, it can lead to mastitis.
The symptoms are a lump which is red and tender and
follow the outline of the breast lobe. The woman has
no fever and feels well. However, sometimes the
woman can have a fever and flu like symptoms.
To prevent mastitis, the baby should be correctly
positioned at the breast. Mothers should be advised
not to wear clothes which put pressure on the breast
and to handle breast gently. If there is any lumpiness,
stroking the affected areas downwards towards the
nipple will encourage drainage from this area. The skin
may also be damaged by the mother using creams,
lotions or spray to which she is sensitive. Damaged
skin presents an opportunity for bacteria to grow.
If mastitis does occur, mothers should be encouraged
to continue breastfeeding. Varying the baby’s feeding
position can aid drainage from the milk ducts.
Usually mastitis improves within a day when drainage
to the affected part of the breast improves. If there is
no improvement after 24 hours then the woman
should be referred for treatment, usually anti-biotics.
Slow weight Gain/Faltering growth
Breastfeeding babies who are slow to gain weight are
of concern to parents and professionals. It is often a
cause of mothers deciding to give artificial milks
instead. Consistent, accurate and practical advice is
necessary to ensure that both mother and baby remain
healthy.
It is vital to make a distinction between slow weight
gain where the baby is gaining weight on a lower
centile position but is healthy, and faltering growth
where the baby’s weight gain will be dropping down
centile positions, and may be showing signs and
symptoms of illness. A medical review should be
arranged under the latter condition.
For practical advice on how to deal with a child with
faltering growth, refer to the Breastfeeding Factfile.
8
The Under Fives
(v)
BREASTFEEDING AND DRUGS
Although very few medicines taken by the
mother would contraindicate breastfeeding,
women must be advised that no drugs should
be taken unless advised as safe by a doctor or
pharmacist.
(vi)
BREASTFEEDING AND HIV
It is important that the mother who has HIV is
empowered to make a fully informed decision
about infant feeding and that she is suitably
supported. There is evidence that HIV can be
transmitted through breast feeding (5-20%
transmission rates have been reported38).
If the mother can be ensured access to
nutritionally adequate breast milk substitutes
(formula) that are safely prepared, the infant is
at less risk of death and illness if they are not
breast fed. (This is the most likely situation in
Developed Countries).
If breastfeeding is the chosen route of feeding
- exclusive breast feeding is recommended for
6 months.
- When weaning foods are introduced breast
feeding should stop immediately and infant
formula started (this is known as ‘abrupt
weaning’).
(vii)
BREASTFEEDING AND THE PRE-TERM
INFANT
Breast milk is the preferred choice of milk for
pre-term infants. If necessary whilst in hospital
breast milk can be fortified with a breast milk
fortifier to meet the increased nutrient demands.
Non breastfed pre-term infants should be fed an
appropriate artificial formula suitably chosen to
meet the individual needs of the infant
concerned.
(viii) EDUCATION AND SUPPORT
Ante-Natal Education
Education on the benefits of breastfeeding is
important during pregnancy. All women should
be in a position to make an informed choice
about infant feeding. Ideally this education
should be aimed at the pregnant woman, her
partner and any other significant people involved
(e.g. mother, mother-in-law).
As the baby milk companies invest in producing
attractive, detailed information on bottle
feeding, it is vital to ensure that information of
at least equivalent quality is available on
breastfeeding.
The general public have a low level of
knowledge about the health benefits of
breastfeeding over bottle feeding, and myths
about feeding problems are widespread. It is
estimated that less than one in a hundred
women are actually unable to breast feed.
Success depends on the right sort of support at
crucial moments, and confident, consistent and
accurate advice from all members of the health
care team.
Ideally the public as a whole should be educated
so that the community is in favour of and
supportive to breastfeeding mothers.
Post-Natal Support Groups
Co-operation and collaboration with voluntary
groups such as the National Childbirth Trust, La
Leche League, the Association of Breastfeeding
Mothers is desirable. Their vital role in the
promotion of post-natal support is recognised,
but there is scope for greater Health Service
provision of support groups and telephone
helplines. However, local schemes such as Best
Buddies (HoBtPCT) and Feeding Friends Peer
Support (in some areas of BENPCT) are in
operation. Please refer to your local PCT to see if
your area is covered.
Supporting women to breastfeed
NHS premises should ensure that both private
and public areas are available for women to
breastfeed their babies. Signs should be
displayed to this effect. (see Appendix A for
further guidance)
NHS National Breastfeeding Support Helpline:
0844 20 909 20.
9
The Under Fives
SUMMARY - BREASTFEEDING
Breastfeeding is the most desirable means of
providing nutrition for the healthy infant.
The composition of breast milk is ideally suited to
the infants needs.
Breastfeeding results in health benefits for the infant
in both the short and long term and also for the
mother.
Informed, consistent and confident advice and
support are important to overcome any difficulties
encountered, and to ensure that successful
breastfeeding is maintained. Potential problems may
include:l
l
l
Successful initiation of breastfeeding is fundamental
to achieving and maintaining adequate lactation.
Factors affecting the potential success of lactation
include:l
l
l
l
l
l
Establishment of early contact between mother
and baby.
Correct positioning of the baby at the breast.
Baby-led feeding.
Avoidance of “complementary feeding”.
Avoiding nipple confusion.
Ongoing encouragement and practical support
from health professionals.
l
l
l
Mothers own concerns regarding the adequacy of
her milk supply.
Sore nipples.
Milk engorgement.
Mastitis.
Inadequate baby care facilities in public places.
Mothers should be encouraged to continue to
breastfeed until such a time as it becomes
inappropriate for herself or the baby.
A gradual “tailing off” rather than an “abrupt” end
to breastfeeding will be more comfortable for
mother and baby.
Women who are HIV positive or those at high risk
who have not been serologically tested, should be
discouraged from breastfeeding.
1.2 INFANT FORMULAE
Infant Formula and Follow-on Regulations 1997 has
been updated and is currently under review for 2008.
Breastfeeding should be encouraged, but where not
possible or desirable, an infant formula is a suitable
alternative. Parents should be supported in their
informed choice, and receive advice on appropriate
equipment and preparation of feeds.
When used, it is recommended that infant formula is
given for the first year of life and is given as the sole
source of nutrition until the infant is weaned at about
6 months and thereafter as part of a mixed diet.
l
Nutritional Composition of Infant Formulae
The composition of infant formulae for use in the
U.K. accords with the “Infant Formula and Followon Regulations 1995 and the amendments to this
in 199717. The nutritional composition of infant
formulae when correctly made up for consumption
10
by the infant, is designed to be as close to the
composition of human milk as possible. However,
infant formulae do not possess any of the
immunological benefits of breast milk.
A recent review showed that the majority of
formulae on sale in the UK are now available in a
variety of different presentations including ready to
feed milk and pre measured sachets18. Care needs
to be taken to ensure parents are aware of how to
use these products safely.
The promotion of breast milk substitutes is strictly
regulated by UK Law and the World Health
Organisation International Code of Marketing of
Breast Milk Substitutes. A description of the
legislation and good practice relating to the
marketing of infant formula is given opposite.
The Under Fives
Infant Formula and Follow on Formula Regulations 1995
THIS LAW ONLY APPLIES TO INFANT FORMULA AND, IN PARTS, TO FOLLOW-ON MILKS.
1. NO ADVERTISTING OR PROMOTION OF INFANT FORMULA OUTSIDE THE HEALTHCARE SYSTEM
2. ADVERTISING IS ONLY PERMITTED IN BABY CARE PUBLICATIONS DISTRIBUTED THROUGH THE HEALTH CARE
SYSTEM
3. PERMITTED ADVERTS MAY ONLY CONTAIN SCIENTIFIC AND FACTUAL INFORMATION AND MUST NOT CARRY
BABY PICTURES.
4. NO PICTURES OF BABIES ON INFANT FORMULA LABELS, NO OTHER PICTURES OR TEXT WHICH MAY IDEALISE
THE PRODUCT.
5. NO FREE SAMPLES OF INFANT FORMULA TO MOTHERS OR PREGNANT WOMEN.
6. NO FREE OR SUBSIDISED SUPPLIES TO HOSPITALS.
7. NO GIFTS TO PROMOTE SALE TO THE PUBLIC.
8. FORMULA COMPANIES MAY ONLY GIVE INFORMATION IF IT IS REQUESTED BY THE RECIPIENT AND
DISTRIBUTED THROUGH THE HEALTH CARE SYSTEM.
Enforcement is the responsibility of Trading Standards or Environmental Health Offices. Members of the public
should report breaches to these offices.
Further restrictions may be provided in the Department of Health guidelines.
THE INTERNATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUTES
1.
2.
NO ADVERTISING OF BREASTMILK SUBSTITUES IN THE HEALTH CARE SYSTEM OR TO THE PUBLIC.
NO FREE SAMPLES TO BE GIVEN TO MOTHERS OR PREGNANT WOMEN
3.
NO FREE OR SUBSIDISED SUPPLIES TO HOSPITALS
4.
NO CONTACT BETWEEN COMPANY MARKETING PERSONNEL AND MOTHERS.
5.
MATERIALS FOR MOTHERS SHOULD BE NON-PROMOTIONAL AND SHOULD CARRY CLEAR AND FULL
INFORMAITON AND WARNINGS.
6.
COMPANIES SHOULD NOT GIVE GIFTS TO HEALTH WORKERS.
7.
NO FREE SAMPLES TO HEALTH WORKERS, EXCEPT FOR PROFESSIONAL EVALUATION OR RESEARCH AT THE
INSTITUTIONAL LEVEL.
8.
MATERIALS FOR HEALTH WORKERS SHOULD CONTAIN ONLY SCIENTIFIC AND FACTUAL INFORMATION.
9.
NO PICTURES OF BABIES OR OTHER IDEALISING IMAGES ON INFANT FORMULA LABELS
10. THE LABELS OF OTHER PRODUCTS MUST PROVIDE THE INFORMATION NEEDED FOR APPROPRIATE USE,
SO AS NOT TO DISCOURAGE BREASTFEEDING.
Governments are expected to adopt the Code as legislation.
Companies should comply with the Code, even if it has not been adopted as law.
11
The Under Fives
Melamine in Formula Milk
Melamine is a chemical used in plastics that has been
linked to kidney failure.
The Food Standards Agency can confirm that no
formula manufactured in China can be sold legally in
the UK and that manufacturers of formula sold in the
UK can not use any milk or milk products imported
from China.
*Ref: Food Standards Agency (Sept 2008)
http:www.food.gov.uk
l
Types of Infant Formulae
Most infant formulae are based on
cow’s milk. Some however are
based on other proteins for infants
with special requirements e.g.
soya.
(i)
Standard Formulae
Unmodified cow’s milk is nutritionally unsuitable for
use as the sole source of nutrition for infants, in view
of its high protein and mineral content and hence,
high renal solute load. Cow’s milk is highly modified to
produce standard infant formulae. Such formulae are
classified according to whether the dominant protein is
WHEY OR CASEIN.
Whey based e.g.
Casein Based e.g.,
SMA Gold (SMA)
SMA White (SMA)
Cow & Gate First (Cow & Gate)
Cow & Gate milk
for hungrier babies
Apamil First (Milupa)
Aptamil Extra (Milupa)
Nurture Newborn (Heinz)
Nuture for hungrier
babies (Heinz)
still hungry and not satisfied by the feed. Many
mothers were found to change from a whey to a
casein dominant formula believing this would be more
satisfying. Such beliefs however, are based on
anecdotal evidence. There is no scientific evidence that
changing feeds from a whey to a casein dominant
formula “satisfies” a baby’s hunger.19
Hungry or unsatisfied infants should be offered larger
or more frequent feeds rather than a
change of formula. However, a
change of formula would be
preferable to the premature
introductions of solids.
(ii)
The Committee of Toxicity of
Chemicals in food, Consumer
Products and the Environment (COT)
recommends20 that the use of soya-based formula in
infants is not appropriate unless there is any clinical
indication to do so. This is due to concern about the
possible negative long term effects of early exposure
the phyto oestrogens (which occur naturally in soya
bean) these are very similar to the female hormone
oestrogen. The British Dietetic association has
published a statement on soya which states that there
are some grounds for concern. The COT’s
recommendation20 (March 2003) was that the use
of soya-based formula infants is not appropriate
unless there is any clinical indication to do so.
Soya formula and products should only be used
for infants under 6 months if:
l
Hipp Organic Infant Milk
l
These Formulae are available with Healthy Start
vouchers.
Casein based formulae (marketed for hungrier babies)
have a higher casein to whey ratio than whey based
formulae. They also have a higher protein and mineral
content, and hence renal solute load, than both whey
based formulae and breast milk. As whey based
formulae more closely resemble breast milk than
casein based formulae, it would seem appropriate
to recommend their use.
The ONS survey (2000) found that by the 6th to the
10th week of life 35 per cent of mothers had already
changed the type of formula they were giving to their
bottle-fed infants. The most common reason for
changing was that the mother thought the baby was
12
Soya Formulae
l
There is a cow’s milk protein allergy and
hypoallergenic formula is refused (relatively
rare in infants under six months).
The mother is vegan and has chosen not to
breast-feed.
The child has galactosaemia
Examples of soya formula:
Infasoy
Cow &Gate
Wysoy
SMA
Nuture soya
Heinz
The risk of permanent changes is greatest prior to 6
months of age, as the dose of phytoestrogens per kg
body weight is higher at a key developmental stage. In
infants over 6 months the risks associated with soya
products are reduced as milk is not the sole source of
nutrition and soya products can be used. If using soya
formula under the age of 6 months the issues should
be discussed with the parents/carer.
The Under Fives
Therefore, if under 6 months of age, a child presenting
with symptoms of cow’s milk protein intolerance and
not being breastfed, the formula of choice should be a
protein hydrolysate (see section iv).
Soya milks bought in supermarkets or health food
shops are unsuitable for use as a milk substitute for
infants and young children. If, despite the
recommendation above, a soya formula is required
they are available over the counter and on prescription.
The aluminum content of soya formulae is higher than
that of cow’s milk based infant formulae, but it is still
within currently accepted safety levels.
Care should be taken with the use of soya formulae
and dental hygiene, because the carbohydrate source is
glucose rather than lactose. It is therefore essential to
stress the importance of dental health for infants
taking soya formula (see Dental Health, section 1.7).
For a review of the nutritional adequacy of the diet,
particularly calcium intake, advice on weaning a child
onto a cow’s milk free diet and advice on appropriate
formula to use, refer the child to a registered dietitian.
(iii)
Lactose Free, Cow’s Milk Based Formulae
Example
SMA LF
Enfamil Lactofree
Brand
(SMA Nutrition)
(Mead Johnson)
These formulae contain cow’s milk protein but are
lactose free and therefore can be used in children with
lactose intolerance.
They are available over the counter and on
prescription.
(iv)
Protein Hydrosylates
Example
Pregestimil
Nutramigen
Pepti Junior
Prejomin
Pepti
Pepdite
MCT Pepdite
Protein source
Casein
Casein
Whey
Whey
(not lactose free)
whey
Non milk
Non milk
Brand
Mead Johnson
Mead Johnson
Cow & Gate
Milupa
Cow & Gate
SHS
SHS
(v)
Elemental Formula
These formulae are hypoallergenic, nutritionally
complete for use as a sole source of nutrition in
infancy. The protein source is based on essential and
non-essential synthetic amino acids. These formulae
are free from gluten, lactose, milk protein and sucrose.
These formulae are only available on prescription.
Example
Neocate (<1 year)
Neocate advance (>1 year)
Nutramigen AA (from birth –
use as infant formula)
(vi)
Brand
SHS
SHS
Mead Johnson
Follow-on Formulae
Example
Brand
Progress
SMA
Hipp Organic follow on
Hipp
Hipp organic Growing up (>10months)
Aptamil Follow on
Milupa
Aptamil Growing up (>12 months)
Nurture Follow on
Heinz
These milks are marketed for use from 6 months
(unless indicated differently on table). Follow on milks
have a similar calorie but higher protein, mineral, (e.g.
sodium and calcium), and iron content than normal
formula milks. They also contain more of certain
vitamins (e.g. vitamin D) than standard infant
formulae.
They can be useful where there is concern regarding
an infant’s iron intake, perhaps as a consequence of an
inadequate intake of formula, too early an introduction
to cow’s milk, an excessively large intake of cow’s milk,
or a poor weaning diet.
The main advantage of these milks is their higher iron
content. However, there is no evidence that follow-on
formulae have a beneficial effect on iron status in
children who have been weaned according to
guidelines and normal formula continued until one
year of age.
They are however not available on the Healthy Start
Scheme for low income families and for the majority of
infants the nutritional and financial benefits of
continuing breastfeeding or infant formula to 12
months of age should be stressed.
Protein hydrosylates are based on hydrolysed protein
sources, they are clinically lactose free and
hypoallergenic. These milks are highly specialised and
may be used in cases of milk intolerance as an
alternative to cow’s or soya based formulae. Their use
should always be under the direction of the medical
practitioner/dietitian. These formulae are only available
on prescription.
13
The Under Fives
(vii)
Low Birthweight/Pre-term Formulae
Example
SMA Gold Prem
Nutriprem 1
OsterPrem
Pre-aptamil
Pre Nan Nestle
(x)
e.g.
Brand
SMA
Cow & Gate
Farleys
Milupa
These formulae are specifically designed to meet the
needs of the low birthweight or preterm infant, whilst
in hospital. They are unsuitable for full term infants,
including those with faltering growth. These formulae
are for hospital use only until the infant reaches 2500g.
High Energy Formulae
SMA High Energy
(SMA)
Infatrini
(Nutricia)
These formulae have a higher calorie and protein
content and are officially designed for use with infants
with faltering growth. They are only available on
prescription in a ready to feed format. They should be
used under the direction of the medical practitioner or
dietitian.
(xi)
Goats milk formulae
e.g.
Nanny
(viii) Follow-on Low Birthweight Formulae
Brand
(Cow & Gate)
Example
Nutriprem 2
Low birthweight infants may need to change on to a
follow-on low birthweight formulae prior to being
established on a standard infant formula. This will be
determined by their clinician/dietitian. These formulae
are now available on prescription for children before 35
weeks gestation and small for gestational age until 6
months corrected age.
(ix)
Other Formulae
Suggested use
Acid reflux
Aid digestion
Night time
Formula
Examples
SMA
Staydown
Enfamil AR
Comfort first
Good Night milk
(gluten free)
Good Night
Milk drink
Brand
SMA
Age range
Birth
Mead Johnson
Cow & Gate
Cow & Gate
Birth
Birth
From 6
months
From 6
months
Hipp
Night time Formulae
E.g. Cow & Gate Good Night Milk (Cow & Gate), Hipp Organic Good
Night Milk Drink (Hipp)
Infant formula and follow-on formula based on goats’
milk protein are not suitable for babies, are not
recommended by the Department of health and are
not approved for use in Europe. Some proteins in
goats’ milk are similar to those in cows’ milk and the
levels of lactose in the formulas are similar. Most babies
who react to cows’ milk protein or who have lactoseintolerance are also likely to react to goats’ milk
formulas.21
Goat’s & Sheep’s Milk
Unmodified goat’s milk, like cow’s milk is low in iron,
vitamins A and D and folic acid. Sheep’s milk is also
low in iron, vitamin D and folate. Although these milks
may be perceived as less allergenic or providing special
nourishment, none of these claims have been
substantiated. As these milks have a high solute load,
are nutritionally inadequate and frequently are
unpasteurised, they are unsuitable for infants under 12
months. They may be given after one year so long as
precautions against mineral and vitamin deficiencies
are taken and that due regard is paid to
microbiological safety. Check the nutritional status of
the diet and ensure milk is pasteurised.
FEED PREPARATION
Manufacturers are bringing out new formulae that are
reported to help settle baby at bedtime and which are
also reported to be gentler on babies’ tummies. They
differ from infant formula and follow-on formula in
that they have added starch, making it more viscous.
Currently there is limited evidence to support the
claims made with respect to settling the baby for the
night or being gentler on babies’ tummies. These are
also more expensive than other formulae.
14
(See Appendix F)
Infant formula are presented as:
Liquids which are ready to feed.
(i)
(ii)
Liquids or powders which require the addition of
water but no other substance.
Detailed instructions on preparing the feeds for
consumption by the infant are provided by the
The Under Fives
manufacturer on the packaging and in leaflets. These
instructions must be closely followed.
The following points may require reinforcement by the
health professional:(i)
Hygiene
Hygiene and the prevention of infection is a primary
concern when preparing infant formula feed.
months of age. Care should be taken when choosing
a bottled water, as some have an unacceptably high
mineral content. Carbonated bottled water should not
be used.
When abroad, boiled tap water should be used. If this
is unsuitable, boiled non-carbonated bottled water may
be used. Any bottled water with a sodium content of
under 200mg per litre is suitable.
(iv)
Handwashing should be the first stage in preparing
feeds and before offering feeds to baby.
All equipment used (bottles, teats, caps, rings) should
be suitably sterilized for the first 12 months.
Storage of Prepared Feeds
Bottles of feed may be stored for up to 24 hours, this
is no longer considered ideal particularly for young
babies because the bacterial content continues to
increase during storage which increase the risk of
infection for the baby.
Available methods are:
Chemical
Steam Boiling
Boiling
Microwave
Oven
(ii)
Use of a hyperchlorite solution
(cold water) e.g. Milton.
Use of a steam steriliser (electrical)
Boiling of equipment for 10 minutes
(submerged in water).
Use of specially designed microwave
sterilising sets.
Making up feed
All formulae should be made up with cooled boiled
water.
Correct dilution of the feed is essential. Powdered
feeds are made up by the addition of one level
unpacked scoop to each fluid ounce (30ml) of cooled
boiled water (check manufacturers instructions).
Some powdered feeds are now available in measured
sachets. The manufacturer’s instructions should be
closely followed when making up these feeds.
Also feed should not be stored in large volumes as this
could promote inadequate cooling and hence lead to
the growth of bacteria.
The risk of infection to the baby will be lower if the
feed is only stored for a short period of time.
(v)
Warming of Feeds
Only remove stored feed from the fridge immediately
before use. Feeds should be warmed to blood
temperature. Warm feeds by standing them (in their
bottles) in hot water. Always test before giving to baby.
The use of microwave oven is not recommended for
warming feeds due to dangers of uneven heating and
hot spots which could cause severe scalding. If a
microwave oven is used, the carer should be advised of
this risk and encouraged to mix well and test before
giving to baby.
No sugar or salt should be added to formula feeds. No
solids such as rusk or cereals e.g. Weetabix should be
added to the formula feed. Adding solids to formula
will change the consistency and increase the risk of
choking and may also increase the risk of gut
sensitivity.
(iii)
Water for feed preparation
Cooled boiled tap water should be used for making
any infant formula.
Allow tap water to run for 1 – 2 minutes before use.
Artificially softened water and filtered water should not
be used. Bottled waters are not sterile and
consequently any bottled water must be boiled before
use in preparing formulae or food for infants under 12
15
The Under Fives
(vi)
Thickening of Feeds
Any thickening of feeds can only be done following
advice from a Doctor, Speech and Language Therapist
or Dietitian. Reasons for thickening may be; gastro
oesophageal reflux, frequent posseting or poor
swallow co-ordination.
(vii)
Transporting feeds
●
Because of the potential for growth of harmful
bacteria during transport, feeds should be first
cooled in a fridge (below 5ºc) and then
transported.
Prepare feed as outlined in section ‘(ii)Making
up feed’ and place in the fridge. Ensure feed
has been in the fridge for at least an hour
before transporting and only remove feed from
the fridge immediately before transporting.
Transport feeds in a cool bag containing a
frozen ice block.
Feeds should be used within 4 hours following
transport or they should be kept in the fridge
for a maximum of 24 hours from the time of
preparation – this is not ideal as the risk of
illness increases the longer it is stored.
Re-warm feed as detailed in section
‘(v) Warming of feeds’.
●
Examples of thickeners are
Example
Brand
Age of use
Information
Thick and Easy
Fresenius Kabi
Thicken up
Nestle/Novartis
Vitaquick
Vitaflo
Thixo-D original
Sutherland
Health Ltd
Cow and Gate
Nutricia
<1 year if
faltering growth
<1 year if
faltering growth
<1 year if
faltering growth
< 1 year if
faltering growth
< 1 year
>3 years
Instant Carobel
Nutilis
Other
Healthcare
professional
will provide
information
on amounts
to use.
For infants who have faltering growth, Vitaquick,
Thixo-D or Thick and Easy may be suitable. These
thickeners provide an additional 4Kcal/g of thickening
powder. Nutilis is a thickener that can be used from 3
years of age. Enfamil AR and SMA stay down are
thickened. Enfamil AR thickened formulae available
prescribed and over the counter, but should only be
used under medical/dietetic supervision.
Also available are infant formula which has thickening
agents added during manufacturing:
Enfamil AR (Mead Johnson) and SMA Staydown are
the two available options.
16
●
●
The Under Fives
SUMMARY - INFANT FORMULAE
When used, infant formulae should be continued
throughout the first year of life.
Types of Infant Formulae
(i)
Standard Formulae
These are produced from cow’s milk which is highly
modified. They are suitable for the majority of
infants who are not breastfed.
Whey based formulae more closely resemble breast
milk than casein based formulae, and are therefore
the formula of choice.
(ii) Soya Formulae
May be used as an alternative to cow’s milk based
formulae in cases of intolerance to cow’s milk protein
and / or lactose, from 6 months old.
Soya milks bought in supermarkets or Health Food
Shops are unsuitable for use as a milk substitute for
young children and infants.
All soya formulae are free from animal products and
are therefore suitable for vegetarians, vegans and
cultures which only consume halal or kosher foods.
(iii) Lactose Free
Cow’s milk based formulae can be used for infants
who are lactose intolerant.
(iv) Protein Hydrosylates
These may be used in cases of cow’s milk intolerance
as an alternative to cow’s or soya based formula.
Only available on prescription.
(v) Follow-on Milks
These are cow’s milk based formulae suitable for
infants from six months of age. For the majority of
infants they offer little benefit when compared with
standard formulae. The higher iron and vitamin D
content however may make them useful for older
infants in whom these nutrients are at risk.
(vi) Low Birthweight / Pre-term Formulae
These are specifically designed to meet the needs of
low birthweight or pre-term infants. They are not
suitable for full term infants, including those who are
failing to thrive.
(vii) Follow-on Low Birthweight Formulae
Some low birthweight infants may need to progress
on to a follow-on low birthweight formula prior to
being established onto a standard infant formula.
(viii) Other formulae
There is limited data to support the use of novel
formulae. They are more expensive
than standard formulae
(ix) High Energy Formulae
Designed for infants with faltering growth.
Only available on prescription.
Goat’s & Sheep’s Milk
These should not be given to infants under 12
months of age. They may be given from the age of
1 year if precautions are taken against vitamin and
mineral deficiencies and they are microbiologically
safe.
FEED PREPARATION
l Ensure manufacturers instructions for
reconstituting formulae are followed closely.
l
Hygiene and the prevention of infection is a
primary concern.
l
All equipment used should be suitably sterilised.
l
Cooled boiled water should always be used for
making up formulae.
l
Correct dilution is essential i.e., 1 level unpacked
scoop of infant formula powder to one fluid
ounce (30mls) of cooled boiled water. Check the
label for exact procedure.
l
No sugar, salt or solids e.g. rusk or cereal, should
be added to the formula.
l
Feed may be stored in a refrigerator for a
maximum of 24 hours although this is not ideal as
bacterial content continues to increase during
storage. Feed should be stored for as little time as
possible to keep risk of infection low.
l
Feeds should be warmed to blood temperature by
standing the bottle in hot water. The use of a
microwave oven for reheating is not
recommended.
l
Only appropriate thickeners should be used when
thickened fluids are required. Medical, Speech
and Language Therapist, Dietetic advice should be
sought.
17
The Under Fives
1.3 FLUIDS OTHER THAN MILK FOR
INFANTS UNDER 6 MONTHS
AIMS OF WEANING
l
Whether babies are fed solely on breast milk or a
correctly reconstituted infant formula they rarely
require additional fluids providing adequate milk is
given. Generally 130 – 150ml per kg per day is
recommended but individual circumstances need to be
taken into account.
l
l
In very hot weather additional breast feeds may be
required and for formula fed babies, extra fluids.
Cooled boiled water is recommended. If fruit juices are
given they should be well diluted – at least 10 parts
cooled boiled water to 1 part juice. Citrus juices
should be discouraged before 6 months. “Baby drinks”
are not needed but if given they should be used
sparingly and parents should be advised to use a cup
(as opposed to a lidded beaker or bottle) to safeguard
infant dental health.
SUMMARY –
FLUIDS OTHER THAN MILK
l
l
l
l
Fluids in addition to breast milk or formula are
rarely required provided adequate milk is given.
Exclusively breast fed babies should never require
extra fluid.
In very hot weather additional fluids may be
required for bottle fed babies.
Water should be used in preference to juices.
When juices are given they should be well
diluted.
Citrus juices should be discouraged before 6
months.
1.4 WEANING
During the first few months of life, breast or formula
milk provides a baby with all the nourishment needed
for growth and development. At around 6 months
nutritional requirements cannot be met by breast or
formula milk alone so this is the time to start
introducing solids. This process is known as weaning.
Weaning is a gradual process extending over a period
of weeks or months progressing from smooth purees
to mixed feeding including family foods. (see table
‘Aims of Weaning) In addition to weaning foods all
infants should also be offered breast or formula milk
up to 1 year old.
Satisfactory growth and development in children is
intrinsically linked to their diet antenatally and from
birth onwards.
18
l
l
To encourage appropriate eating habits in
childhood which will form the basis of a healthy
and varied diet in later life.
The infant is born with a store of iron, but these
are running low by 6 months. A variety of foods
should therefore be introduced to replenish these
stores
To encourage acceptance of textures and tastes
at an optimal time in the child’s development.
To promote appropriate eating habits at
mealtimes as an important part of social
development
To encourage the use of home cooked foods in
addition to commercially produced products
whenever possible/appropriate to facilitate
weaning onto a family diet
It teaches the baby to:
l
l
l
l
l
Take foods rather than milk, with different tastes
and textures
Learn how to bite, chew and swallow
Use a spoon
Drink from a cup
Enjoy the social aspects of eating
Following WHO guidance, the Department of Health22
has issued recommendations on breast feeding: “Breast
feeding is the best form of nutrition for infants.
Exclusive breast feeding is recommended for the first
six months (26 weeks) of life as it provides all the
nutrients a baby needs”.
Breast feeding mothers need appropriate nutritional
advice (and supplementation where necessary) to
ensure they remain healthy to feed and care for their
babies.
There are nutritional and developmental reasons why
infants need solid foods from six months. Infants who
are weaned at or near six months will need to be
moved on to a mixed diet more quickly than those
weaned earlier to ensure continued development of
normal feeding behaviour and continued nutritional
adequacy.
The Under Fives
Despite the Department of Health’s advice, many
parents will choose to give solid foods before six
months. Parents should firstly be encouraged to wait
until 6 months and informed of the disadvantages of
early weaning.
Whatever feeding decisions parents make (breast
feeding or bottle feeding; early or later weaning), they
need to be supported and given appropriate advice to
ensure that all infants are fed safe, nutritionally
adequate diets23.
The table ‘When to Wean’ describes the rationale for
the guideline23 (See Appendix G).
WHEN TO WEAN
Reasons for not introducing
solids too early
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Immature kidneys
Potential allergic reactions
All the nutritional requirements up to 6 months of
age
Solids may reduce availability of nutrients in milk
Absorptive capacity of the gut is not developed
until four months
Neuromuscular co-ordination is not sufficiently
developed to: - (a) pass food from front to back of
mouth (b) leave food in the mouth to bite or chew
or (c) to sit up in the best position to receive food
from a spoon
Increased risk of obesity
Signs that an infant is ready to start weaning
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Doesn’t seem satisfied after a good milk feed or
starts to demand feeds more frequently for an
extended period (e.g. one week).
Shows an interest in food, perhaps reaching out for
food.
Shows an increased need to chew, dribbles more
frequently.
Starts to put things into his or her mouth to
explore the taste and texture.
Although infants may start to show some of these
signs at an early age, it is recommended to wait until
he or she is 6 months old before introducing solids.
In all cases the individual child’s circumstances need to
be considered. Further considerations may be necessary
for children with special needs.
Weaning preterm infants24
Preterm infants form a nutritionally vulnerable group
with a higher than average rate of feeding problems. It
is essential that appropriate advice is given to help to
prevent and overcome these difficulties.
Preterm infants should be weaned around 6 months
Reasons for introducing solids
at 6 months
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Nutrient needs are increased
Decreased body stores of iron
Breast or formula milk no longer provides all the
nutrients required for a growing infant
To encourage chewing
Key developmental stages may be missed
Less chance of food refusal
chronological age as for term infants. Some infants
may need to be weaned earlier than this, but this
should not occur before 4 months chronological age.
Chronological age means from their actual date of
birth. Concern has been raised about the safety of
introducing solids before 4 months post due date (i.e.
40 weeks gestation). However, the introduction of milk
feeds leads to a precocious development of the
gastrointestinal tract with respect to digestion and
motility. There is no evidence for increased risk of
allergy or obesity. On the other hand, preterm infants
seem to have a higher prevalence of behavioural
feeding problems. This may be due to solids
(particularly lumps) having been delayed beyond a
critical period of acceptance.
Some preterm infants may suffer physical
developmental delay which may delay the weaning
process. Weaning should be attempted well before
seven months of age; if it does not progress
satisfactorily it could be halted and retried after a brief
break. There should be some assessment as to the
degree to which the infant is participating so that
passive over or force feeding is avoided. In those
infants approaching seven months in whom weaning
has not been successful, referral to a speech and
language therapist is advised.
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The Under Fives
Weaning
The following describes the weaning ages. It is
recommended that weaning starts at 6 months.
Weaning ages
6-9 months
An infant starting solids at 6 months may need to be
given pureed food initially for a very short time (days).
Choose a time when both mother and infant are
relaxed, and the child is not tired. Initially try solids at
one feed, but this can quickly be increased as the child
becomes familiar with eating solid food.
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Aims
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To promote the use of different/stronger tastes and
textures of food
To promote the use of foods that contain iron in
order to replenish iron stores
To promote the use of foods and drinks that will
provide Vitamin C which will help with the
absorption of iron
To promote the use of foods that encourage
chewing
Consistency
The infant should now be ready to progress to mashed,
minced and soft finger foods and should experience
different textures of foods and stronger tastes.
Progressing to these textures plays an important part in
the development of the ability to chew, bite and may
help with the development of speech muscles.
Although potentially messy, children should be
encouraged to use feeder cups and to feed themselves
with appropriate utensils.
The addition of salt and sugar is not recommended.
INFANTS MUST NEVER BE LEFT UNSUPERVISED
WHEN EATING AS THEY CAN EASILY CHOKE.
NB: The infant may spit out lumps at first but will
learn to chew them.
Appropriate foods:
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Family foods mashed and blended to soft lumps
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Cooked vegetables and fruit mashed to a coarse
texture
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Meat, fish or pulses coarsely pureed
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Soft finger foods e.g. toast, cooked green beans
and carrots, chopped hard boiled egg, soft raw
20
fruit, e.g. banana, pear, peach, melon, tomato
Cereals e.g. Weetabix, rice, pasta
Yogurt, milk custards and milk puddings
Honey and corn syrup should should not be given
to infants under one year old. Very occasionally it
can contain spores which can cause serious illness
(infant botulism).
Salt should not be added to food, sugar should be
used sparingly and only to increase the palatability and
acceptance of foods such as sour fruit. A small baby’s
system cannot cope with more salt than is naturally
found in foods. Cutting down on salt is generally
good for everyone.
Sugar can encourage a sweet tooth and lead to tooth
decay. Honey is also a form of sugar.
Manufactured weaning foods may also be used, but
ensure they are for the correct age. By 9 months of
age the infant should be taking a variety of foods at
each meal, three times a day.
9 – 12 months
This age of weaning marks a progression to a diet of 3
main meals interspersed with snacks or milk drinks.
Nutritional breast feeds will probably be reduced to 3
or 4 a day.
Formulae fed infants will still need 500 – 600ml of
formula milk daily.
Consistency - Chopped and finger foods.
Appropriate foods:
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Bread, preferably wholemeal, pasta, rice
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Unsweetened breakfast cereals
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Cooked vegetables & fruits need only be chopped.
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Meat & fish may need to be minced and finely
chopped
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Pulses should be lightly mashed
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Finger foods e.g. small cubes of fruit, vegetables,
potato, toast, cheese or soft meat at each meal
The Under Fives
At the age of 12 months a full family diet should be
offered. The use of salt should still be discouraged.
Consistency
Smooth consistency and bland taste.
Home prepared weaning foods
Appropriate Foods
Wherever possible, home prepared weaning foods
should be encouraged over manufactured weaning
products.
With a little preparation and cooking, a whole variety
of basic household foods can be used to provide an
excellent weaning diet.
Purees may be prepared at home by mashing or sieving
or by using a hand or electric blender / liquidiser. If
additional fluid is necessary to achieve the correct
consistency either cow’s milk, breast milk, infant
formula or cooled boiled water may be added.
Storage of cooked foods for re-use should be in
suitable sealed containers in refrigerators for no more
than 24 hours or alternatively foods should be frozen.
Care and attention must be given to the washing of
hands and equipment when preparing any weaning
foods.
Nutrient content of home prepared food is variable and
can be low in fat, energy, protein and iron.
It is important therefore as solids begin to replace the
milk diet, that infants receive a diverse diet which
provides enough energy for growth and development.
It is also important that parents do not impose the high
fibre, low fat diet that is recommended for adults onto
young children.
Suitable first foods could be:
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Gluten free cereals e.g. baby rice, thin porridge
made with rice, cornmeal, maize.
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Pureed potato, carrot, swede, parsnip or yam
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Pureed fruits – e.g. apples, pears, banana, mango.
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Plain (unsweetened) full fat yogurt, fromage frais*
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Plain milk custard*
*NB: Cow’s milk products are suitable
provided there is no family history of
eczema, asthma or other allergy.
Once the infant is accustomed to taking
solids from a spoon, different tastes and
textures should be introduced e.g. wellcooked pureed meat or pulses and a wider
variety of cereals, fruit and vegetables.
Encourage parents to use home prepared foods, which
should be thin, smooth and free from lumps. This can
be achieved by sieving, liquidising or mashing.
It is also important to avoid adding solids to a bottle
feed – this won’t teach an infant how to bite and
chew and there is also a danger of choking on the
thickened food.
Give small amounts 1 – 2 teaspoons to begin with.
Be guided by the child’s appetite and progress with an
increasing amount and number of weaning foods each day.
All infants should be managed individually so
that insufficient growth or other adverse
outcomes are not ignored and appropriate
interventions are provided. Consequently there
may be instances where an infant is weaned
before 6 months but this should never be before
17 weeks. The following information should be
followed when weaning at 17 weeks.
Advice for weaning before 6 months
Starting off
Initially solids should be introduced at one feed time
only. A time should be chosen to suit both mother and
infant, when both are relaxed and the child is not too
tired. It may be best to give a little of breast or
formula milk before offering solids. A hungry baby
will not be willing to try anything new and will just get
frustrated.
21
The Under Fives
Foods to avoid before 6 months:
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Wheat-based foods which contain gluten e.g. flour,
breakfast cereals, rusks.
Nuts and seeds – ground nuts and crunchy nut
spreads. Whole nuts should not be given to
children under 5 years in case of choking.
Eggs.
Fish and shellfish
Citrus fruits
Follow on milk
*Honey (refer to section 6-9 month weaning)
COMMERCIAL FOODS
Commercial baby foods are intended only to contribute
to a mixed weaning diet of family foods. They are
convenient to use but are expensive and the energy
levels can be low. If commercial foods are used
excessively during the first stage of weaning,
many parents find that the infant is unwilling
to move on to family foods later. The sole
use of commercial foods by families, whose
religious or cultural beliefs or
personal preferences lead
them to avoidance of foods
that contain animal
products, can result in an
unduly restricted weaning
diet.
MILK AND OTHER
FLUIDS
The number of milk
feeds will be reduced
during the weaning period
so that by 12 months of age,
approximately one pint of milk should
be taken daily or the equivalent as
cheese or yogurt (1/3 pint/200ml
milk = 1 oz/30g cheese = 5 fl
oz/125g yogurt). Additional
fluids should be given as water
or very diluted juice. Water is the
best alternative drink to milk.
Bottled water may contain high
levels of some minerals and fizzy
bottled water can damage teeth
due to its acidity. If a bottled
water needs to be used a still
water should be chosen.
Fruit juices can be used after 6
months. They are a good source
of vitamin C, but contain sugars,
22
which can cause tooth decay and are acidic. Dilute 1
part fruit juice with 10 parts water and give in a
feeding cup at mealtimes only.
Squashes, flavoured milk and juice drinks - are
unsuitable for babies as they contain sugars. Sugary
drinks, including fruit juices, can cause tooth decay
especially when given in a bottle.
‘Baby’ and herbal drinks usually contain sugar and their
use is not recommended.
Tea and coffee are not suitable drinks for babies or
young children as they reduce iron absorption and if
sugar is added may contribute to tooth decay.
SUMMARY - WEANING
All children are different and may therefore reach the
various stages of weaning at slightly different ages.
The above is intended as a guide. However, early
and late weaning can have a detrimental effect upon
the child’s health and development.
By the time the child is taking a mixture of foods,
cups should be used for drinks. It should be noted
that keeping a child on a bottle for a prolonged
period of time could cause problems with dental
caries.
1.5
FURTHER CONSIDERATIONS
Iron and the weaning diet
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A good variety of foods in sufficient quantities
should provide enough dietary iron and other
minerals.
Vitamin C in adequate amounts given with or
included in meals will assist iron absorption. This is
especially important if the diet is meat free.
Tea and coffee inhibit the absorption of iron from
food and should not be given to young children.
The bioavailability of iron from breast milk is
reduced if given at the same time as solids.
Therefore some breastfeeds should be given
separately.
If there are concerns about the adequacy of iron in
the diet after the first year, the continued use of
iron-enriched infant formula or follow-on milk
should be considered as the main milk drink for
several months more. (NB follow-on milk is not
available on Healthy Start for low income families).
See appendix C for dietary sources of iron and
vitamin C.
The Under Fives
Iron Deficiency
Heavy prolonged reliance on cow’s milk
There are many practices, which may contribute to the
development of iron deficiency anaemia25. They
include:
Large amounts, particularly over 1 pint/600ml daily of
cow’s milk consumed beyond 12 months of age will
reduce the child’s appetite at mealtimes. The energy
intake is usually adequate but intake of other nutrients,
including iron will be low.
Late initiation of weaning
An infant is born with a store of iron which is usually
sufficient to meet the infant’s need. However, if the
mother was herself anaemic or poorly nourished the
infant’s iron stores may be less than adequate. By the
age of 6 months the infant stores are becoming
depleted so weaning foods should include good
sources of iron.
Slow progression through the stages of weaning
The introduction of lumpy foods to encourage chewing
or progression from weaning to family foods may be
delayed. It is essential that lumpier textures are
introduced at approximately 6 months of age or the
child may reject lumps at a later stage and become
‘stuck’ on smooth purees.
The reluctance to introduce lumpy or finger foods may
be due to a fear of the child choking.
Heavy reliance on commercially produced
products
VITAMIN D AND RICKETS
Vitamin D can be obtained in the body from the action
of sunlight on exposed skin. However, in the UK
sunlight can be limited and as there are only a limited
number of foods which contain vitamin D, some
individuals are at particular risk of deficiency. The risk is
heightened in those who are dark skinned as they can
filter the sun’s rays more effectively (less vitamin D
synthesised). It is also heightened in those who remain
covered up when outside due to cultural or religious
reasons.
If a mother has a low intake of vitamin D during
pregnancy or poor exposure to sunlight, infantile
rickets and hypocalcaemic fits may result9. Infants,
toddlers and pre-school children can also develop
rickets, particularly if breast-fed by a vitamin D
deficient mother or if sunlight exposure and intake of
foods containing vitamin D are limited. Dietary sources
of vitamin D are shown in Appendix D.
Healthy Start
There may be a dependence on tinned/packet
convenience foods and a reluctance to use modified
home prepared foods.
Transferring to fresh cow’s milk
If infants are transferred from infant formula or breast
milk to cow’s milk at less than 1 year of age, the
infants’ iron intake may be detrimentally affected.
The table below shows the iron content of various
types of milk fed to infants.
AVERAGE IRON CONTENT OF MILK
SUITABLE FOR INFANTS
Iron (mg/100ml)
Infant formula
Breast milk
Fresh cow’s milk
0.50
0.07*
0.05
*Although the iron content of breast milk appears
to be low, it is more readily absorbed than the iron
in infant formula or cow’s milk
Current Department of Health policy makes vitamin
supplements (in the form of Healthy Start Children’s
Vitamin drops and Healthy Start Women’s Vitamin
tablets) available at no cost to families as part of the
Healthy Start initiative.
This scheme entitles pregnant women and families on
relevant state benefits (Income Support, income-based
Jobseeker's Allowance or Child Tax Credit) with an
income of £15,575 a year or less (2008/9) to claim
vouchers which can be exchanged for any combination
of milk, fresh fruit, fresh vegetables and infant formula
milk in registered shops. Each voucher is worth £3.00
(2008/9) and beneficiaries receive four vouchers via
post every four weeks.
Once accepted on the scheme, pregnant women,
mothers of children under 12 months old and children
under the age of four (from 6 months up until their
4th birthday) can all obtain free vitamin supplements.
Entitlement to vitamin supplements is printed on the
letter received with the vouchers. Beneficiaries should
then bring this letter with them to claim their vitamins
from the distribution points at their health trust or
health board. Health professionals should give
23
The Under Fives
appropriate health and lifestyle advice about diet in
pregnancy, infant feeding, weaning and vitamin
supplementation when signing an individual on the
Healthy Start scheme.
VITAMINS AND THE WEANING DIET
In HoBtPCT, the policy is different42. HoBtPcT provides
funding to cover the availability of free supplements for
all children from birth up until their 5th birthday, as
well as for pregnant women and mothers of children
under 12 months old regardless of whether they are on
Healthy Start benefits. HoBtPcT believe this is justified
by the number of cases of rickets in their population.
By far the majority of rickets cases could be prevented
by mothers and children taking supplements43.
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PREVENTION OF IRON DEFICIENCY ANAEMIA AND
VITAMIN D DEFICIENCY
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The following steps can be taken:
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Check that the nutritional status of the mother is
adequate with regards to iron and vitamin D.
Weaning foods should be introduced at 6 months
of age and should include foods containing iron
and vitamin C (see appendix C).
Vitamin C enhances the absorption of iron. Try to
include a source of Vitamin C at mealtimes (see
appendix C).
Do not give tea and coffee as these can inhibit iron
absorption.
Encourage good weaning practices such as the use
of adapted family foods and the appropriate use of
commercial weaning foods.
Infants should be breast fed and / or fed with
infant formula until 1 year of age.
Vitamin drops should be used as described in the
next section.
Limit milk intake to one pint per day (equivalent in
food, see page 27) in children (over 12 months of
age).
Include good dietary sources of vitamin D in the
diet of the infant and young child.
(see Appendix D).
24
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Adequate vitamin status should be encouraged for
the infant and the nursing mother through a varied
diet and moderate exposure to sunlight.
Food and drinks which provide good sources of
vitamin C should be encouraged in the weaning
diet.
Most healthy, full term infants under 6 months do
not need vitamin supplementation. This is
dependant on the mother’s vitamin status being
adequate during pregnancy, and appropriate breast
milk or formula feeding. However, if there are
concerns then supplementation can begin from 1
month. In HoBtPCT free supplementation is
encouraged from birth42.
All infants should receive vitamin drops containing
A, C & D from when they are established onto
solid foods, up to 2 years and preferably up to 5
years of age.
Pre-term and LBW infants are usually
recommended for vitamin and mineral supplements
by the paediatrician responsible for their care.
Under the Healthy Start scheme, children are entitled
to free vitamin drops from 6 months until the age of
four. In HOBtPCT all children registered with a GP are
entitled to free vitamin drops from birth until the age
of five (even if their parents are not on the Healthy
Start scheme). It is vital that health professionals
remind parents to collect their drops, and give them to
their babies in view of concerns about high rates of
vitamin D deficiency in the UK.
Vitamin drops should be omitted if the child is given
vitamin supplements from other sources e.g. over the
counter preparations. Vitamin supplements from
sources other than Child Health Clinics should be
checked for suitability for the age group27.
The following groups of children may be considered to
be at risk of vitamin/mineral deficiencies:
i) Infants/toddlers being fed unsuitable diets for their
age.
ii) Too early or too late weaning.
iii) Restrictive or limited diets due to toddler food
refusals, religious or cultural beliefs or practices,
food intolerances.
iv) Poor pre-natal diet leading to vitamin D deficiency.
v) The use of unmodified cow’s milk before 12 months
of age.
vi) The absence of vitamin/iron rich foods in the diet.
vii) Infants/children who are exhibiting faltering growth.
The Under Fives
1.6 VEGETARIAN AND VEGAN WEANING
A proportion of parents from all cultures will choose to
give a vegetarian diet to their children. The principles
of weaning previously outlined apply to children being
weaned onto a vegetarian diet. A little extra care may
be required to ensure the child gets all the nutrients it
requires from food. The term ‘vegetarian’ generally
refers to an individual who does not eat meat, poultry,
fish or food products made from these, but who does
take milk, milk products and eggs.
The foods which a vegetarian is prepared to eat does
vary. It is advisable to check with the parents/carers,
which foods they are willing for their child to eat.
Meat, poultry and fish are sources of protein, iron and
B vitamins. All varieties of beans, lentils, cheese and
eggs are suitable substitutes and should be included
daily.
Infants on vegetarian diets should also be weaned at
six months.
All infants should be managed individually so
that insufficient growth or other adverse
outcomes are not ignored and appropriate
interventions are provided. Consequently there
may be instances where an infant is weaned
before 6 months but this should never be before
17 weeks. The following information should be
followed when weaning at 6 months.
SUITABLE FOODS FOR VEGETARIAN WEANING
6 – 9 months
Cheese, tofu (soya curd)
Mashed peas and beans
Smooth peanut butter.
(* for info on nut
allergies see section 3.3)
Wheat based cereals
e.g. weetabix, and
porridge made from
oats.
VEGAN WEANING
The term ‘vegan’ generally refers to an individual who
does not eat meat, poultry, fish, eggs, milk , milk
products or any animal product.
A nutritionally adequate vegan diet can be achieved
through a careful combination of nuts*, pulses and
cereals.
A great deal of consideration and planning of meals is
required to wean an infant onto a vegan diet. It is
recommended that parents/carers who are considering
such practice should be referred to a dietitian for
advice.
The Vegan Society produce useful information on
vegan weaning.
*For information on nut allergy see section 3.3
SUMMARY VEGETARIAN
AND VEGAN WEANING
Vegetarian Weaning
A little extra care may be required to ensure
adequate nutritional intake.
Beans, lentils, cheese and eggs are suitable
substitutes for meat and should be included daily.
Combine vegetable sources of protein (pulses,
nuts*) with cereal based foods (bread, chapatti,
rice, pasta).
Iron containing foods should be eaten every day.
Eat with foods rich in vitamin C.
Vegan Weaning
Parents/carers who are considering weaning an
infant onto a vegan diet should be referred to a
dietitian for advice
9 – 12 months
Include beans, lentils and cheese at 2 meals each day.
Weaning from 17 weeks
Pureed potato
Carrot
Cauliflower
Spinach
Baby rice, thin porridge
made from rice, cornmeal.
Vegetable and fruit purees.
Mashed lentils
Pureed beans
(add small amount of
oil to soften beans)
A wider variety of fruits
and vegetables
e.g. bananas, cabbage,
broccoli, swede.
Pureed apple and pear.
Sago or millet
Yoghurt
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The Under Fives
1.7 DENTAL HEALTH
Despite a decrease in dental caries during the last
twenty years it still remains a health and social
problem, with peak activity occurring during childhood.
Dental disease is not inevitable and research has shown
that it can be prevented.
Children from disadvantaged backgrounds have a
greater risk of poor dental health and priority should
be given to preventative work with children from these
groups.
Toothbrushing should begin as soon as the babies
teeth erupt. It is important to try and establish a
twice-daily routine.
Use a toothbrush with a small head and soft/medium
bristles to ensure you can reach all the surfaces of the
teeth. (If a young baby dislikes a toothbrush at first, try
using a soft cloth). Low fluoride toothpaste e.g.
Macleans Milk Teeth, Colgate 0-6 years, should be
recommended for the under 6 years of age.
Using only a smear of toothpaste, a gentle scrub
technique is very effective.
Children should be encouraged to spit out the paste
after brushing.
Rinsing with water should be discouraged, as there is
evidence that this reduces the benefit of the fluoride.
Children’s toothbrushing should be supervised until
approximately 8 years of age.
VISITS TO THE DENTIST
Parents should be encouraged to register their children
with a dentist as early as possible, and
introduced to the dentist from the
age of 6 months. (It is advisable to
discuss this with their dentist).
FLUORIDE
The water supply in Birmingham
and Solihull is fluoridated,
therefore no supplements (drops or
tablets) should be taken unless
they are recommended by a
dentist.
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SUGAR
Dental decay is a sugar-related disease. The sugars
most responsible for dental caries are non-milk extrinsic
(NME) sugars which are added to many foods and
drinks during processing and manufacture. The
commonest NME sugars are sucrose, glucose, maltose
and fructose.
To reduce the incidence of tooth decay, food and
drinks containing sugar should be restricted to meal
times, between meals snacks free of NME sugars
should be used in preference.
SNACKS FREE OF NME SUGARS
Cubes of cheese
Bread with usual family spread
Toast
Slices of fruit
Crunchy raw vegetables
If sugary food and drinks are consumed then they
should be finished quickly rather than over a period of
time.
Carbonated, acidic drinks and sugary drinks should be
avoided. The carbonated drinks can cause the tooth’s
surface to dissolve, the acid causes erosion, and the
sugar causes decay.
Try to encourage milk, water or very dilute 1:10 pure
unsweetened fruit juices as an alternative.
Sweetened drinks should not be given in bottles, nonspill beakers or comforters where they may be in
contact with the teeth for prolonged periods of time
e.g. at bedtime. This can result in what is commonly
known as “bottle caries”.
Parents should be encouraged to introduce an open
cup or free-flowing beaker from the age of 6 months
and to aim to stop the use of bottles by 1 year of age.
Some baby food and drinks are labelled as free from
added sugars. However, sugars may still be
incorporated e.g. as concentrated fruit juices. These
can be equally damaging to the teeth.
Some children may experience acute or chronic
conditions which may require specialist dental advice.
These may include children who are enterally fed, have
faltering growth or are immunosuppressed. Health
Professionals should contact their local Personal Dental
Service to agree a programme for these children.
The Under Fives
SUMMARY – DENTAL HEALTH
SUMMARY – FEEDING THE ONE
TO FIVE YEAR OLDS
As soon as the teeth erupt, dental care should be
introduced. Regular visits to the dentist should be
initiated from the age of 6 months.
A diet low in fat and sugar and high in fibre is not
recommended for the Under 5’s because it is then
difficult to meet nutritional requirements for energy,
vitamins and minerals.
Fluoride drops or tablets are unnecessary in
Birmingham.
Fat is an essential contribution to the energy intake
of the Under 5’s but excessive consumption should
not be encouraged.
Sugar rich foods, snacks and drinks should be limited
in quantity and frequency. A cup should be
encouraged from about 6 months of age in
preference to a bottle. Bottle feeding should ideally
stop at 1 year of age.
2.
Whole milk should be given until 2 years of age at
which stage semi-skimmed milk can be introduced.
Sugary foods should be restricted in quantity and
frequency of consumption.
FEEDING THE ONE TO FIVES
2.1 HEALTHY EATING FOR THE
ONE TO FIVES
A moderate intake of fibre is recommended. A high
fibre diet is too bulky for most children to eat
enough food to meet their energy requirements.
Eating habits established in the first years of life will
influence peoples’ food choices throughout their lives.
It is well recognised that a healthy diet for adults, that
is, one which is low in fat, sugar and salt, and high in
dietary fibre, has an important role to play in reducing
both morbidity and mortality from diet related
diseases, such as cardiovascular disease, hypertension,
diabetes, obesity and cancer. It is essential to establish
good eating habits in the under 5’s.
It is inappropriate however to apply the healthy eating
recommendations intended for the adult populations,
(WHO 199028, COMA 199129, & 199430) to the under
5’s. Were this to be the case, the overall nutritional
adequacy of the diet may be detrimentally affected. In
particular, the intake of energy, vitamins and minerals
would be at risk.
To guard against nutritional inadequacy the transition
from a low fibre, high fat diet to higher fibre,
moderate fat diet should be a gradual process.
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Fat
Fat makes an essential contribution to the energy
intake in the under 5’s. Inappropriate over-emphasis
on the reduction of fat consumption is not
recommended unless the child has a problem with
obesity. However, an excessive intake of high fat snacks
e.g. crisps, biscuits, chocolate, and fried foods in the
under 5’s, may mean that attempts to moderate fat
intake in late childhood are more problematic.
At about 5 years of age children can gradually
increase their fibre intake and reduce their fat
intake.
Good eating habits should be established at an early
age.
Whole milk is recommended until two years of age.
Semi-skimmed milk can be given from two years
provided the child has an adequate, well-balanced diet.
Skimmed milk should not be used before five years of
age.
One pint of milk per day is recommended, or the
equivalent as cheese or yogurt (1/3 pint/200ml milk =
1 oz/30g cheese or a 5 oz/125g serving of yogurt).
Chosen spreads or oils should be high in
polyunsaturates or monounsaturates and low in
saturates eg olive oil or rapeseed based.
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Sugar
Excessive consumption of sugar may contribute to
obesity and is certainly implicated in the development
of tooth decay. Favourable habits developed early in
life will have benefits for the primary and the
permanent dentition.
To prevent tooth decay, sugar and sugar rich foods,
snacks and drinks e.g. sweets, chocolate, biscuits,
27
The Under Fives
cakes, puddings, and sugar containing squashes, fizzy
pops should be restricted. Adding sugar to food and
drinks is not necessary.
It is important to not only restrict the quantity of sugar
and sugary foods consumed, but also the frequency
with which they are eaten. Such foods are best eaten
after, rather than between meals.
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Dietary Fibre or “Non-Starch Polysaccharides”
Fibre is found in foods such as wholemeal bread,
wholegrain breakfast cereals (Weetabix, porridge,
shredded wheat, branflakes etc), brown rice,
wholemeal pasta, jacket potatoes, fruits and
vegetables. It has an important role together with fluid
in preventing constipation.
A moderate intake of fibre is recommended for the
under 5’s. A high fibre intake may, due to its bulk,
compromise energy intake, and is therefore not
recommended, particularly for children with small
appetites.
Where children do consume high fibre containing
foods, attention must be given to ensuring an
adequate fluid intake. Bran as a source of fibre is not
recommended for young children.
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Fruit and Vegetables
The entire UK population is encouraged to eat 5
portions of fruit and vegetables every day. 5 portions
are recommended for children, just that they are childsized portion and not an adults. However, children
should be encouraged to try fruit and vegetables as
part of everyday meals and snacks. Frequency of trying
fruit and vegetables is more important than quantity at
this age.
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Salt
We eat more salt, as a nation, than we need. Salt is
used as a flavouring to which we become accustomed.
By restricting the use in the under 5’s the taste for salt
is less likely to be acquired.
Only a little salt should be used in cooking and salt
should be avoided at the table. Highly salted snacks
and foods e.g. crisps, salted nuts, tinned foods and
cured or smoked meats and fish should be eaten
infrequentlY.
Children from-3 years old should have less than 2g salt
per day. Children between 4-6 years should have less
tha 3g salt per day40.
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Vitamins See section 1.7
28
2.2 FOOD FADS
Young children often become fussy about their food.
Parents should be reassured that this is quite normal
and that eating habits will improve. If this problem
persists or becomes a regular source of conflict, parents
may need additional support. Encouragement should
be given to the parents to continue offering the child a
variety of different foods. Parents should be advised
not to force-feed their children and should be
discouraged from giving in to the temptation of
allowing the child to eat food of poor nutritional value
e.g. sweets, biscuits, pop, crisps, at the expense of
more nourishing meals. A positive approach and
encouragement of a wide range of flavours is
important.
See Appendix E for further suggestions on handling
difficult situations at mealtimes.
3.
FOOD ALLERGY AND INTOLERANCE
If a child is thought to be allergic or intolerant to a
particular food, it is important that the condition is
properly diagnosed by a doctor.
A dietitian should be consulted so that the child’s diet
can be properly assessed for its nutritional adequacy.
Measures which can help to prevent food intolerance
include exclusive breastfeeding until 6 months of age,
and following the weaning guidance in section 1.4.
Infants and children from atopic (i.e. those with a
family history of asthma, eczema or food intolerance)
families should follow the advice on peanuts in section
3.3.
3.1 COW’S MILK PROTEIN
INTOLERANCE/LACTOSE INTOLERANCE
Cow’s Milk Protein Intolerance
Intolerance to cow’s milk protein can present with
symptoms such as rhinitis, eczema, abdominal pain,
The Under Fives
vomiting, diarrhoea and wheezing. Cow’s milk protein
intolerance is usually a temporary problem and most
children will grow out of the symptoms by the age of 2
– 3 years. Children on cow’s milk free diets should be
referred to a dietitian to ensure all sources of cow’s
milk are avoided.
For infants from non-atopic families, there is no need
to specifically delay the introduction of peanuts.
Peanuts of a suitable texture (e.g. smooth peanut
butter) can be introduced from 6 months of age.
Whole nuts are not recommended for the under fives
due to the risk of choking.
Lactose Intolerance
These restrictions will be of limited nutritional
consequences, unless the mother or child is a
vegetarian or vegan. Individuals with peanut allergy
should be under the care of a medical
practitioner/dietitian.
This is not an allergic disorder but may come about
from a primary deficiency of the enzyme lactase, or
more commonly as a secondary temporary deficiency
of the enzyme following a period of gastroenteritis or
trauma to the gut. The enzyme lactase is required to
break down lactose. A deficiency of the enzyme may
result in severe diarrhoea, dehydration, and possibly
faltering growth.
Children need to follow a lactose free diet and an
appropriate milk substitute will be required e.g
hydrolysed protein formula or lactose free formula.
Soya formula should not be used before 6 months of
age. The advice of a dietitian should be sought from a
Dietitian if the child has primary lactose intolerance or
if the milk substitute is not accepted.
3.2 COELIAC DISEASE
Children from atopic families (i.e., those with a history
of asthma, eczema or food intolerance) may be at a
greater risk of developing an intolerance to gluten. To
reduce the risk of coeliac disease the cereals given to
infants less than 6 months should preferably be gluten
free, such as rice or maize. Otherwise there is no need
to observe any special dietary restrictions.
Gluten is found in wheat, barley, rye and oats and
foods made from these.
3.4 HYPERACTIVITY
Particular foods or drinks might make some children
hyperactive, disruptive or irritable. There are no tests
available that reliably indicate which foods or additives
an individual may be intolerant to.
The most reliable way to investigate is
- to follow a regular healthy diet, then to keep a
diary of what the child has eaten and their
behaviour throughout the day. By looking back
on this diary over a period of weeks the parents
maybe able to identify a trigger to a certain
behaviour.
- The next step is to remove this trigger and
monitor behaviour for a further 2 weeks.
- Then re introduce the trigger and monitor if the
symptoms reappear.
Care must be taken before cutting out a nutritious
food or food group out of a child’s diet long term. If
this is the case it would be recommended to seek
support from a registered Dietitian.
3.5 GASTROENTERITIS
If an infant or child is diagnosed with coeliac disease,
support and advice from the dietitian and paediatrician
is essential. Gluten free weaning products are
available.
3.2 PEANUT ALLERGY
The incidence of peanut allergy appears to be
increasing. There are reports of anaphylaxis on first
exposure to peanuts suggesting that sensitisation can
occur through breastfeeding or in utero.
Pregnant or lactating mothers from atopic families may
choose to avoid nuts from their own diets. The
introduction of peanuts and nuts to the diet of their
infants should be delayed until about the age of 3
years or at the age advised by their medical
practitioner47.
Acute gastroenteritis in infants and young children
poses many risks, including dehydration, vomiting and
post-gastroenteritis lactose intolerance.
An evidence-based review of treatment for acute
gastroenteritis recommends that the following steps
should be taken.
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Breastfeeding should continue through rehydration
and maintenance phases of treatment.
Formula feeds should be restarted at full strength
following completion of rehydration. There is loss
of nutrients and no advantage seen by introducing
diluted feeds.
29
The Under Fives
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If there is persistent diarrhoea after reintroduction
of feeds, evidence for lactose intolerance should be
sought. If stool pH is acidic and contains 0.5%
reducing substances, a lactose free formula should
be considered. Other milk products should also be
excluded.
Lactose intolerance is usually short term (8-12
weeks). The baby’s weight should be checked
during this time and appropriate dietary advice
given if necessary.
3.6 ACUTE DIARRHOEA
Medical advice should be sought if the baby’s fluid
intake diminishes and/or if there are more than four
diarrhoea stools in 12 hours and/or the child seems ill
in a general sense.
SUMMARY –
FOOD ALLERGY AND INTOLERANCE
Allergies to various foods are uncommon.
If food intolerance is suspected and dietary
manipulation is being considered, a dietitian should
be consulted.
A cow’s milk protein or lactose intolerant child will
need to follow a milk free diet and an appropriate
milk substitute will be required e.g. soya or protein
hydrosylate formula.
4.
Constipation is common in the under fives, especially
when toilet training is in progress. It results in misery
for the child and may be compounded by parental
anxiety.
Bowel habit is variable between individuals, making
constipation difficult to define. It is important to check
exactly what a parent or carer means by constipation
as the condition is often misdiagnosed.
Constipation does not usually occur in the breastfed
infant where a normal bowel habit may vary from
passage of stool after each feed to once every 10 days,
so reassurance of the mother is needed.
Bottle fed infants may produce a harder stool. This is
commonly due to over concentration of feed, or
inadequate fluid intake (including underfeeding).
Solutions are:
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Children should avoid gluten containing foods until
they are 6 months old.
Unresolving post gastroenteritis diarrhoea may
require the exclusion of milk-containing products
temporarily. (see section 3.5)
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Children from atopic families should avoid peanuts
and nuts until 3 years. Pregnant and lactating
mothers from these families may avoid nuts in their
own diet.
30
Check feeds are of the correct concentration and
the correct scoop is being used.
If underfeeding is suspected, check fluid given per
kg per 24 hours, and if necessary increase.
Additional drinks of cooled boiled water may be
needed.
If the above measures are unsuccessful, then the
child’s medical practitioner or paediatrician should
be consulted. Diluted juice or sugar solutions
should not be offered as these have not been
shown to be effective and may be used
inappropriately and encourage an early taste for
sweetness.
Once a child is weaned, the following should be
encouraged:l
If an infant’s fluid intake diminishes and there are
more than four diarrhoea stools in 12 hours and the
child seems ill in a general sense medical advice
should be sought.
CONSTIPATION
Reducing milk intake (if over 1 pint per day) to
encourage the inclusion of other foods.
Regular meals and snacks.
Check adequate fluid.
Increase fibre content of the diet (see section 2.1).
Behaviour modification may be required, if child is
reluctant to open their bowels.
The Under Fives
5.
OBESITY
As with the adult population, the incidence of obesity
in the under 5’s population is the UK is increasing32.
Overweight and obese children are best managed on a
long-term basis with a family-based programme
encompassing both the child’s and family’s lifestyle33.
Intervention for child hood overweight and obesity
should address lifestyle with the family and social
settings45.
Advice that may be offered includes: -
The effect of obesity during childhood can have lasting
effects on self-esteem, body image, and risk factors for
a range of illnesses in later life.
l
In the under-fives a strict ‘calorie-counted’ regime is
rarely appropriate. Advice should be given to carers
on a balanced healthy diet as described in section 2.1.
It is important to address the whole family’s eating
habits in order to prevent the pattern of obesity
continuing into later life.
Too much emphasis on “diet” in front of the child can
lead to a feeling of victimisation and resentment and
he/she may become self-conscious over their size from
an earlier age than is usual.
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Ensure carers react appropriately to child’s crying by
not interpreting all crying as hunger, when in fact
the child may be bored, tired or uncomfortable.
Drinks of water should be offered with and in
between meals. If the child is reluctant to drink
water, pure unsweetened fruit juice, diluted 1 part
juice to 10 parts water.
Crisps, sweets, chocolate and added sugar should
be seen as occasional rather than everyday foods.
Lower fat and lower sugar snacks should be
offered instead e.g. fresh fruit, handful of dried
fruit, low fat yogurt.
Do not give food or sweets to a child as a reward
or to console them. Try to find other ways of
rewarding the child e.g. a trip to the park, star
charts etc.
Increase the child’s activity by reducing pushchair
use, the amount of television watched, and by
encouraging active play.
31
The Under Fives
APPENDIX A - BREAST FEEDING POLICY IN SUPPORT OF THE UNICEF BABY FRIENDLY
COMMUNITY INITIATIVE SEVEN POINT PLAN
Below is an abbreviated version of the BEN PCT
Policy with respect to breast feeding. Please refer
to BEN PCT Clinical Policies for full document.
STATEMENTS IN SUPPORT OF THIS POLICY
The Breastfeeding Policy and the Breastfeeding Fact
File have been developed by a multidisciplinary
team, which includes representatives from the
voluntary sector and will be reviewed annually.
Compliance with the policy will be audited annually
by the Infant Feeding Lead. Comments and
suggestions towards revised versions of the policy
are cordially invited and should be sent to the lead
professional.
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AIM
To improve the health of women and children in
Birmingham East and North PCT by promoting and
facilitating successful breastfeeding.
OBJECTIVES
To train all Health Care Staff who come into contact
with prospective and new parents, to enable them to
provide correct, consistent information, advice and
support based on current research, at a level
appropriate to their role.
To ensure that the benefits of breastfeeding compared
with artificial feeding are discussed with prospective
parents in the antenatal period to facilitate pregnant
women making an informed choice (where Health
Visitors are involved in the antenatal period).
To ensure that a friendly welcoming atmosphere for
breastfeeding families is provided by Birmingham East
and North PCT and to work with partner agencies to
develop a breastfeeding culture throughout the local
community.
It is mandatory that all staff adhere to this policy to
avoid conflicting advice. Any deviation from the
policy must be done in the context of professional
judgement and should be documented in the
Personal Child Health Record.
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Midwives and Health Visitors have shared
responsibility for supporting breast feeding women
up to the 28th day after which the Health Visitor,
supported by Nursery Nurses, Staff Nurses and Link
Workers, has the primary responsibility.
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Protocols for the support of breastfeeding in special
situations and the management of common
complications exist. Please refer to the
Breastfeeding Fact File.
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It is the responsibility of all healthcare professionals
to liaise with others should concerns arise about a
baby’s health.
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PRINCIPLES
1. Birmingham East and North PCT recognises that
breastfeeding is the healthiest way for a women to
feed her baby and acknowledges the important
health benefits now known to exist for both the
mother and her child.
2. The PCT recognises and accepts its responsibility to
provide accurate and contemporary information on
the nutritional and health needs of infants and
children to health professionals working within the
Trust.
3. The PCT believes that all mothers have the right to
make a fully informed choice as to how they feed
and care for their babies. The provision of clear and
impartial information to all mothers at an
appropriate time is therefore essential.
4. Healthcare staff will not discriminate against any
woman, irrespective of the method of feeding and
will fully support her when she has made that
choice.
32
Health Visitors should support parents who have
made an informed choice to artificially feed their
babies, by assessing their knowledge and
understanding of the latest guidelines for making
up and storing formula feeds.
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1.
COMMUNICATING THIS POLICY
1.1
This policy is to be communicated to all
healthcare staff who have contact with pregnant
women and mothers. All staff will have access
to the Breastfeeding Policy and, where
appropriate, the Breastfeeding Fact File.
1.2
All new staff will be introduced to the policy
during their induction period.
The Under Fives
1.3
1.4
2.
2.1
2.2
A Mothers Guide to the Breastfeeding Policy will
be displayed in all areas offering care to mothers
and babies. This will also be inserted into the
Personal Child Health Records. The full policy
will be available on request.
2.9
The PCT will seek to provide information in an
appropriate format for people with a disability or
for whom English is not their first language.
Contact the Lead Professional for Infant Feeding
for other formats.
3.
Update training will be offered annually to all
staff who have received initial training or when
significant policy/best practice changes occur.
All clerical and reception staff based in PCT
health centres will be orientated to the policy
and receive training to enable them to refer
breastfeeding queries appropriately. All other
PCT employees will receive breastfeeding
awareness information. Refer to Appendix 1.
2.3
Key strategic partner organisations will be
offered access to PCT Breastfeeding Awareness
and Management Training Modules.
2.4
Breastfeeding training will be consistent with the
UNICEF Baby Friendly Initiative best practice
standards as embodied in the Seven Point Plan.
This will complement the Baby Friendly Hospital
Initiative – The 10 Steps to Successful
Breastfeeding.
2.5
Training curricula will be available.
2.6
All training will be evaluated and an annual
report compiled by the PCT Infant Feeding Lead.
2.7
New Staff
2.8
The PCT Breastfeeding Policy in Support of Baby
Friendly Community Initiative Seven Point Plan
will be included in the Induction Programme for
all new staff employed by the PCT.
2.9
All new staff, clinical or non-clinical, who have
regular contact with pregnant women and
mothers will be required to attend initial training
within 6 months of being appointed.
INFORMING PREGNANT WOMEN
ABOUT THE BENEFITS AND
MANAGEMENT OF BREASTFEEDING
3.1
Where Health Visitors or other health workers
are involved, every effort must be made to
ensure that the benefits of breastfeeding
compared with artificial milk are discussed so
that all women can make an informed decision
on their chosen method of feeding. Where
appropriate fathers, other family members as
well as mothers, should be provided with
information.
3.2
All pregnant women should have the
opportunity for a one to one discussion about
breastfeeding with a health professional who
has up to date knowledge and expertise in
breastfeeding management.
3.3
The physiological basis of breastfeeding is to be
clearly and simply explained to all pregnant
women, together with good management and
some of the common experiences they may
encounter. The aim is to give women
confidence in their ability to breastfeed.
3.4
All materials and teaching should reflect the PCT
Breastfeeding Policy. Information should be
clearly written, well designed and illustrated and
should not contain the name or logo of any
manufacturer of artificial baby milk.
3.5
No routine group instructions on the preparation
of artificial feeds are to be given in the antenatal
period as this has the potential to undermine
confidence in Breastfeeding. Should a parent
request instruction in the antenatal period this
will be provided on a one to one basis.
TRAINING HEALTHCARE STAFF
All healthcare staff, who’s role involves
supporting pregnant and breastfeeding mothers,
will receive training in breastfeeding
management and awareness in order to provide
full and competent support appropriate to their
role. Training will be mandatory. Refer to
Appendix 1.
Update Training
33
The Under Fives
4.
4.1
4.5
Health workers should encourage and support
the continuation of breastfeeding during periods
of infant or maternal illness, and during periods
of separation of mother and baby. The
importance of breastmilk for sick/pre-term
babies should be discussed with the mother.
4.6
Mothers should be advised that supplementary
or complementary feeds are unnecessary and
can interfere with breastfeeding.
4.7
Healthcare staff should not recommend the use
of artificial teats or dummies during the
establishment of breastfeeding. Parents wishing
to use them should be advised of the possible
detrimental effects such use may have on
breastfeeding to enable them to make a fully
informed choice.
4.8
Handover of care from Midwife to Health Visitor
will follow standard procedure in the form of
written and/`or verbal communication to ensure
a seamless transition of care for new mothers.
Nipple shields will not be routinely
recommended except in exceptional
circumstances and then only for as short a time
as possible. Any mother considering using a
nipple shield must have the disadvantages
explained to her prior to commencing use and
will be given support to discontinue its use as
soon as possible.
4.9
Mothers can expect help from suitably trained
members of staff until they feel confident in
their own ability to position and attach their
baby successfully. A full Breastfeeding
assessment should be carried out by the Health
Visitor at first face to face contact with the
breastfeeding mother. This should be
documented on the Assessment Form and an
individual plan of care developed. Breastfeeding
progress should be discussed and or observed in
a sensitive manner on each contact with the
mother. This will enable early identification of
any potential complications and allow
appropriate information to be given to prevent
or remedy them.
Women’s intentions regarding returning to work
outside the home should be explored as early as
possible so that each mother can be helped to
formulate the plan best suited to her
commitments. Legislation regarding
breastfeeding when returning to work should be
discussed. Support should therefore be offered
to enable the mother to continue to breastfeed
for a long as she wishes.
5.
SUPPORTING EXCLUSIVE AND
CONTINUED BREAST FEEDING, WITH
APPROPRIATELY TIMES INTRODUCTION
OF COMPLEMENTARY FOODS
5.1
Health workers should encourage women to
breastfeed exclusively for 6 months. This means
that no water or artificial feeds must be
recommended for a breastfed baby except by an
appropriately trained health or medical
professional. Parents who chose to supplement
breastfeeding with formula milk or water should
be made aware of the health implications and
the impact this would have on breastfeeding, to
enable them to make a fully informed choice.
SUPPORTING MOTHERS TO INITIATE
AND MAINTAIN BREASTFEEDING
Health workers in the community should support
mothers by discussing:(a) The importance and significance of early skin
to skin contact after the birth and benefit of
skin to skin at later stages to resolve
difficulties with attachment, breast refusal or
to comfort an unsettled baby.
(b) The importance and significance of a first
breastfeed just as soon as mother and baby
are ready after the birth, regardless of the
feeding method (usually within the first
hour).
(c) That baby often wants to breast feed
frequently therefore unrestricted baby-led
breastfeeding should be encouraged for all
healthy babies. Community staff should
inform mothers about the importance of
demand feeding and night feeds for milk
production.
4.2
4.3
4.4
34
Mothers should be shown how to hand express
their breastmilk and its importance in the
prevention and management of breastfeeding
conditions such as engorgement and mastitis.
Mothers should be offered supporting literature
in a variety of media to include safe storage of
breastmilk.
The Under Fives
5.2
Health Workers should encourage mothers to
continue baby-led feeding during this period.
Mothers should be encouraged to keep their
babies near them so they can learn to interpret
their baby’s needs and feeding cues and they
should be given appropriate information about
the benefits of and contraindications to bed
sharing.
6.2
The PCT will ensure that all Health Centres,
Clinics and departments are breast feeding
friendly, providing a welcoming atmosphere and
facilities, where possible, for breastfeeding
families. Notices should be displayed advising
mothers that they are welcome to breastfeed
anywhere on the premises and that every effort
will be made to ensure privacy when requested.
5.3
Mothers should be encouraged to continue
breastfeeding during and beyond the process of
weaning on to solid foods up to a minimum of 1
year (DOH 2004). All weaning information
should reflect this ideal. Mothers will be
supported to breast feed for as long as they
wish.
6.3
Healthcare workers employed by the PCT, will
encourage the primary health care team within
G.P premises to become breastfeeding friendly.
6.4
Healthcare workers will provide all breastfeeding
mothers with information on breastfeeding
outside the home, including local places where
breastfeeding is welcome.
7.
ENCOURAGING COMMUNITY SUPPORT
FOR BREASTFEEDING
7.1
PCT staff will ensure that breastfeeding mothers
are provided with information resources
containing details of which health professionals
to contact for breast feeding support, how to
access local breast feeding support groups, peer
support and voluntary organisations. These
resources should be updated regularly. Mothers
will also be provided with the Breastfeeding
Helpline numbers for outside of surgery and
office hours.
7.2
School Nurses together with health worker
colleagues should use their knowledge and
influence to affect the incidence of
breastfeeding in future years.
7.3
Health workers will be expected to take
advantage of the opportunity of promoting
breastfeeding in day to day work within the
wider community and a welcoming atmosphere
for breastfeeding mothers in public places.
7.4
Voluntary Breastfeeding Counsellors or Peer
Supporters should continue to participate in the
development of PCT policies and guidelines.
7.5
The PCT will work jointly with regional and pan
Birmingham breastfeeding steering groups
which exist to promote and support
breastfeeding.
5.4
Data on infant feeding showing the prevalence
of both exclusive and partial breastfeeding will
be collected at the primary visit, six weeks and
six months.
5.5
Breastmilk substitutes will not be sold by the
PCT.
5.6
Breastmilk substitutes, bottles, teats and
dummies will not be promoted on PCT premises.
5.7
Any literature, posters, calendars, diary covers
etc., with baby milk company logos printed on
them are not to be displayed on PCT premises or
used by community health workers as they may
endorse the company products.
5.8
6.
6.1
Formula milk representatives will not have access
to PCT health care staff and instead will see the
Infant Feeding Co-ordinator to offer scientific
product information updates which, the Infant
Feeding co-ordinator will disseminate to health
care staff.
PROVIDING A WELCOMING
ATMOSPHERE FOR BREAST FEEDING
FAMILIES
Breastfeeding will be regarded as the preferred
way to feed babies and young children.
However, mothers choosing to feed artificially
will not be disadvantaged in their access to
information.
35
The Under Fives
BREASTFEEDING TRAINING AND INFORMATION FOR STAFF EMPLOYED BY
BIRMINGHAM EAST AND NORTH PCT
1. CORPORATE INDUCTION - Breastfeeding Awareness Information
All new staff
2. LOCAL INDUCTION – Awareness of Breastfeeding Policy
All new staff
3. BREASTFEEDING AWARENESS AND MANAGEMENT TRAINING – Mandatory
Module 1 – Breastfeeding Awareness: Why breastfeeding is a key public health issue and the barriers to
breastfeeding – roles and responsibilities.
Suitable for all levels of staff, for general breastfeeding awareness, breastfeeding promotion and best practice
standards.
PCT staff (Health Visitors and Support Staff, Clinical Medical Offers, Managers, staff from Children Centres, and
other key partner agencies working within BEN PCT such as GP surgeries.
Modules 2, 3, 4 – Suitable for clinical staff, and staff from other agencies who support pregnant and
breastfeeding mothers.
1. BREASTFEEDING AWARENESS INFORMATION – Orientation to the Breastfeeding Policy
Health Centre Receptionists
Health Visitor Clerks
Breastfeeding Volunteer Peer Supporters
2. BREASTFEEDING AWARENESS INFORMATION
All other PCT employees
36
The Under Fives
APPENDIX B - BREASTFEEDING POSITIONING
1.
Assessing a Breastfeed - Positioning
4
Good Positioning
2.
Poor Positioning
8
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The baby’s head and
body is in a straight line.
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The baby’s neck is
twisted.
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The baby’s whole body
is facing his mother.
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The baby is not close to
its mother’s body.
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The baby’s face is close
to the breast.
l
The baby’s body is
turned away from its
mothers body.
l
The mother supports
the baby’s bottom.
Assessing a Breastfeed - Attachment
Good Attachment
4
Poor Attachment
8
l
The baby’s chin is
touching the breast.
l
The baby’s lower
lip is turned outwards.
l
The baby’s mouth
is wide open.
l
The baby’s mouth
is not wide open.
l
There is more
areola above the
upper lip than
below it.
l
Too little of the
areola is in the
mouth.
With good attachment you will hear or see the baby
swallowing and the jaw moving rhythmically. The baby
will be relaxed and will release the breast at the end of
the feed.
l
The baby’s chin is
away from the breast.
l
The lower lip is
turned in.
With poor attachment the baby will take small quick
sucks, the cheeks may be pulled in and the mother will
experience nipple pain.
37
The Under Fives
APPENDIX C
DIETARY SOURCES OF IRON AND VITAMIN C (Ref. Bolton Health Authority 1989)
The absorption of inorganic iron is improved by the presence of animal protein and Vitamin C at the same mealtime.
3-4 helpings of iron containing foods should be given each day.
IRON
PROTEIN
VITAMIN C
Good Sources
Good Sources
Good Sources
Animal Protein
Eggs (yolk)
Red meat e.g. lamb
Beef, liver
Kidney
Spinach
Cereals fortified with iron
Rusk & baby cereals
Meat
Poultry
Fish, Eggs
Milk, Cheese
Yoghurt
Vegetable Protein
Pulses e.g. peas, beans, dhals, lentils
Average Sources
Poultry
All pulses e.g. peas, beans, lentils
Dhals
Bread and flour
Breakfast cereals
Dark green vegetables e.g. peas,
cabbage
Dried Fruit
e.g. figs, apricots
Average Sources
Cereals
Bread
Chapatti
Flours, soya flour
Lentil or gram flour
Nut flour
Oranges
Guava, mangoes
Blackcurrants
Gooseberries
Fresh pineapple
Strawberries
Tangerines
Tomatoes
Orange Juice (Remember to dilute)
Kiwi fruit
Average Sources
All other fresh fruit
Potatoes
Vegetables, especial raw salad
vegetables
Beansprouts
N.B., vegetables should be cooked
for as little time as possible in a
minimum amount of water.
APPENDIX D
GOOD DIETARY SOURCES OF VITAMIN D
Vitamin D can be obtained in the body from the action
of sunlight on exposed skin. However, in the UK
sunlight can be limited so vitamin D needs to be
obtained in other ways. There are only a very limited
number of foods which contain vitamin D and often
supplements are recommended. Vitamin D can be
identified on labels as Vitamin D, D3 or cholecalciferol.
l
Oily fish (such as salmon, sardines, pilchards, trout,
kippers, eel are the only foods which naturally
contain significant amounts of vitamin D).
38
l
Other foods which contain small amounts of
vitamin D are:
eggs,
margarine
some fortified breakfast cereals.
The Under Fives
snacks can be given between meals e.g. toast.
Set times for snacks may be a good idea. When
a child refuses food, do not offer them anything
else, they will not go hungry if they
decline/refuse food.
APPENDIX E
HANDLING MEALTIMES
Food is essential for growing children. Consequently
parents become worried and upset when they feel
their child is not eating properly. Even young children
know this and will try to use food as a means of
getting their own way at their parents’ expense. If
children are unhappy they may show little or no
interest in food or may grossly overeat, steal or hoard
food.
Eating difficulties are common to many families and
can be changed surprisingly easily by adopting a
slightly different approach.
6.
If the child can feed themselves do not give in
and feed them.
7.
Never deprive the child of meals, or parts of
meals, as punishment for other bad behaviour.
If a child has been really naughty stop sweets or
treats but never take away basic food.
8.
When a child’s bad behaviour at mealtimes is to
get attention, be strong and ignore it.
If the child refuses to eat a meal you know they
like, remove it calmly but don’t offer anything
else instead.
How to Make Mealtimes Easier Golden Rules
1.
Ignore moans and complaints about the food.
Main meals should be
regular so that the child
knows when to expect
food.
Routine and regularity is
important in helping the child
understand the day to day
pattern of eating.
2.
Mealtimes should be organised and calm.
Avoid disorganised, disturbed, noisy meals and
avoid getting the child excited. The parent
should be calm and in control.
3.
The parent should decide what the child will
eat, taking into account likes and dislikes, tastes
and favourites.
Too much choice or too little choice may lead to
battles. Often simple things are the favourites.
Avoid spending hours preparing special food
which may be refused.
Allow the child 30 minutes to eat and then take
the food away.
4.
Aim to provide a healthy diet and good eating
habits.
Guide the child as early as possible into healthy
and happy eating habits.
5.
Snacks or sweets should not
be taken instead of a meal.
If the child refuses to eat at
mealtimes do not let them
top up on sweets, crisps, pop,
biscuits etc. As long as meals
are being eaten, appropriate
Don’t allow silly, unacceptable behaviour at
mealtimes, like throwing food around
interfering with other people’s food etc. Take
the child away from the food and don’t give
him/her any attention until he/she behaves
properly.
9.
Food should be enjoyable and mealtimes should
be a pleasant time together.
Make food look attractive and be imaginative
e.g. bangers and mash can look like a face.
Keep portions small - they can always ask for
more.
Mealtimes will develop a child’s social skills.
10.
If you are distressed / frustrated / angry avoid
showing the child this reaction.
11.
Involving children in preparing and cooking food
is an excellent way to encourage good eating
habits.
ANY CHANGES FOR THE BETTER,
HOWEVER SMALL, SHOULD BE
REWARDED BY PRAISE AND A CUDDLE.
39
The Under Fives
APPENDIX F BOTTLE FEEDING - A PRACTICAL GUIDE
1.
2.
CHOOSING AN INFANT MILK
You should use a special
infant formula (infant milk).
Your midwife or health
visitor will explain the
differences between the
types available and which is
the most suitable for your
baby.
These milks must not be
used for bottlefeeding
young babies because they
provide unsuitable levels of
many nutrients and babies
cannot digest them well.
CLEANING THE
BOTTLES
Rinse the bottles, teats and
feeding equipment in
warm water to remove any
remaining detergent. They
are now ready to be
sterilised.
BEFORE YOU START
Wash the used bottles,
teats and feeding
equipment in warm water
with washing up liquid.
Scrub the bottles using a
bottle brush and turn the
teats inside out to clean
them thoroughly.
3.
STERILISING THE BOTTLES
Make up the sterilising
solution according to the
manufacturer’s instructions.
Leave feeding equipment in
the sterilising solution for at
least 30 minutes. Change
the sterilising solution every
24 hours.
Place the clean bottles,
teats and feeding
equipment into the
solution. Ensure they are
kept completely immersed
with no air bubbles visible.
Leave for the amount of
time required before using
shake off any excess
solution or rinse with
cooled boiled water from
the kettle. (Do not put
metal utensils in the
sterilising solution).
B. STEAM
STERILISATION.
C. BOILING WATER
STERILISATION.
Follow the manufacturer’s
instructions.
This steriliser is a special
unit that uses steam to
sterilise equipment and
needs to be plugged in to
an electrical outlet. Place
clean bottles, teats etc
facing down in the steamer.
Any equipment not used
straight away should be
re-sterilised before use.
Place clean bottles, teats
and feeding equipment
facing down in the
steamer. Any equipment
not used straight away
should be re-sterilised
before use.
A. COLDWATER OR
CHEMICAL
STERILISATION
The sterilisation process usually takes
only a matter of minutes.
IMPORTANT: Breastfeeding is best for your baby. Consult
your doctor, midwife, nurse or health visitor for any advice
you need. if you are using an infant milk, it is important
for your baby’s health that you follow all preparation
instructions carefully.
40
All babies are individuals. They will grow at different rates
and have varying needs. Ask your midwife, health visitor
or other health professional for advice and information on
infant feeding.
*Reference to all of these:
Department of Health (2007) Bottle Feeding.
www.dh.gov.uk Product number: 278959
The Under Fives
4.
GOOD HYGIENE
Good Hygiene and careful feeding practices will help avoid tummy upsets and other possible problems.
Before starting to prepare
feeds clean and disinfect
your worktop surface and
keep all pets out of the
preparation area. Make
sure there are no flies or
other insects around.
5.
FEED PREPARATION
It is vital that all
feeding equipment is
absolutely clean and is
sterilised before you
make up any feeds.
Wash your hands
before you start.
Stand the bottle on a
clean surface. Keep
the teat and cap on
the upturned lid of
the steriliser – avoid
putting them on the
work surface.
The feeding guide on the infant milk pack gives guidelines on how much feed you should give your baby. Make up
the infant milk according to the instructions on the pack.
Wash your hands.
(a) Boil water in kettle and
leave to cool, use fresh
tap water (not bottled
water) to fill the kettle.
Let the water cool for no
more than 30 minutes, do
not use artificially
softened water or
repeatedly boiled water. If
you have to use bottled
water, you will still need
to boil it.
(b) Make sure all
the feeding bottles
etc have been
sterilised and then
rinsed with
previously boiled
water.
(c) Pour the amount of
water you need into the
feeding bottle.
d) Dip the scoop provided
in the pack into the
granules/powder. For
granules, gently shake to
give a level scoop.
Powdered infant milks will
require a knife to level off
the scoop. (Please follow
individual pack guidelines.)
Add the required number of scoops to the water in the bottle (I scoop to I
fl.oz of water.) Do not add extra granules / powder this could give your
baby constipation and can cause your baby to become dehydrated, while
too little powder may not provide your baby with sufficient nourishment.
do not add sugar or cereals to the feed in the bottle
Place the disc and cap on
the bottle, hold the edge
of the teat, put it on the
bottle. Screw the retaining
ring onto the bottle.
Cover the teat with a cap
and shake the bottle well
until the powder is
dissolved.
Hold the bottle at an
angle so that there is
always milk and not
air in the teat. After
each feed throw away
any leftover infant
milk. Never leave your
baby alone with a
bottle
Test the temperature of the milk before feeding by shaking a few drops
on the inside of your wrist. The milk should feel warm but not hot. Cool
your baby’s milk down to the required temperature. To cool it, hold the
bottle, with the cap covering the teat, under cold running water.
41
The Under Fives
APPENDIX G INFANT FEEDING RECOMMENDATIONS - DEPARTMENT OF HEALTH
1
Introduction
1.1
Appropriate feeding practices are of
fundamental importance for the survival,
growth, development and nutrition of infants
and children everywhere. The optimal duration
of exclusive breastfeeding is one of the crucial
public health issues that the World Health
Organization (WHO) has been keeping under
continued review.
Early in 2000, WHO commissioned a systematic
review of the published scientific literature on
the Optimal duration of exclusive
breastfeeding1,2; more than 3000 references
were identified for independent review and
evaluation. The outcome of this process was
subject to a global peer review, after which all
findings were submitted for technical scrutiny
during an expert consultation.
The WHO revised its guidance in 2001, to
recommend exclusive breastfeeding for the first
six months of an infants’ life. At the World
Health Assembly, the UK represented by the
Chief Medical Officer supported this resolution
and since its adoption, 159 Member States have
demonstrated their determination to act by
preparing to strengthen their national nutritional
policies and plans. In 2001, the UK’s Scientific
Advisory Committee on Nutrition (SACN) stated
that there was sufficient evidence that exclusive
breastfeeding for six months is nutritionally
adequate.
Following WHO’s revised guidance, Hazel Blears
(then Minister for Public Health) announced the
Department of Health’s recommendation on
breastfeeding in May 2003. A wide range of
professional and voluntary bodies has supported
this recommendation, including the Royal
College of Midwives, the Community
Practitioners and Health Visitors’ Association,
voluntary and non-government organisations.
In light of this recommendation, the Department
of Health has reviewed its guidance on the
introduction of solid food and this paper
summarises the latest advice. We hope this will
inform and assist health professionals supporting
parents in optimising their infants’ nutrition.
1.2
1.3
1.4
1.5
• Exclusive breastfeeding is recommended for
the first six months (26 weeks) of an infant’s
life
• Six months is the recommended age for the
introduction of solid foods for infants
• Breastfeeding (and/or breastmilk substitutes,
if used) should continue beyond the first six
months, along with appropriate types and
amounts of solid foods
All infants should be managed individually so
that insufficient growth or other adverse
outcomes are not ignored and appropriate
interventions are provided.
3
Is there any risk associated with the
recommendations?
3.1
There is extensive scientific evidence to support
the consensus that breastfeeding is the best way
to feed an infant. WHO undertook a systematic
review on the Optimal duration of exclusive
breastfeeding3. The main objective of the review
was to assess the effects on child health, growth
and development and on maternal health of
exclusive breastfeeding for six months compared
with exclusive breastfeeding for three to four
months with mixed feeding (introduction of
complementary liquid or solid foods with
continued breastfeeding) thereafter through six
months.
Sixteen independent studies were reviewed
(seven from developing countries and nine from
developed countries). The conclusions were:
• infants who are exclusively breastfed for six
months experience less gastrointestinal and
or respiratory infection.
• no deficits were demonstrated in growth
among infants who were exclusively
breastfed for six months.
• no benefits of introducing complementary
foods between four and six months have
been demonstrated.
• exclusively breastfeeding for six months is
associated with delayed resumption of the
menstrual cycle and greater postpartum
weight loss in the mother.
Naylor and Morrow4 conducted a review, which
concluded that exposure of the infant to
pathogens that are commonly present in food,
could result in frequent infection. The human
gut is functionally immature at birth in the fullterm infant. Immaturities in digestion,
absorption and protective function exist that
3.2
3.3
2
What are the Department of Health’s
recommendations on feeding infants?
• Breastmilk is the best form of nutrition for
infants
42
The Under Fives
may predispose the infant to age related
gastrointestinal disease during the first six
months of life. They suggested that exclusive
breastfeeding supports the infant’s gut function
during the first six months of life.
The review supported the recommendation that
infants should be exclusively breastfed up to six
months.
4
What is the scientific evidence for
exclusively breastfeeding for six months?
4.1
The systematic review conducted by the WHO
concluded that ‘while infants must be managed
individually, the evidence demonstrated that
there are NO apparent risks in recommending,
as a public health policy, exclusive breastfeeding
for the first six months of life in both developing
and developed countries’.
Although there is no evidence to suggest that
giving a baby solid food before six months has
any health advantage, it is important to manage
infants individually so that any deficit in growth
and development is identified and managed
appropriately.
All infants are individuals and will require a
flexible approach to optimise their nutritional
needs. Mothers should be supported in their
choice of infant feeding.
4.2
4.3
5
What are the health benefits of
breastfeeding?
5.1
Breastmilk provides all the nutrients a baby
needs for healthy growth and development for
the first six months of life and should continue
to be an important part of babies’ diet for the
first year of life.
Breastfed babies are less likely to develop:
• gastric, respiratory and urinary tract
infections (Howie,19905, Kramer, 20021
Wilson, 19986, Cesar, 19997, Pisacane, 19928,
Marild, 19909.)
• obesity in later childhood (Fewtrell, 200410,
Gilman, 200111, Koletzko, 200412.)
• juvenile-onset insulin-dependent diabetes
mellitus (Sadauskaite-Kuenhne, 200413,
Mayer, 198814, Virtanen,199115)
• atopic disease (Fewtrell, 200410, Lucas,199016,
Saarinen and Kajosaari, 199517).
Breastfeeding mothers have:
• reduced risk of developing pre-menopausal
breast cancer (Newcombe, 199418, Beral
200219)
• increased likelihood of returning to their prepregnancy weight (Dewey, 199320)
5.2
5.3
• delayed resumption of the menstrual cycle
(Kennedy ,198921).
6
Does the new recommendation apply to
babies fed infant formula milk?
6.1
Yes. The Sub-group on Maternal and Child
Nutrition of the Scientific Advisory Committee
on Nutrition (SACN) concluded that there are
unlikely to be any risks associated with delaying
weaning to six months in infants who are mixed
fed (on breast and infant formula milk) or solely
fed on infant formula milk.
Six months is the recommended age to
introduce solid foods for all normal healthy
infants. Health professionals should consider
infants’ individual development and nutritional
needs before giving advice to introduce solid
foods any earlier.
6.2
7
Why introduce solid foods at six months?
7.1
Exclusive breastfeeding to six months provides
the best nutrition for babies.
There are nutritional and developmental reasons
why infants need solid food from six months.
Infant’s need more iron and other nutrients than
milk alone can provide.
Infants are usually able to take soft pureed foods
from a spoon, form a bolus and swallow it at
about five months. However, it is not until about
six months that infants actively spoon-feed with
the upper lip moving down to clean the spoon,
chew,22 use the tongue to move the food from
the front to the back of the mouth, are curious
about other tastes and textures and develop
their eye-hand co-ordination. By six months, an
infant can also have finger foods. The older the
baby, the more readily they will accept a varied
diet of texture, taste and amount (COMA
199423).
7.2
8
Will waiting until six months affect a baby’s
ability to chew?
8.1
No. This misconception appears to have arisen
from an old scientific/research paper presenting
case studies of children who remained on a
liquid diet for 6-10 months, most of whom had
developmental delays or disabilities. A
hypothesis was suggested that ‘if children are
not given solid foods to chew at a time when
they are first able to chew, troublesome feeding
problems may occur’. This has since been
quoted and inappropriately extended to younger
babies with normal development24.
43
The Under Fives
9
Is waiting to introduce solids until six
months likely to produce a ‘fussy eater’?
9.1
No. There is no evidence to support the idea
that starting solids at six months is more likely to
be associated with the baby being a fussy eater.
Indeed, a randomised trial comparing breastfed
babies started on solids at either four months or
six months in Honduras found no difference in
appetite or food acceptance as reported by the
mothers25.
10
What about parents who choose not to
follow the new recommendations?
10.1 Parents should be advised of the risks associated
with weaning before the neuro muscular coordination has developed sufficiently to allow
the infant to eat solids. However, if an infant is
showing signs of being ready to start solid foods
before six months, for example, sitting up,
taking an interest in what the rest of the family
is eating, picking up, and tasting finger foods
then they should be encouraged. Solid foods
should not be introduced before 4 months.
11
What are the risks associated with starting
solids early?
11.1 Introducing solids before sufficient development
of the neuro-muscular co-ordination (to allow
the infant to eat solid foods) or before the gut
and kidneys have matured (to cope with a more
diverse diet), can increase the risk of infections
and development of allergies such as eczema
and asthma.
11.2 Certain foods are more likely to upset a baby or
cause an allergic reaction than other foods.
These foods should not be introduced before six
months (COMA 199423).
12
Will baby food manufacturers be persuaded
to alter their labelling from four months to
six months?
12.1 Weaning foods are currently labelled in
accordance with the European Union Directive.
The European Commission has indicated that it
intends to review the labelling of these foods
but has not given a timeframe for this work.
When this review takes place the Department of
Health and Food Standards Agency will work
closely to ensure that the labelling of weaning
foods supports the Department’s advice.
44
13
Will all weaning information for parents be
updated so the advice they are receiving is
consistent?
13.1 The Department of Health wishes to give a clear
and consistent message to mothers, health
professionals and the public. Leaflets and books
such as The Pregnancy Book, Birth to five and
Weaning your baby are being amended to
reflect the current recommendations.
References:
1.
Kramer MS and Kakuma R. The optimal duration
of exclusive breastfeeding:
A systematic review. Cochrane Library (2002).
2.
World Health Organization. 54th World Health
Assembly. Global strategy for infant and young
child feeding. The optimal duration of exclusive
breastfeeding. Geneva (2001).
3.
World Health Organization. The optimal
duration of exclusive breastfeeding: Report on
an expert consultation. Geneva (2001).
4.
Naylor AJ and Morrow AL. Reviews of literature
concerning infant gastrointestinal, immunologic,
oral motor and maternal reproductive and
lactational development. Wellstart (2001).
5.
Howie PW and Forsyth JS, Ogston SA, Clark
A and Florey CD. Protective effect of
breastfeeding against infection. BMJ; 300:11-16
(1990).
6.
Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau
C, and Howie PW. Relation of infant diet to
childhood health: seven year follow-up of cohort
of children in Dundee infant feeding study. BMJ;
316:21-5 (1998).
7.
Cesar JA, Victoria CG, Barros FC, Santos IS and
Flores JA. Impact of breastfeeding on admission
for pneumonia during postnatal period in Brazil:
nested case-control study. BMJ ;318:1316-22
(1999).
8.
Pisacane A, Graziano L, Mazzarella G,
Scarpellino B and Zona G. Breastfeeding and
urinary tract infection. J Pediatr;120:87-9 (1992).
9.
Marild S, Jodal U and Hanson LA. Breastfeeding
and urinary tract infection. Lancet 336:942
(1990).
10. Fewtrell MS. The long term benefits of having
been breastfeed. Current paediatrics 14:97-103
(2004).
11. Gilman MW, Rifas-Shiman SL, Camargo CA,
Berkey CS, Frazier AL and Rockett HRH Risk of
overweight among adults who are breastfed as
infants. JAMA 285:2461-7 (2001).
12. Koletzko B. Benefits of breastfeeding on
childhealth in Europe. (2004).
The Under Fives
13.
14.
15.
16.
17.
18.
Sadauskaite-Kuehne V, Ludvigsson J, Padaiga Z,
Jasinskiene E and Samuelsson U. Longer
breastfeeding is an independent protective
factor against development of type 1 diabetes
mellitus in childhood Diabetes Metab Res Rev,
March 1, 20(2):150-7 (2004).
Mayer EJ, Hamman RFand Gay EC. Reduced risk
of IDDM among breast fed children: the
Colorado DDM registry. Diabetes 37:1625-32
(1988).
Virtanen SM, Fasanen L and Aro A. Infant
feeding in Finnish children under 7 years of age
with newly diagnosed IDDM. Diabetes Care
14:415-17 (1991).
Lucas A, Brooke OG, Morley R, Cole TJ and
Bamford MF. Early diet of preterm infants and
development of allergic or atopic disease:
randomised prospective study. BMJ 300:837-40
(1990).
Saarinen UM and Kajosaari M. Breastfeeding as
prophylaxis against atopic disease: prospective
followup study until 17 years old. Lancet
346:1065-9 (1995).
Newcomb PA, Storer BE and Longnecker MP.
Lactation and a reduced risk of premenopausal
breast cancer. N Engl J Med 330:81-7 (1994).
19.
20.
21.
22.
23.
24.
25.
Beral V. Breast cancer and breastfeeding:
collaborative reanalysis of individual data. 47
epidemiological studies in 30 countries,
including 50302 women with breast cancer and
96973 women without the disease. Lancet 360:
187-95 (2002).
Dewey KG, Heinig MJ and Nommsen L.
Maternal weight loss patterns during prolonged
lactation. Am J Clin Nutr 58:162-6 (1993).
Department of Health (2204) Infant Formula
Milk - Goat’s Milk Based Infant Formula
Stevenson RD and Allaire JH. The development
of normal feeding and swallowing. Ped. Clin.
North Am.38: 1439-53 (1991).
Department of Health. COMA working Group
on the weaning diet. Weaning and the weaning
diet. London (1994).
Illingworth RS and Lister J. The critical or
sensitive period, with special reference to certain
feeding problems in infants and children. The
Journal of Ped, 65, 840-8 (1964).
Cohen. Report on food acceptance of breastfed
infants from 6-12 months in low income,
Honduran population. J Nutr Nov 125
(11):2787-92 (1995).
ACKNOWLEDGEMENTS
The Department of Nutrition & Dietetics wishes to acknowledge the input of all current and
previous contributors to this document, including Dietitians, Nutritionists, Infant Feeding
Advisors, Health Visitors, Nursery Nurses, Breastfeeding Counsellors and many others.
45
The Under Fives
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2)
Successful Breasfeeding – Royal College of Midwives
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3)
Howie, PW et al (1990) Protective effect of
breastfeeding against infection BMJ, 300: 11-16
4)
Wilson AC et al (1998) Relation of infant diet to
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6)
18)
Renfrew, MJ, Ansell, P, Macleod, KL (2003) Formula
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Taitz LS, Scholey E, (1989) Are babies more satisfied
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Piscane A, Grazione L, Zona G (1992) Breastfeeding
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23
Duncan B et al (1993) Exclusive breastfeeding for at
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British Dietetic Association Paediatric Group
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King C (2007) Preterm Infants. In Clinical Paediatric
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Blackwell Publishing Ltd
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FSIDS (2008)
8)
Mayer EJ et al (1998) Reduced risk of IDDM among
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Diabetes, 37, 1625-32
25)
9)
Lucas, A, Cole,TJ (1990) Breast milk and necrotising
enterocolitis Lancet 336: 1519-1523
Aukett A (1996) Iron deficiency in children, British
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cognitive development: a meta-analysis. Am J Clin
Nutr 70: 525-535
Fitzpatrick S et al (2000) Vitamin D deficient rickets: a
multifactorial disease Nutrition Reviews 58: 218-222
27)
Ko MLB et al (1992) what do parents know about
vitamins? Arch Dis Child 67: 1080-1081
11)
Collaborative Group on Hormonal Factors in breast
cancer. Breast cancer and breastfeeding: 2002
collaborative reanalysis of individual data from 47
epidemiological studies in 30 countries, including 50
302 women with breast cancer and 96973 women
without the disease. Lancet 360: 187-195
28)
WHO Technical Report Series No. 797 “Diet Nutrition
and the Prevention of Chronic Disease. Report of
WHO Study Group. Dec 1990.
29)
Department of Health, Dietary Reference values for
Food Energy and Nutrients for the United Kingdom.
(Report on Health and Social Subjects; No.41 London:
HMSO (1991)
30)
Department of Health and Social Security (1994)
Nutritional Aspects or Cardiovascular disease,
London: HMSO (Reports on Health and Social
Subjects No. 46)
12)
Rosenblatt KA et al (1993) Lactation and the risk of
epithelial ovarian cancer - the WHO Collaborative
Study of Neoplasia and Steroid Contraceptives. Int J
Epidemiol 22: 499-503
13)
National Breastfeeding Working Group, Breastfeeding
Good Practice. Guide to the NHS 1995
31)
14)
Morhbacher, N & Stock, J, (2003) The Breastfeeding
Answer Book. 3rd edition. La Leche League
International
Murphy, MS (1998) Guidelines for Managing Acute
Gastroenteritis Based On A Systematic Review Of
Published Research. Arch Dis Child 79 279-284
32)
15)
World Health Organisation: Breastfeeding: The
Technical basis and recommendations for action. Ed
Saadeh, RJ, Geneva 1993
Eilly, JJ (99) Epidemic of Obesity in UK Children Lancet
354 1874-5
33)
Scottish Intercollegiate Guidelines Network (SIGN)
2003. Management of obesity in children and young
people.
www.sign.ac.uk/guidelines/published/index.html (see
under child health, guideline 69
34)
www.ic.nhs.uk/webfiles/publications
35)
Horta BL et al (2007). Evidence on the long-term
effects of breastfeeding. World Health Organisation
36)
Department of Health (2007) Breastfeeding at work.
http://www.dh.gov.uk
37)
Breastfeeding Network (2008) Expressing and Storage
of Breast milk
http://www.breastfeedingnetwork.org.uk
16)
Reynolds & Davies Clinical audit of cotside blood
glucose measurement in the detection of neonatal
hypoglycemia. J Paed & Child Health 29:289-91
17)
The Infant Formula and Follow-on Formula
Regulations 1995 – implement Commission Directive
91/321/EEC at 14 May 1991 (OJ No. L175,4.7.91) on
infant formula and follow on Formula. The infant
Formula and Follow-on Formula (Amendment)
Regulations 1997 which Implement Commission
Directive 96/4/EC of 16 February 1996 (OJ No.
L49,28.2.96).
46
The Under Fives
REFERENCES/RESOURCES continued
38)
DeCock KM et al (2000) Prevention of Mother to
Child HIV transmission in resource-poor countries
- Translating Research into policy and practice.
JAMA. 283 1175-1182
Lanigan J (2007) HIV and AIDS. In Clinical
Paediatric Dietetics, 3rd edn. Eds Shaw V &
Lawson M, pp. 142-162. Oxford: Blackwell
Publishing Ltd
39)
Baynes Clarke et al (2003) Special feeding
requirements in A Guide to Feeding Infants. pp
38. Anglia Digital Print Ltd. Norwich
40)
Food Standards Agency (Sept 2008)
http:www.food.gov.uk
41)
Department of Health (2007) Advice on infant
milks based on goats' milk. www.dh.gov.uk
42)
8
43)
Dijkstra S H et al. High prevalence of vitamin D
deficiency in newborn infants of high-risk
mothers. Arch. Dis. Child. 2007; 92; 750-753
44)
British Dietetic Association. (2007) Diet, Behaviour
and Learning in Children. Food Fact Sheet.
45)
NICE 2006 Obesity guidance on the prevention,
identification, assessment and management of
overweight and obesity in adults and children.
NICE Clinical Guideline 43. www. nice.org.uk
46)
Department of Health (2007) Bottle Feeding.
www.dh.gov.uk Product number: 278959
47)
Department of Health Committee on Toxicity of
Chemicals in food, consumer products and the
Environment Peanut allergy. London DH (1998)
Heart of Birmingham Teaching Primary Care
Trust. Vitamin D Supplementation of children
under 5 years of age and pregnant and
breastfeeding women. Reference no: CLIN/016
http://www.bpcssa.nhs.uk/policies/_hob/policies/8
82.pdf
ADDITIONAL READING
Heart of Birmingham Teaching Primary Care Trust.
Vitamin D Supplementation of children under 5 years
of age and pregnant and breastfeeding women.
http://www.bpcssa.nhs.uk/policies/_hob/policies/882.pd
f Reference no: CLIN/016
Lawrence, R. Breastfeeding: A Guide for the Medical
profession. Pub: Mosby 1999.
Royal College of Midwives (2002). Successful
Breastfeeding –A practical guide for mothers and
midwives and other supporting breastfeeding mothers
(3rd edition).
La Leche League. A range of books and leaflets.
www.lllbooks.co.uk
Healthy Diets for infants and young children (1997).
MAFF. Reference number: PB2026.
La Leche League. Breastfeeding Answers.
www.llliorg.nb
Department of Health (2008). Weaning, starting solid
food. Reference number: 278960
Department of Health (2004). Breastfeeding. Reference
number: 31636
MIDIRS Midwifery Digest. September 2008.
Shaw and Lawson (2007). Clinical Paediatric Dietetics.
Blackwell. ISBN 9781405134934.
Infant feeding in Asian families: Early Feeding Practices
and Growth. Social Services Division, Office of National
Statistics on behalf of Department of Health, 1997.
RESOURCES FOR HELPING MOTHERS WHO
NEED TO EXPRESS MILK
Guidelines for the collection, storage and handling of
mother’s breast milk to be fed to her own baby on a
neonatal unit. British Association of Perinatal Medicine
& UNICEF. Baby Friendly Initiative Published September
1997. Price £7.50. [email protected]
The Breastfeeding Network. Expressing and Storing
Breast Milk. www.breastfeedingnetwork.org.uk. £15
for 50 leaflets.
La Leche League. A mother’s Guide to Pumping Milk.
www.lllgbbooks.co.uk. £1.99.
La Leche League. Hand Expression of Breast Milk.
www.lllgbbooks.co.uk. £4.99.
La Leche League. Storing Your Milk.
www.lllgbbooks.co.uk. £4.99.
La Leche League. Choosing a Breast Pump.
www.lllgbbooks.co.uk. £4.99.
United Kingdom Association for Milk Banking
Newsletter – published twice a year.
www.ukamb.org/newsletter
47
The Under Fives
USEFUL ADDRESSES/CONTACTS
Community Nutrition & Dietetic Service
Vegetarian Society of the United Kingdom Ltd
Centre for Community Health
St. Patricks
Frank Street
Highgate
Birmingham
B12 0YA
Tel: 0121 446 1021
Parkdale
Durham Road
Altrincham
Cheshire WA14 4QG
0161 925 2000
www.vegsoc.org
National Childbirth Trust (NCT)
Fernbank Surgery
508-516 Alum Rock Road
Ward End
Birmingham
Tel: 0121 678 3875
The Springfield Centre
Raddlebarn Road
Selly Oak
Birmingham
West Midlands
B29 6JB
Tel: 0121 627 1627 Ext. 51484
Vegan Society
Donald Watson House
21 Hylton Street
Hockley
Birmingham
B18 6HJ
0121 523 1730
www.vegansociety.com
NHS Breastfeeding Information
National Breastfeeding Helpline
0844 209 0920
www.breastfeeding.nhs.uk
48
Alexandra House
Oldham Terrace
Action
London
W3 6NH
Tel: 0300 33 00 770
www.nct.org.uk
La Leche League of Great Britain
La Leche League of Great Britain
PO Box 29
West Bridgford
Nottignham
NG2 7NP
0845 456 1855
www.laleche.org.uk
Best Buddie
Under 5’s programme
(HOB – 0121 255 0134)
West Midlands Regional Infant Feeding Group
www.wmpho.org.uk/infantfeeding
Healthy Start Scheme
www.healthystart.nhs.uk
Older People
CONTENTS
1
INTRODUCTION
2
AGEING AND NUTRITION
3
NUTRITIONAL NEEDS
- THE ‘FIT’ AND THE ‘FRAIL’
4
COMMON NUTRITION
RELATED HEALTH PROBLEMS
a) -
diabetes
b) -
anaemia
c) -
constipation
d) -
dementia
e) -
risk of falling
5
IDENTIFYING NUTRITIONAL
RISK FACTORS
6
COPING WITH A SMALL
APPETITE
Appendix I
Nutritional Risk Factors
Appendix II
Community Nutritional Screening Tool
Bibliography
Resources and Useful Addresses
1
Older People
1.0 INTRODUCTION
The purpose of this section is to provide practical
information about the nutritional needs and nutritional
problems of older people (ie those over 65), and
provide guidance to aid management of these
problems.
The number of older people in Britain is increasing
with numbers aged over 65 years having doubled in
the last 70 years. The over 80 years age group is the
fastest growing section of the population and the
number of people over 90 years is expected to double
in the next 25 years1.
2.0 AGEING AND NUTRITION
The normal ageing process can have several nutritional
consequences. These changes occur at different rates
and degrees in each individual.
With ageing lean body mass (metabolically active
tissue) is reduced and so energy requirements are
reduced. If energy intake is therefore not reduced
weight gain will occur.
Renal function and thirst perception decline with age,
increasing the risk of dehydration in the older person.
Smell and taste diminish, making eating less enjoyable
for some.
Digestion and gut motility slow which can contribute
to malabsorption and constipation respectively. Bone
density decreases, increasing the risk of osteoporosis
and fractures.
Vision may be impaired which can affect the older
person’s ability to eat and prepare food and drink for
themselves.
3.0 NUTRITIONAL NEEDS
The nutritional needs of older people are best thought
of by dividing the population into ‘the fit’ and ‘the
frail’
‘The Fit’ - nutritional needs are similar to those of the
general population - see core section. As energy
requirements decrease with age, it is essential that the
diet is nutrient dense. Following healthy eating
guidelines should ensure a balanced, nutrient rich diet.
A Vitamin D supplement (10 µg daily) may be
advisable in those aged over 65 years, and for those
who are housebound.
2
‘The Frail’ - appetite and dietary adequacy are often
poor in this group, leading to a high risk of
malnutrition. Healthy eating guidelines are probably
inappropriate as maintaining adequate energy and
protein intake becomes essential to help preserve
strength, muscle function, skin integrity and an
effective immune system. Energy dense foods and
drinks become a priority and nutritional supplements
may be necessary. Section 6 gives specific advice to
manage this.
4.0 COMMON NUTRITION RELATED
HEALTH PROBLEMS
A
DIABETES
Type 2 Diabetes increases with age. It occurs in 610% of people aged 70 years and over, compared to
1-2% in the general population. Treatment is by diet
or diet and medication. Symptoms of diabetes may
not be obvious in older people and are often blamed
on ‘old age’ so diagnosis can be delayed.
Aims of treatment
To prevent symptoms, which can be:
l
Increased thirst
l
Passing water more frequently especially at night
l
Tiredness
l
Weight loss
l
Blurred vision
l
Genital itching/recurrent thrush
l
Stabilise blood sugar levels. Ideally to keep
between 4-10 mmol/l
Dietary Aims
l
l
l
Regular meals
Low sugar intake
Higher fibre intake
A low fat intake using lower fat milks and low fat
spreads is NOT necessary for frail older people.
B
ANAEMIA
From a study of people aged over 60 years 17% were
found to be anaemic2. Anaemia can cause tiredness,
weakness and loss of appetite. Causes can be poor
dietary iron intake, reduced iron absorption, and
multiple medication. Encourage the consumption of
iron rich foods and take vitamin C rich foods with
meals to aid iron absorption.See ‘The Eatwell Plate’
(core section) for sources of iron and Vitamin C.
Older People
C
CONSTIPATION
Low mood and not bothering to cook.
This is a common problem in older people. Encourage
a good fibre intake from wholemeal or wholegrain
bread and cereals, together with fruit and vegetables.
Increase fibre intake gradually to allow the body to
adjust. Fluid intake needs to be at least eight full cups
daily. If fibre intake is increased without adequate
fluids it can make constipation worse.
Loss of strength - unable to walk far or stand for long.
D
Leaving food, only eating small amounts.
DEMENTIA
Pallor or sunken eyes.
Skin appears dry and/or flaky
Delayed wound healing.
People with dementia may have a variety of problems
with eating and drinking. They often need a lot of
prompting, reassurance and encouragement to eat.
Seek advice for specific problems.
(See resources/ useful addresses)
Guidelines for the treatment of undernutrition in the
community have been developed which use a nutrition
screening tool. This asks questions about current
weight, recent weight changes and appetite/ability to
eat. (see Appendix II)
E
ENRICHED FOOD AND DRINK
RISK OF FALLING
Dietary factors which affect the risk of falling include:
l
l
l
l
l
l
l
dehydration
high alcohol intake
anaemia
uncontrolled/undiagnosed diabetes
long gaps without food
insufficient calories
osteoporosis
Aims
l
l
l
l
l
Regular meals and snacks
Eight mugs of fluid daily
Eating foods from all the main food groups daily
Having the equivalent of 1 pint of milk daily (for
calcium)
Some exposure to sunlight or a vitamin D
supplement if housebound
The nutritional content of many foods and drinks can
be increased by adding extra energy and protein.
Ideas include the following:
Fortified Milk - add 4 tbsp dried milk powder to 1
pint of full cream milk. Use the fortified milk in place
of ordinary milk for extra protein and energy.
To savoury foods - (eg soup, toast, potato,
vegetables etc.) add cream, cheese, margarine/butter
or milk for extra energy and protein.
To puddings and breakfast cereals - add cream,
sugar, jam, syrup, honey, evaporated or condensed
milk, ice cream, fresh or dried fruit for extra energy.
Use fortified milk on breakfast cereals and in custard.
5.0 IDENTIFYING NUTRITIONAL RISK
FACTORS
There are many factors that affect a persons ability to
eat well. These can be social, economic and medical
(see appendix I).
Signs of poor nutritional intake include:
Weight loss - clothes looser, dentures too big, rings
and watch straps very loose.
Underweight or thin appearance
Frequent falls - very unsteady on feet.
3
Older People
6.0 COPING WITH A SMALL APPETITE
When appetite and food intake is reduced, it is
important make food and drink as nourishing as
possible. The following contains information on how
this can be achieved and is recommended to be
passed on to older people and their carers. Eating
regularly with 3 small meals and 2-3 snacks or milky
drinks is vital. It is important to eat a variety of foods
choosing foods from each food group as follows to
maintain a balanced intake.
Have fruit and vegetables for vitamins,
minerals and fibre. Try a glass of fruit
juice/smoothies or squash fortified with
vitamin C. If not able to eat foods from
this group, a multi-vitamin
and mineral supplement
could be helpful. Tinned or
canned fruit and vegetables
are as nutritious as fresh.
Eat foods from this group at
least twice a day. These
foods provide protein and
iron.
Eat some of these
foods at each meal.
Choose wholemeal
varieties for extra
fibre.
Add extra fat
(butter or
margarine) to
bread, toast and
potatoes. Add extra
sugar to cereals.
Use at least 1 pint of full cream
milk daily. Choose full fat dairy
foods. Dairy foods contain
energy, protein and calcium.
These foods contain lots of energy and make useful snacks
or puddings for those needing to eat more energy.
Snacks and Nourishing Drinks
These when taken in addition to meals, provide extra
energy and protein to help maintain strength and
weight. Eating ‘little and often’ also helps improve a
reduced appetite. High energy snack ideas include
scones, cakes, biscuits, crisps, nuts, yoghurt, cheese,
bananas, crumpets, fruit pie, trifle and chocolate.
However these should be take as well as small meals,
not instead of.
Nourishing drinks include milk, hot chocolate, cocoa,
fruit smoothies, Ovaltine, Horlicks, milkshakes, milky
coffee, ‘Cup a soup’ made with milk. Build Up,
Complan and Nourishment are examples of nourishing
4
drinks available to buy in supermarkets and chemists.
They come as milkshakes/powders in sweet, savoury
and neutral/unflavoured varieties.
Appetite Stimulants
Eating little and often can help improve a reduced
appetite. The following may also help stimulate a
small appetite prior to a meal:
- Fresh air
- Exercise
- Small amount of alcohol (check with doctor or
pharmacist if taking medication)
The Eatwell Plate is © crown copyright material and
is reproduced with the permission of the controller
of HMSO and Queen’s printer for Scotland.
Older People
APPENDIX I
NUTRITIONAL RISK FACTORS
REFERRAL
INTERVENTION
SOCIAL FACTORS
Lonely / isolated
Discuss local groups / day centres
Social Services
Local Age Concern
Housebound
Supplements of calcium and vitamin D.
GP
Depression
Review medication
Discuss reasons
GP to treat depression
Low income
Discuss possible claim income support
Citizens Advice Bureau
Social Worker
Access to shops
Discuss local availability of home
shopping services, home delivery
Carer
Social Worker
Poor dentition / dentures limits
food choice
Advice re: community dental service
Community Dental Service
Multiple Medication
Ask for blood tests to check vitamin levels
GP review
Confusion / forgetfulness
Discussion with carers, relatives,
neighbours
Carers to contact Alzheimer’s
Society
ECONOMIC
HEALTH / MEDICAL
GP to refer to local Mental Health
Service
Swallowing difficulties
Assess food/drink intake
Refer via GP to Speech and
Language Therapist
Physical difficulties in
preparing food
Obtain suitable aids/equipment
Refer to Occupational Therapist.
Long gaps without food
Help plan meals, snacks throughout day
Use Food Boosters leaflet
Available from local Primary Care
Trust Prescribing Advisors
Little fruit and vegetables
Encourage more use of fruit juice,
tinned fruit, frozen vegetables.
No margarine used
Encourage use of margarine
(for vitamin D content)
No breakfast cereals
Encourage cereals and milk for
breakfast or snack. Most cereals are
enriched with iron and folate
FOOD CHOICES
5
Older People
APPENDIX II
COMMUNITY NUTRITIONAL SCREENING TOOL
This screening tool has been designed for use within community settings to highlight those patients who require
nutritional intervention. The target group are those adult patients over the age of 16 years with chronic disease or
conditions in which the nutritional status of the patient may be compromised eg. sick elderly, cancer, neurological
disease etc.
Criterion 1
Criterion 2
Criterion 3
Visual Assessment of
Body Weight
(use body mass index (BMI)
if height & weight are available)
Unintentional Weight loss
Intake of Food and Fluids
Visually, weight is acceptable
(or BMI>20)
No weight loss
0
No problems
0
0
* Visually, thin
(or BMI 18.5-20)
3-6kg within 12 months
(1/2 - 1 stone)
2
1
Some problems with
intake of food & fluid
for > 3 days
1
* Visually, very thin
(or BMI < 18.5)
>6kg within 12 months
(> 1 stone)
3
3
3
>3kg within 3 months
(>1/2 stone)
3
Severe problems with
intake of food & fluid
for > 3 days
Select 1 score from each Criterion.
Add together for total score.
0
= No further action required
1-2
= Monitor weight where possible/repeat
screening tool in 4 weeks
3+
= INTERVENTION REQUIRED
Determine underlying cause and take action
See full guidelines.
Actions are recommended for specific problems and meal/snack ideas are given in a leaflet ‘Foodboosters’.
* Acceptable BMI for older people differs slightly from that of the general population.
6
Older People
REFERENCES
1 National Service Framework for Older People.
Department of Health 2001.
2 Gaskell, H. Moore, R, A. and McQuay, H, J. (2008)
Prevalence of anaemia in older persons: systematic
review. BMC Geriatrics. 8:1
3 The Nutrition of Elderly People Report of
Committee on Medical Aspects of Food Policy No.
43. Department of Health 1992. London: HMSO
4 Eating Well for Older People: Practical and
nutritional guidelines for food in residential and
nursing homes. Caroline Walker Trust 2004.
5 Nutritional Care for Older People – a guide to food
practice. June Copeman. Age Concern
6 Guidelines for the treatment of undernutrition in
the community – including rationale for oral
nutritional supplement (sip feed) prescribing.
Birmingham Specialist Community Health Trust.
RESOURCES
NAGE (Nutrition Advisory Group for the Elderly group
of the British Dietetic Association). Send SAE for order
form of resources available (videos and leaflets) to:
NAGE, The British Dietetic Association Unit 21,
Goldthorpe Industrial estate, Goldthorpe, Rotherham,
South Yorkshire, S63 9BL. Tel 01709 889900.
Fax 01709 881673
The Birmingham Older Persons Website, National
Health Service. www.olderpeople.bham.nhs.uk
Food Standards Agency, Ages and Stages –
Older People www.eatwell.gov.uk
Eating Well for Older People 2nd Edition (2004),
The Caroline Walker Trust
Available from:
The Caroline Walker Trust, 22 Kindersley Way, Abbots
Langley, Herts, WD5 0DQ www.cwt.org.uk
Hydration Toolkit for Hospitals and Healthcare,
Water UK (2007) www.water.org.uk
USEFUL ADDRESSES
Alzheimer’s Society
Devon House
58 St Katherine’s Way
London
E1W 1JX
Tel 020 7423 3500
Diabetes UK (central Office)
Macleod House
10 Parkway,
London
NW1 7AA
Tel 020 7424 1000
Fax: 020 7424 1001
Parkinson’s Disease Society
215 Vauxhall Bridge Road
London
SW1V 1EJ
Tel: 020 7931 8080
Fax: 020 7233 9908
The Stroke Association
240 City Road
London
EC1V 2PR
Tel 020 7566 0300
Fax 020 7490 2686
Help the Aged (England)
207-221 Pentonville Road,
London
N1 9UZ
Tel 020 7278 1114
Fax 020 7278 1116
Age Concern (England)
Astral House
1268 London Road
London
SW16 4ER
Tel: 020 8765 7200
National Institute for Health and Clinical
Excellence (NICE)
Clinical Guideline 21 The assessment and prevention of
falls in older people (2004)
Clinical Guideline 42 Dementia - Supporting people
with dementia and their carers in health and social
care (2006)
Available From:
National Institute for Health and Clinical Excellence,
MidCity Place, 71 High Holborn, London, WC1V 6NA
Tel 0845 003 7780 www.nice.org.uk
7