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NHDmag.com Issue 84 May 2013 Preventing and treating bone loss Dr Carrie Ruxton p9 nutrition support intervention in cystic fibrosis Helen White Principal Lecturer/Specialist Dietitian Nutritional intervention and support is crucial for optimal care in cystic fibrosis. The evidence . . . p17 coeliac UK’s awareness week dietary cholesterol Elderly nutrition crohn’s disease Nutrimenthe: prenatal nutrition dieteticJOBS • NHD Clinical • new research • Subscription offer ISSN 1756-9567 (Print) First for cow’s milk allergy Helping him towards tolerance to cow’s milk 70 years. 70 studies. Only Nutramigen. Up to 6 months From 6 months ew ram i ard N ut nd Previous studies have shown that children with cow’s milk allergy (CMA) commonly acquire tolerance between 3–5 years of age.1–2 ® tt IL : Se ing the n s ta Nutramigen LIPIL® is the only cow’s milk allergy formula with evidence of tolerance to cow’s milk IP nL ge Tolerance to cow’s milk protein with Nutramigen3 90 NEW data has demonstrated that 53.6% of Nutramigen-fed infants are tolerant to cow’s milk after 12 months of treatment.3 Infants acquiring tolerance (%) 80 70 54 60 50 40 30 20 % 21% 10 0 At 6 months Cumulative at 12 months Oral tolerance with Nutramigen LIPIL® means: Avoiding unnecessary healthcare costs sts4 – with potential cost savings on overall CMA management vs formulas without evidence of tolerance. her and child4 Optimal quality of life for both mother – assisting a return to a normal diet. Effective symptom relief 5 and could help you achieve your goal of faster tolerance acquisition on in CMA. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. EU 11.564. * Trademark of Mead Johnson & Company. LLC. © 2013 Mead Johnson and Company. LLC. All rights reserved. Advertisement Feature Acquisition of oral tolerance in infants with CMA Nutramigen Lipil, as a first-line formula for cow’s milk allergy (CMA), is effective in more than 90% of infants, and may promote acquisition of oral tolerance whilst also reducing costs in the first year of management in primary care. 3,5,6 Cow’s milk allergy is a major paediatric health problem in the UK, affecting 2-7.5% of infants.7 Common symptoms include colic and an increased risk of nutrient deficiencies and growth problems.8 Acquisition of oral tolerance to cow’s milk protein with Nutramigen Lipil 3 “Choosing an appropriate formula for the infant should be based on clinical presentation, nutritional composition and residual allergenicity of the formula, although the palatability of the formula and age of the infant will also be factors. It is thought that an extensively hydrolysed formula (eHF) will improve symptoms in up to 90% of infants with cow’s milk protein allergy” 9 explains Dr. Carina Venter. Acquisition of oral tolerance in infants with CMA receiving Nutramigen Lipil 3 Oral tolerance to cow’s milk is an acquired state where the infant no longer reacts to cow’s milk proteins (CMP). • • A recent study shows that after 6 months 21% of infants with CMA receiving Nutramigen Lipil are tolerant to cow’s milk, which increases to 54% after 12 months of Nutramigen Lipil treatment 3 In the study, infants accepted Nutramigen Lipil without problems, and no adverse events were observed Clinical tolerance to CMP is maintained in infants receiving Nutramigen Lipil 3 • • • Clinical tolerance to CMP was still present when infants with a negative challenge were reassessed after 6 months 3 No signs or symptoms related to CMA were noted following consumption of regular doses of cow’s milk daily 3 Acquisition of oral tolerance to CMP can improve the quality of life of the child and the whole family Percentage of infants acquiring tolerance to CMPa Clinical tolerance to CMP present when infants with negative challenge reassessed after 6 months at 6 months 6/28 21% at 12 mon months ths 15/28 15/28 54% a After an exclusion diet, a double-blind, placebo-controlled food challenge was performed • • To achieve tolerance, it is suggested that limited exposure to the antigen is needed. Some eHF seem to retain a small immunogenic effect compared to amino acid based formulas and as a result may induce tolerance 14-17 Recent clinical evidence supports Nutramigen Lipil, an eHF, as promoting the acquisition of oral tolerance 3 Nutramigen Lipil aligns with expert guidelines whilst also reducing costs 6 A comparison of healthcare resource use and associated costs between an eHF (Nutramigen Lipil) and an amino acid formula (Neocate) has demonstrated: • • • No signiﬁcant difference in clinical outcome In comparison to this amino acid formula, using Nutramigen Lipil as first-line formula reduces NHS costs by £1,300 per patient over the first 12 months of management 6 Compared to an amino acid formula, starting treatment for CMA with an eHF was the cost-effective option For those infants who need an amino acid formulation due to their clinical presentation, treatment of their CMA should be the priority over potential cost savings. Latest evidence provided by Canani et al. reviewed by Dr. Carina Venter, Senior Dietitian, The David Hide Asthma and Allergy Research Centre References: 1. Wood RA. J Pediatr 2003; 111:1631–1637. 2. Bishop JM et al. J Pediatr 1990; 116:862–867. 3. Canani R et al. J Allergy Clin Immunol 2012; 129:580–582. 4. Koletzko S et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221–229. 5. Dupont C et al. Br J Nutr 2011:1–14. 6. Taylor R et al. Pediatr Allergy Immunol 2012; 23:240–9. 7. Du Toit G et al. Arch Dis Child Educ Pract Ed 2010; 95:134–44. 8. Vandenplas Y et al. Arch Dis Child 2007; 92:902–908. 9. Host A et al. Arch Dis Child 1999; 81(1):80–4. 10. de Boissieu D et al. J Pediatr 1997; 131(5):744–7. 11. de Boissieu D et al. Acta Paediatr 1997; 86(10):1042–6. 12. Hill DJ et al. Clin Exp Allergy 2007; 37(6):808–22. 13. Fiocchi A et al. Pediatr Allergy Immunol 2010; Suppl 21:1–125. 14. Omata J. Allergy Clin Immunol 2005; 115:822-27. 15. Sicherer S et al. J Allergy Clin Immunol 2006; 117:S470-5.16. Pabst et al. Mucosal Immunol 2012; 5:232-9. 17. Høst A et al. Allergy 2004; 59 (Suppl 78):45-52. First Line for CMA Up to 6 months Cumulative total number of infants tolerant to cow’s milk proteina Number of infants acquiring tolerance: Nutramigen Lipil, an eHF, is effective in >90% of infants with CMA.5 For those infants with more severe presentations of CMA e.g. severe eczema, food protein-induced enterocolitis syndrome or anaphylaxis, an amino acid based formula will be required.4,10-13 Oral tolerance is the active non-response of the immune system to an antigen administered through the oral route. In infancy, a failure to establish or maintain oral tolerance to a food antigen results in a specific food allergy. Low dose exposure to food allergens may contribute to the acquisition of oral tolerance in early life.14-16 First for cow’s milk allergy From 6 months +44 (0)1895 230575 www.nutramigen.co.uk from the editor Neil Donnelly NHD editor Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders What do Gwyneth Paltrow, Anna Friel and Samantha Brick have in common? Simple. All three have the ability to express their extreme opinions on dietary matters and create a media maelstrom and a dietetic nightmare as a result. Samantha, age 42, states that she has been on a permanent diet for the past 30 years, lived for the best part of a year on Marmite on toast, invented the polo diet (two packs per day) and looked fantastic until her dentist pointed out the damage to her teeth. She also follows an extreme low-calorie diet four times a year. She loses half a stone each time, though the side effects mean that she doesn’t have the mental or physical fortitude to work! Who needs a dietitian? Gwyneth and Anna wade in with their own versions of a gluten free, sugar free, dairy free, meat free world which translates into a new book or a ‘master cleanse’. When are we going to have an ‘A list’ dietitian to address such celebrity comments? Celebrities are not HPC Contributors registered so have a free reign to speak their thoughts. Sadly it appears that they are likely to have more effect on consumer dietary habits than health professionals. Having recently undertaken (see previous issue) my guest lecture to MSc Nutrition students maybe this is the way forward. A Post Graduate Course designed to manufacture ‘Dietitians to the Stars’. A professional they can go to who understands their world and can shape their views. It’s time to think outside the box and not take a hit from the Brick! On Monday 10th June the British Dietetic Association (BDA) holds its AGM in Birmingham. These are usually poorly attended (less than percent of the membership attended last year). This year there is a Special Resolution to change the Articles of Association – the ‘governing rules’. As a signatory with 26 colleagues who have submitted their views to the BDA by letter I have voted against the resolution. Find out more and use your vote. Contents 4 News Ursula Arens Writer; Nutrition & Dietetics 5 Product/industry news Chris Rudd 6 Coeliac UK Awareness Week 13 Dietary cholesterol Dietetic Advisor, Sheffield PCT Medicines Management Team Dr Anita MacDonald Consultant Dietitian in IMD, Birmingham Children’s Hospital Dr Amelia Lake Lecturer in Knowledge Exchange in Public Health, Centre for Public Policy & Health, Durham University Dr Carrie Ruxton Freelance Dietitian Kate Harrod-Wild Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board 16 17 23 25 26 NHD Clinical: Cystic fibrosis: nutritional interventions Crohn’s disease: presentation & management Web watch Improving diet in the elderly 9 Cover Story Preventing and treating bone loss Alison Burton Shepherd Nutr (Scientist) BSc (Hons) MSc RGN TCH Queens Nurse 28 Nutrimenthe: prenatal nutrition Helen White Principal Lecturer/Specialist Dietitian Cystic Fibrosis, Leeds Metropolitan University, Leeds Teaching Hospitals Trust 30 dieteticJOBS & Events & courses Cathy Forbes Registered Dietitian, South Essex Partnership University NHS Foundation Trust Vittoria Romano Registered Dietitian, South Essex Partnership University NHS Foundation Trust Arash Assadsangabi Specialist Registrar in Gastroenterology Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust Dr Mark McAlindon Consultant Gastroenterologist, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust Dr Claire Horton Beta Technology Ltd, Doncaster Photos: istockphoto.com unless otherwise stated Editor Neil Donnelly RD FBDA Features editor Ursula Arens RD NHD Clinical editor Chris Rudd RD Design Heather Dewhurst Sales Richard Mair [email protected] Publisher Geoff Weate Publishing Assistant Lisa Jackson Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Skype NHDmag Fax 0870 762 3713 Email [email protected] www.NHDmag.com www.dieteticJOBS.co.uk All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to [email protected] and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons. NHDmag.com May 2013 - Issue 84 3 news Enteral nutrition survey Dr Carrie Ruxton PhD, RD Freelance Dietitian Enteral feeding, also known as tube feeding, is often used as a mode of nutrient delivery for patients unable to swallow safely, and is a key tool in paediatric dietetics. Now, a new survey has investigated healthcare professionals’ knowledge in this area. A cross-sectional survey was carried out and a questionnaire sent to units listed in the Paediatric Intensive Care Audit Network database, which led to a response rate of 90 percent (108 individual responses). Responses showed that most units (96%) had some written (brief and generic) guidance on enteral nutrition with 85 percent of staff reporting that guidelines helped to improve energy delivery. However, fluidrestrictive policies (60%), the child being ‘too ill’ to feed (17%), surgical post-operative orders (16%), staff being slow in starting feeds (7%), frequent procedures requiring fasting (7%) and haemodynamic instability (7%) were all reported to reduce energy delivery. Gastric residual volume (GRV) is also often used to assess the safety of enteral feeding. Survey results highlighted that there was great variation in relation to the use of GRV. Overall, this work highlighted a clear need for updated, uniform enteral feeding guidelines that can be embedded safely in a practice environment. For more information see: Tume L et al (2013). British Journal of Nutrition Vol. 109 (7): pg 1,304-22. Promoting bone health Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com 4 Osteoporosis is a major public health issue, affecting around three million people in the UK. It is well recognised that certain lifestyle factors, e.g. lack of exercise or smoking, can contribute to the development of osteoporosis, but simple dietary changes can also help to improve long-term bone health. Several nutrients can support normal bone health, but most research relates to vitamin D and calcium, which work in combination to strengthen and stabilise bone tissue. In the UK, calcium intakes are low in some groups, mainly younger women and girls, while vitamin D deficiency is widespread across the age spectrum. Vitamin D3, the most bioavailable form of vitamin D, is only present in a few natural foods e.g. eggs and oily fish, and intakes of these are too low at present. Sunlight, the main source of blood vitamin D, is an unreliable and controversial means of boosting vitamin D status, due to poor recent summer weather and concerns about skin cancer. Thus, fortified foods and supplements have an important role in helping to ‘top up’ dietary intakes. Post-menopausal women and older women, who are most at risk of osteoporosis may particularly benefit from such dietary modifications. For more information see: Ruxton CHS (2013). Nursing Standard Vol. 27 (28): pg 41-49. NHDmag.com May 2013 - Issue 84 Fibre and appetite It is believed that fibre-rich diets leave us feeling fuller, reducing appetite later in the day. Now, this theory has been studied in more detail. A cross-over trial recruited 121 healthy adults, aged 18 to 50 years and randomised them to eat cookies containing: 1) no extra fibre (control), 2) cellulose (5.0g/100g), 3) guar gum (1.25g and 2.5g/100g) and 4) alginate (2.5 and 5.0g/100g). Gastric emptying rate was measured using 13C breath tests and ad libitum intake measured using video recordings. Results showed that energy intake was 22 percent lower with the 5.0g/100g alginate versus the control cookie (p<0.001). This cookie also took nearly 50 percent longer to eat. Gastric emptying time was significantly faster with the alginate cookie compared with the control. Further studies are needed to confirm these findings, but the addition of alginate to low-fibre cookies seems to lead to earlier satiety and may have a future role in weight management diets. For more information see: Wanders AJ et al (2013). British Journal of Nutrition Vol. 109 (7): pg 1,330-37. Evidence shows no effect of sugar on risk factors for heart disease A new review (1) funded by the World Sugar Research Organisation published in Critical Reviews in Food Science and Nutrition, the authors, led by Sigrid Gibson, Director of Sig-Nurture Ltd, systematically reviewed 25 studies where sucrose had been exchanged for other caloric nutrients in the diet of healthy adults. The review concludes that sucrose intake, within typical consumption levels, does not have negative effects on risk indicators for cardiovascular disease. Gibson and her team concluded that no adverse effects on cardiovascular risk factors, including blood lipids, glucose and insulin levels, were apparent when sucrose replaced starchy foods at levels of up to 25 percent of energy intake. Due to the scarcity of published studies, firm conclusions could not be made when sucrose was substituted for other components of the diet, such as fat, or when consumed at levels greater than 25 percent of energy intake. Gibson states that, “it is important to put the conclusions of this study into context. National dietary surveys typically report much lower average intakes of sucrose, for example in the UK, the average intake of sucrose for adults is approximately eight percent of food energy (1).” Recent dietary guidelines for reducing the risk of cardiovascular disease have proposed reducing saturated fat with replacement by other caloric nutrients including carbohydrates. However, the nature of this replacement carbohydrate has been questioned, with suggestions that refined carbohydrate, which includes sucrose (table sugar), may not be beneficial in terms of cardiovascular risk (2). This systematic review of studies found that in normal healthy people, risk factors for heart disease were not adversely affected when starchy foods were replaced with an equal amount of energy from sucrose. References: 1 Gibson et al. The effects of sucrose on metabolic health: a systematic review of human intervention studies in healthy adults. Critical Reviews in Food Science and Nutrition 2013; 53:6, 591-614. Available for free via open access: http://dx.doi.org/10.108 0/10408398.2012.691574. 2 Astrup et al. The role of reducing intake of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010? Am J Clin Nutr 2011;93: 634-8 news The Eatwell week It is often difficult to translate the pictorial Eatwell plate into a weekly meal pattern that consumers can understand. This has now been done by a group of scientists from Glasgow University. A seven-day diet, providing 2,000 kilocalories and meeting the targets of the Eatwell plate, was developed using commonly-eaten foods identified by a consumer survey. Three main meals and two snacks were presented as interchangeable within the weekdays and two weekend days to achieve adult food and nutrient recommendations. Main meals were based on potatoes, rice or pasta with fish (two meals; one oily), red meat (two meals), poultry or vegetarian accompaniments. The five-a-day target for fruit and vegetables was achieved daily. The average salt content was below recommended maximum levels (<6.0g/day). All key macro- and micronutrient values were achieved. It was concluded that affordable, popular foods can be incorporated into a healthy balanced menu. For more information see: Leslie W et al (2013). Public Health Nutrition Vol. 16(5): pg 795-802. Latest on vitamin D Three new studies have uncovered interesting findings about vitamin D and health. A randomised trial, published in The American Journal of Clinical Nutrition, investigated whether supplementation with 10µg or 50µg vitamin D3 daily for six months could improve physical performance and muscle strength in an elderly population aged 65 to 95. The results showed that markers of physical performance (chair-stands) improved after either level of supplementation, particularly in elderly with low levels of baseline physical function. A second study looked at whether supplementation with 100µg vitamin D3, taken daily for six months could improve markers of insulin sensitivity in obese teenagers (n=35). Serum 25(OH)D levels increased significantly by the end of the study, compared with teenagers taking the placebo. Fasting insulin levels also improved, but no other changes in markers of glycaemia or inflammation were seen. Supplementation with vitamin D may help to treat insulin resistance in this at risk population. A third study investigated whether vitamin D3 supplementation could help to slow the progression of Parkinson’s disease (PD) amongst patients with certain genotypes. Patients with PD (n=114) were randomly assigned to take 30µg vitamin D3 or a placebo over 12 months. The results showed that vitamin D3 supplementation helped to stabilise PD for a short period of time in patients with Fokl TT or CT genotypes, without triggering hypercalcaemia. Further trials are now needed to build on this work. For more information see: Lagari V et al (2012). Journal of Bone Mineral Research [Epub ahead of print]; Belenchia AM et al (2013). American Journal of Clinical Nutrition Vol. 97(4): pg 774-81 and Suzuki M et al (2013). American Journal of Clinical Nutrition [Epub ahead of print]. Product / industry news Advertisement text New Warburtons Gluten Free Bran Crackers on prescription To supplement our award-winning range of gluten-free prescription loaves and rolls, we are pleased to announce the launch of our new Gluten Free Bran Crackers 150g, available on prescription for diagnosed coeliacs. Available from 1st May from AAH Pharmaceuticals and Alliance-Healthcare. Warburtons Gluten Free Bran Crackers 150g - pip code 378-4865. www.warburtonsglutenfree.com/ healthcareprofessionals To book your company’s product news for the June 2013 issue of NHD Magazine call 0845 450 2125 (local call rate) Erratum In NHD issue 83, the article Omega-3 fatty acids in health and disease: the science behind the headlines refers to a Figure 1, Metabolic relationships among omega-3 fatty acids. This was omitted from the publication and is reproduced below. Alpha-Linolenic acid (18:3n-3) Enzyme: Delta-6 desaturase Stearidonic acid (18:4n-3) Enzyme: Elongase Eicosatetraenoic acid (20:4n-3) Enzyme: Delta-5 desaturase Eicosapentaenoic acid (EPA; 20:5n-3) Enzyme: Elongase Docosapentaenoic acid (22:5n-3) Three enzymatic steps Involved including Delta-6 desaturase Docosahexaenoic acid (DHA; 22:6n-3) Figure 1: Metabolic relationships among omega-3 fatty acids NHDmag.com May 2013 - Issue 84 5 news feature Coeliac UK’s Awareness Week: Gut Feeling Coeliac UK, the national charity for people with coeliac disease and dermatitis herpetiformis, will be raising awareness during Gut Feeling Week to drive up diagnosis of the condition. The week, which runs from 13th to 19th May, asks the nation to listen to its gut to see if those unexplained symptoms could be coeliac disease. Coeliac disease is an autoimmune condition caused by intolerance to gluten which is found in wheat, barley and rye. It is a serious health condition and, if undiagnosed, can lead to infertility, osteoporosis and even small bowel cancer. It is much more common than many may think as one in 100 people have the condition, but as diagnosis is not as good as it should be, only 10 to 15 percent of these people are diagnosed. This is something Coeliac UK is working hard to change; to make sure that people get the help and support they need much earlier on and to find the missing half a million people in the UK currently undiagnosed with coeliac disease. Joe Simpson, mountaineer, author and subject of the BAFTA award winning film Touching the Void, has recently been diagnosed with coeliac disease and is supporting the campaign. Joe explains, “I was diagnosed with coeliac disease in October last year after enduring numerous blood tests and, because of poor awareness on the part of my GP, I ended up fearing I had cancer. I am supporting Coeliac UK’s campaign to help find the many thousands of people in the UK who are currently undiagnosed and I encourage anyone who is struggling with symptoms to speak to their doctor and insist that they are tested for coeliac disease.” The symptoms of coeliac disease range from mild to severe and can vary between individuals. Not everyone with coeliac disease experiences gut-related symptoms; any area of the body can be affected. Symptoms can include bloating, abdominal pain, nausea, constipation, diarrhoea, wind, tiredness, anaemia, headaches, mouth ulcers, recurrent miscarriages, weight loss (but not in all cases), skin problems, depression, joint or bone pain and nerve problems. Often, coeliac disease is misdiagnosed as Irritable Bowel Syndrome (IBS) and the campaign particularly wants to reach those people with an IBS diagnosis who may not be improving with their medication and could be living with undiagnosed coeliac disease. Almost 25 percent of coeliac patients had previously been told that they had IBS or were treated for it before they were diagnosed with coeliac disease, according to recent research, suggesting that tens of thousands of people are not being investigated early enough for coeliac disease. The National Institute for Health and Clinical Excellence (NICE) issued guidance that GPs should screen for coeliac disease before a diagnosis of IBS is given. The first 6 NHDmag.com May 2013 - Issue 84 stage of diagnosis is a simple blood test which looks for antibodies in blood. In people with coeliac disease, these appear in response to eating gluten, so it is essential that people continue to eat food that contains gluten for the test to work. The recommendation is to eat gluten in at least one meal everyday for six weeks before the tests. The next stage of diagnosis is an endoscopy which looks at the gut to see if there is damage typical of coeliac disease. If this is positive then patients will be diagnosed with coeliac disease and put on a gluten-free diet which is the only treatment for the condition. Sarah Sleet, Chief Executive of Coeliac UK, said, “People can develop the condition at any age and it can be triggered by a range of things such as stress or after a tummy bug. You cannot catch coeliac disease but are genetically predisposed and we are hoping this campaign will persuade anyone who has been diagnosed with IBS or who has symptoms to ask their GP for a test. It is essential, however, to keep eating gluten until the tests are completed otherwise the results could give a false negative.” Gluten is a protein found in wheat, barley and rye and is found in bread, pasta, pizza, cakes and more. However, it is also often used in a wide range of products including mayonnaise, soy sauce, sauces, sausages and many processed goods. “The Charity is seeing around 1,200 new Members join every month, but we still know that there are many people who are undiagnosed,” continued Sarah Sleet. “Doctors should be following NICE guidelines which state that patients with IBS symptoms should be tested for coeliac disease first, but it seems some are too quick to diagnose people with IBS rather than arrange for a coeliac blood test. This research, showing nearly a quarter of coeliac disease patients had a previous diagnosis IBS before ruling out coeliac disease, illustrates the scale of the problem. The sooner someone is diagnosed and begins a strict gluten-free diet, their gut will begin to heal and the risk of further complications will reduce.” Coeliac UK’s Gut Feeling campaign takes place this month from 13th to 19th May and the Charity is encouraging everyone to consider how their gut is feeling and to discuss any symptoms they have with their GP to help bring down the average length of diagnosis which is currently 13 years. Website: www.coeliac.org.uk/gutfeeling Coeliac UK’s Helpline: 9am to 5pm Monday to Friday. Tel: 0845 305 2060. www.coeliac.org.uk Wellfoods Good enough to eat Gluten free loaves, rolls, burger buns,pizzas and flour . . . Wellfoods Coming soon . . . Wellfoods online store! Towngate, Mapplewell, Barnsley S75 6AS [email protected] Tel: 01226 381 712 www.wellfoods.co.uk NHDmag.com Your essential resource Discover new features and resources with an easy-to-navigate layout Cow & Gate Growing Up Milk Just 2 x 150ml beakers a day of Cow & Gate Growing Up Milk provide hard-to-get nutrients Vitamin D for bone development Omega 3, an essential fatty acid Iron for brain development visit in-practice.co.uk cover story Preventing and treating bone loss Dr Carrie Ruxton PhD, RD Freelance Dietitian Bone loss is often viewed as a disease of the elderly but, as a consequence of widespread obesity, inactivity and low intakes of some bone health nutrients, increasing numbers of adults are facing the debilitating effects of osteoporosis and osteomalacia. Figures from the National Osteoporosis Association (1) suggest that around three million adults in the UK are affected, with post-menopausal women most at risk due to low oestrogen levels (2). Bone: a living tissue Throughout life, bone remains in a slow but constant state of turnover, known as bone remodelling, which involves a cycle of bone synthesis and resorption (i.e. breakdown). The balance of this cycle is influenced by genes as well as dietary and lifestyle factors, such as calcium status and physical activity. The largest changes in bone mass occur at both ends of the lifecycle. In the first two decades of life, bone mass is synthesised until the maximum capacity is reached - also known as peak bone mass (PBM). After a period of stabilisation, there is gradual bone loss which accelerates with age, lack of physical activity and loss of oestrogen (3). Osteoporosis can be diagnosed using a DEXA scan which gives an estimate of bone mineral density (BMD). Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. www.nutritioncommunications.com Bone nutrients While osteoporosis is often viewed as a normal burden of ageing, the scientific evidence suggests otherwise. Nutrition and lifestyle factors have a central role in sustaining normal bone health and reducing the risk of fractures (4). Protein and several micronutrients, including vitamin C, vitamin D, vitamin K, calcium, magnesium, zinc and phosphorus, are all important for the maintenance of normal bone (5). In addition, calcium and vitamin D in combination are proven to reduce bone loss in postmenopausal women and, thus, help prevent osteoporotic fractures (6). Food and drink products, and supplements, containing sufficient amounts of the aforementioned nutrients, can now make bone health claims according to EU law. A sufficient amount is defined as ≥ 15.0% RDA for micronutrients, or ≥ 12.0% energy as protein. Table 1: Percentage with inadequate intakes of bone nutrients Adults (19-64 years) Men Women Vitamin C (mg) 1 1 Calcium (mg) 4 8 Magnesium (mg) 16 11 Zinc (mg) 9 4 Key: Inadequacy defined as intakes below the Lower Reference Nutrient Intake. The mechanisms behind the impact of bone health nutrients are diverse. Calcium gives bones their strength and rigidity while vitamin D works alongside by boosting calcium absorption and utilisation and maintaining the correct ratio of serum calcium and phosphorus. These are by far the most important nutrients for bone health and the most widely studied. Magnesium, phosphorous and fluoride are thought to reinforce the processes of bone formation, whilst iron, zinc, boron, copper and manganese may help to support normal bone metabolism. Finally, vitamin C has a role in normal collagen synthesis which is essential for bone structure. Are we getting enough? The National Diet and Nutrition Survey (NDNS) provides the best estimate of the UK diet. Table 1 reveals that many people have inadequate intakes of calcium, magnesium and zinc, with teenage girls having the lowest intakes of minerals. As the NDNS did not report intakes of vitamin K and phosphorus, no comment can be made on these; however, widespread inadequacy is unlikely. Protein intakes far exceed recommendations and are not a problem for most individuals. Although there are currently no recommendations for vitamin D in the UK for most people, it is clear from nutritional status data that vitamin D deficiency is common. In the latest NDNS, 19 percent of women and adolescent boys, 17 percent of men and 20 percent of adolescent girls were vitamin D deficient, i.e. serum 25-hydroxyvitamin D below 25nmol/L (7). A higher prevalence Children (11-18 years) of vitamin D deficiency - up to 44 percent Boys Girls - has been found in pregnant women (8). 0 1 This reflects a combination of insufficient sun exposure and low vitamin D intakes 7 18 (as natural sources are few). In comparison 27 50 with the EU Recommended Dietary Allow17 19 ance of 5µg, average intakes in the UK are just 3.1µg in men and 1.9µg in women. NHDmag.com May 2013 - Issue 84 9 cover story Table 2: Randomised controlled trials in children review (18) reported that five out of nine trials of vitamin Daily Reference Sample Duration D supplements and 16 out intervention of 22 trials of combined vitaN=71 girls, 800mg Ca + 10µg ↑ BMD min D/calcium supplements, 12 months Moyer-Mileur (10) pre-pubescent vit D suppl. ↑ trabecular BMC produced statistically signifi1,000mg Ca + 5 µg vit No differences in cant improvements in BMD, N=195 girls, D suppl. vs. 1,000mg BMD; ↑ tibia with benefits seen within five 24 months Cheng (11) 10-12yrs Ca suppl. vs. cheese cortical BMC in weeks in those with a poor vi(1000mg Ca) cheese group only tamin D status. N=96 girls, ↑ BMD & BMC 792mg Ca suppl. 18 months Lambert (12) Turning to fracture risk, mean 12yrs ↓ PTH vitamin D and calcium seem to N=235 boys, 850mg Ca fortified 12 months ↑ BMD Chevalley (13) have the strongest impact when mean 7yrs food given in combination. A metaN=154 children, 1,200mg vs. 400mg 18 months No differences Gibbons (14) analysis (19) of 29 randomised 8-10yrs Ca fortified drink trials (involving nearly 64,000 ↑ BMD N=100 girls, participants aged 50 years or 1,000mg Ca suppl. 12 months ↓ PTH and bone Rozen (15) mean 14yrs turnover older) found that giving additional vitamin D and calcium N=144 girls, 1,000mg Ca suppl. 15 months ↑ BMC Stear (16) mean 17yrs + exercise was associated with a statistically significant 12 percent reN=120 girls, 8-14yrs 300mg Mg suppl. 12 months ↑ hip BMC Carpenter (17) duction in fracture risk (or a 24 Key: BMC=bone mineral content; BMD=bone mineral density; Ca=calcium; Mg=magnesium; suppl.=supplement; yrs=years. percent reduction when compliance was high). Daily intakes of 1,200mg calcium and 20µg vitamin D produced the most consistent Adolescents should be eating a healthy, effects. A similar finding was reported by a pooled analysis of seven trials involving 68,500 participants balanced diet to promote PBM, but often fail (DIPART, 2010). Given the very low vitamin D intakes in the UK (3.1µg in men and 1.9µg in women), it is to do this as a consequence of peer pressure, unlikely that these optimal intakes could be achieved without supplementation. dieting, food fads and poor cooking skills. Few trials exist for other bone health nutrients and results for vitamin K, zinc and copper have been inconsistent. However, a recent trial (20) looked at the impact of a daily multivitamin on bone health Evidence for benefit When considering how to advise patients about and falls in 92 elderly living in care homes. After six bone health, it is worth splitting the population into months, the intervention group had a better vitathose who are yet to reach their PBM and those who min D status and a significant improvement in bone mass, as measured by quantitative heel ultrasound, are in an active process of bone decline. compared with the placebo group. Significant changes vs placebo Maximising PBM Adolescents should be eating a healthy, balanced diet to promote PBM, but often fail to do this as a consequence of peer pressure, dieting, food fads and poor cooking skills. Surveys consistently show that teenagers, in particular girls, have the lowest micronutrient intakes (9). Yet, modifications to bone health nutrients can impact positively on health. Recent randomised controlled trials (Table 2) have focused on calcium, vitamin D and dairy products with little research on other bone nutrients, apart from one study on magnesium. Overall, giving additional calcium, with or without vitamin D, has been shown to improve bone mass. Trials of supplements are more common than food trials, with a compliance rate of around 70 percent, as reported by three of the trials. Preventing or slowing bone loss There is a vast literature on the use of calcium and vitamin D to lower the risk of fractures or improve BMD or bone mineral content in adults. A recent 10 NHDmag.com May 2013 - Issue 84 Dietary messages Taking into account the evidence, and current approved claims for the maintenance of normal bone, an increase in bone health nutrients would benefit younger patients by helping them to maximise PBM and middle-aged to older patients by minimising bone loss. Food sources of bone nutrients, such as dairy foods, oily fish, green leafy vegetables, citrus fruits, berries, red meat, seafood, wholegrains, nuts, eggs and soya can all be promoted. However, for people with consistently poor diets, high requirements (due to growth or pregnancy) or age-related bone loss, it is a sensible precaution to recommend a supplement. This could be a simple multinutrient in the case of teenagers, or a specialist bone health supplement containing calcium, magnesium and vitamin D for post-menopausal women. Indeed, the Department of Health already recommends vitamin D supplements for elderly people, children under five years and pregnant/lactating women (21). As cover story . . . a healthy diet encompassing sufficient levels of bone nutrients is an important starting point for osteoporosis management. sun exposure provides 90 percent of the vitamin D in the body, people who are housebound, or who cover up for cultural reasons, are at risk of vitamin D deficiency and should consider taking a multivitamin supplement with vitamin D even if they eat oily fish and eggs, the main sources of vitamin D in the diet. It is worth noting that, even combining average daily intakes of vitamin D (around 2-3μg) with fortified foods (1-5μg) or vitamin supplements (5-25μg), intakes are likely to stay well within the current safe upper limit for vitamin D of 50μg (22). In conclusion, a healthy diet encompassing sufficient levels of bone nutrients is an important starting point for osteoporosis management. For populations with higher requirements, due to growth, pregnancy, age or limited sun exposure, it is advantageous to recommend an appropriate supplement alongside dietary advice. Acknowledgement This review was funded by the Health Supplements Information Service (HSIS) (www.hsis.org.uk; tel: 020 7052 8955) which is supported by a restricted educational grant from the Proprietary Association of Great Britain (PAGB). Neither HSIS nor PAGB had a role in selecting papers or writing the review. The content reflects the opinion of the author. References 1 National Osteoporosis Society (2012). Key facts and figures. Available at: www.nos.org.uk/page. aspx?pid=328/ 2 Clarke BL, Khosla S (2010). Physiology of bone loss. Radiol Clin North Am 48: 483-95 3 Jimi E, Hirata S, Osawa K et al (2012). The current and future therapies of bone regeneration to repair bone defects. Int J Dent: 148261 4Ruxton CHS (2013). Dietary approaches to promote bone health in adulthood. Nursing Standard 27: 41-9 5European Parliament and Council (2012). Commission regulation (EU) No 432/2012. Available at: http:// eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2012:136:0001:0040:en:PDF 6European Food Safety Authority (EFSA) (2009). Scientific substantiation of a health claim related to calcium plus vitamin D3 chewing tablets and reduction of the risk of osteoporotic fractures by reducing bone loss pursuant to Article 14 of Regulation (EC) No 1924/20061. The EFSA Journal. 1180, 1-13 7 Bates B et al (2012). National Diet and Nutrition Survey: headline results from Years 1-3. London: Food Standards Agency/Department of Health 8 Holmes VA et al (2009). Vitamin D deficiency and insufficiency in pregnant women: a longitudinal study. Br J Nutr 102: 876-881 9Ruxton CHS (2011). The diets of young people in the UK. Complete Nutr 11: 12-14 10Moyer-Mileur LJ et al (2003). Bone mass and density response to a 12-month trial of calcium and vitamin D supplement in preadolescent girls. J Musculoskelet Neuronal Interact 3: 63-70 11Cheng S et al (2005). Effects of calcium, dairy products and vitamin D supplementation on bone mass accrual and body composition in 10-12-yr-old girls: a 2-yr randomised trial. Am J Clin Nutr 82:1115-26 12Lambert HL et al (2008). Calcium supplementation and bone mineral accretion in adolescent girls: an 18-month randomised controlled trial with 2-yr follow-up. Am J Clin Nutr 87:455-62 13Chevalley T et al (2005). Skeletal site selectivity in the effects of calcium supplementation on areal bone mineral density gain: a randomised, double-blind, placebo-controlled trial in prepubertal boys. J Clin Endocrinol Metab 90: 3342-9 14Gibbons MJ et al (2004). The effects of a high calcium dairy food on bone health in prepubertal children in New Zealand. Asia Pac J Clin Nutr 13):341-7 15Rozen GS et al (2003). Calcium supplementation provides an extended window of opportunity for bone mass accretion after menarche. Am J Clin Nutr 78:993-8 16Stear SJ et al (2003). Effect of a calcium and exercise intervention on the bone mineral status of 16-18-yrold adolescent girls. Am J Clin Nutr 77:985-92 17Carpenter TO et al (2006). A randomised controlled study of effects of dietary magnesium oxide supplementation on bone mineral content in healthy girls. J Clin Endocrinol Metab 91:4866-72 18Laird E et al (2010). Vitamin D and bone health; potential mechanisms. Nutrients 2: 693-724 19Tang BMP et al (2007). Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 370: 657-666 20Grieger JA et al (2009). Multivitamin supplementation improves nutritional status and bone quality in aged care residents. Eur J Clin Nutr 63: 558-65 21Chief Medical Officers of the UK (2011). Vitamin D - advice on supplements for at risk groups. www. dh.gov.uk/health/2012/02/advice-vitamin-d/ 22Scientific Advisory Committee on Nutrition (2007). Update on Vitamin D Position statement by the Scientific Advisory Committee on Nutrition. London: TSO New Warburtons Gluten Free Bran Crackers, available from 1 May. Our delicious Gluten Free Bran Crackers are now available on prescription, along with our award-winning* gluten-free fresh loaves and rolls. They come conveniently packed with six portions inside, and of course, all the taste you’d expect from Warburtons. Request your free information pack as well as patient sample request leaflets from [email protected] *Foods You Can, winner of Best Gluten Free Prescription Brand 2012 NHDmag.com May 2013 - Issue 84 11 Advertisement Feature Cardiovascular disease remains the biggest killer in the UK Despite the WHO estimating that up to 80% of CHD could be prevented through implementation of positive lifestyle changes1. The term “risk factor” describes those lifestyle, biochemical and physiological characteristics (modifiable and non modifiable) which are related to the potential occurrence of CVD. This approach acknowledges three important facts; 1) that cardiovascular disease has a multi-factorial aetiology, 2) that risk factors can have multiplicative effect, 3) that health professionals are dealing with a whole person and not with isolated risk factors. Therefore an individual with a number of modest risk factors may be at greater risk than another individual with one very high risk factor. Hence, interventions of lifestyle and /or medications should be based on total risk rather than individual risk factors2. A global case control study called INTERHEART3 identified nine potentially modifiable risk factors accounting for over 90% of the population’s initial myocardial infarction (MI). Across all the centres smoking and abnormal lipids were the most important risk factors, contributing to about two thirds of the attributable risk of a MI (gender and ethnicity had no bearing on risk factor). Diet and Cardiovascular Risk Diet can influence the risk of CVD in a number of ways. Exceeding calorie requirement can lead to obesity and poor diet quality can affect diabetes management. Raised and long term intake of salt4 or alcohol5 is related to raised blood pressure and high intakes of saturated fat are related to impaired lipid profiles6. Dietary intervention should be focused on reducing total CVD risk rather than improving specific risk factors, helping individuals to identify their own priorities for reducing their risk, agreeing individual goals and involving partners in any lifestyle change is more likely to lead to longer term success7;8. Dietary advice that has been shown to reduce mortality and morbidity in those with CVD include9: a) Reduction in saturated fat with replacement of unsaturated fat b) Regular intake of omega 3 fatty acids from oily fish in those that have suffered a myocardial infarction c) Intake of a traditional Mediterranean diet. It is thought the best way to improve lipid levels is by ensuring there is the right balance of different dietary fatty acids10. The aim is to replace saturated fat with unsaturated fat. It is still not clear whether individuals should opt for polyunsaturated or monounsaturated as the main replacement11. However, it is important that there is adequate intake of the omega 3 polyunsaturated fatty acids and that the intake ratio of n-6 to n-3 polyunsaturated fat in line with the recommendation of 4:112. Although the UK overall total consumption of fat is reducing, intake of saturated fat remains above the recommended level, at 12% of total energy intake (target <11%)13. There is a greater consumption of monounsaturated fat than n-6 polyunsaturated fatty acids but the intake ratio of n-3 and n-6 fats could be further improved. Can adding plant sterols into the diet help to reduce cholesterol levels further? Following a healthy diet could reduce cholesterol levels by 5%. Plant sterols and stanols are naturally available in foods such as nuts, seeds, vegetable oils, grain products and fruit and vegetables. The average intake from these sources is only about 250mg/d. Consumption of 1.5-2.4g plant sterols through supplemented foods such as Flora pro.activ, have been shown in many clinical studies in the general population to help reduce LDL cholesterol levels by 7-10%, which is greater than a healthy diet alone14. Additional beneficial cholesterol reductions have also been shown in the following patient groups – heterozygous FH, type 2 diabetes, atherosclerotic and metabolic syndrome, although further studies are required15. Consequently many national guidelines16;17 now recommend that individuals should try and consume 2g per day of plant sterols or stanols. An intake of 2g/day is not possible from natural sources so enriched products are required. Heart Health Study Days www.flora-professional.co.uk How do plant sterols work? Plant sterols work by competing with and displacing cholesterol from mixed micelles. This reduces the cholesterol absorption and hence reduces LDL levels without affecting the HDL cholesterol levels. Consuming 1.5-2.4g of plant sterols per day can lower LDL cholesterol by 7-10% in 2-3 weeks when consumed as part of a healthy diet and lifestyle. This amount of plant sterols can be found in 1 Flora pro.activ mini drink (consumed with a meal for optimum results) or 3 portions of Flora pro.activ spreads or milk a day, where by two teaspoons of spread or 250ml of milk is equivalent to one portion. This benefit is only maintained with regular intake of plant sterols and is dose responsive18. Therefore the consumption of the plant sterols should become part of a daily healthy lifestyle routine to ensure maximum benefit (guidelines of 2g/day). Plant sterols may also decrease Triglyceride levels, especially in those individuals with a high baseline triglyceride levels (but this is still requires further research)15. Will they have the same effect if the individual is taking statins? The mode of action of sterol esters is different to that of statins. Therefore, consuming both together is not a problem and can even reduce the cholesterol levels further19. How to achieve 2g/day To achieve the necessary 2g/day an individual would need to consume: 1 mini drink per day OR 3 portions of the spread and/ or milk (1 portion = 2 teaspoons of spread or 250ml of milk) To gain a more in-depth knowledge of cholesterol and heart disease, and the role you can play in reducing your patients’ risk in day-to-day practice, reserve a place at any of the three (3) FREE CPD accredited study days, in association with Flora pro.activ, where you will hear from: s -ICHAELA.UTTALL#ARDIOVASCULAR.URSE3PECIALISTAND#($COORDINATOR FOR.(3"ROMLEY s $R!LISON!TREYNEE-EADSPECIALISTDIETITIANINCARDIOLOGY s 9OURLOCALHEARTHEALTHEXPERTS When & Where? 3TUDYDAYSWILLTAKEPLACEININ.ORFOLK3OMERSETAND7ALES 4HE 3TUDY DAY WILL RUN FROM n WITH LUNCH PROVIDED UPON arrival Norfolk 4UESDAYTH-AY$E6ERE$UNSTON(ALL.ORWICH.201 Local heart health expert: Joanne M. Haws Clinical Education, Training and Consultancy Somerset 4UESDAYTH-AY(YDE0ARK4AUNTON,TD4AUNTON4!"5 ,OCALHEARTHEALTHEXPERT3HARON!SHTON 0UBLIC(EALTH3CREENING0ROGRAMME-ANAGER.(33OMERSET Wales 4HURSDAYTH*UNE)VY"USH2OYAL(OTEL#ARMARTHEN3!,' Local heart health expert: Chris Cottrell Clinical Lead Diabetes/AF/Hypertension *Travel to and from the study days is not included How to register Places are limited so reserve your place now or if you have any questions: simply email [email protected] Places will be allocated on a first com first serve basis. References: (1) WHO/FAO. Diet,nutrition and the prevention of chronic diseases. WHO, editor. 916. 2003. Geneva. WHO Technical Report Series 916. Ref Type: Report. (2) British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primay Care Cardiovascular Society, The Stroke Association. JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91 Suppl 5:v1-52. (3) Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F et al. Effect of potentially modiﬁable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364(9438):937-952. (4) He FJ, MacGregor GA, Hooper L. Modest reduction in salt lake intake may be associated with lower blood pressure in hypertensives and normotensives. Evidence-Based Cardiovascular Medicine 2003; . 7(2). (5) Bobak M, Marmot M. Alcohol and Coronary Disease. In: Marmot M, Elliott P, editors. Coronary Heart Disease Epidemiology. 2 ed. Oxford University Press; 2005. (6) Hooper L, Summerbell CD, Higgins JP, Thompson RL, Clements G, Capps N et al. Reduced or modiﬁed dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev 2001;(3):CD002137. (7) Rollnick S, Mason P, Butler C. Health behaviour change. A guide for practitioners. Churchill Livingstone; 1999. (8) Wood DA, Kotseva K, Connolly S, Jennings C, Mead A, Jones J et al. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial. Lancet 2008; 371(9629):1999-2012. (9) Mead A, Atkinson G, Albin D, Alphey D, Baic S, Boyd O et al. Dietetic guidelines on food and nutrition in the secondary prevention of cardiovascular disease - evidence from systematic reviews of randomized controlled trials (second update, January 2006). J Hum Nutr Diet 2006; 19(6):401-419.(10) Lunn J, Theobald HE. The Health beneﬁts of unsaturated fatty acids. Nutrition Bulletin 2006; 31:178-224. (11) Hooper L, Summerbell CD, Thompson R, Sills D, Roberts FG, Moore HJ et al. Reduced or modiﬁed dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev 2012; 5:CD002137. (12) Simopoulos AP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother 2002; 56(8):365-379. (13) Bates B, Lennox A, Prentice AM, Bates C, Swan G. National Diet and Nutrition Survey - Headline results from years 1,2 and 3 of the rolling programme (2008/2009 - 2010-2011). 2012. Ref Type: Report. (14) Potter D, Whittaker VJ, Burke M, Rigby P, Summerbell CD, Hooper L. Supplemental plant sterols and stanols for serum cholesterol and cardiovascular disease. Potter D , Whittaker VJ , Burke M , Rigby P , Summerbell CD, Hooper L Supplemental plant sterols and stanols for serum cholesterol and cardiovascular disease The Cochrane Database of Systematic Reviews : Protocols 2004 Issue 2 John Wiley & Sons , Ltd Ch 2004. (15) Plat J, Mackay D, Baumgartner S, Clifton PM, Gylling H, Jones PJ. Progress and prospective of plant sterol and plant stanol research: report of the Maastricht meeting. Atherosclerosis 2012; 225(2):521-533. (16) Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA et al. Diet and lifestyle recommendations revision 2006: a scientiﬁc statement from the American Heart Association Nutrition Committee. Circulation 2006; 114(1):82-96. (17) Perk J, De BG, Gohlke H, Graham I, Reiner Z, Verschuren WM et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012) : the ﬁfth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts). Int J Behav Med 2012; 19(4):403-488. (18) Katan MB, Grundy SM, Jones P, Law M, Miettinen T, Paoletti R et al. Efﬁcacy and safety of plant stanols and sterols in the management of blood cholesterol levels. [Review] [137 refs]. Mayo Clinic Proceedings 2003; 78(8):965-978. (19) Blair SN, Capuzzi DM, Gottlieb SO, Nguyen T, Morgan JM, Cater NB. Incremental Reduction of Serum Total Cholesterol and Low-Density Lipoprotein Cholesterol With the Addition of Plant Stanol Ester-Containing Spread to Statin Therapy. Am J Cardiol 2000; 86:46-52. Cholesterol Dietary cholesterol: dispelling the myths The aim of this article is to briefly review the ways in which cholesterol is transported in the body and its relationship with the development of CHD. There will then follow a discussion which will seek to dispel the myths surrounding dietary cholesterol and the development of CHD, particularly in healthy individuals. Alison Burton Shepherd PGCAP (ed) FHEA R Nutr (Scientist) BSc (Hons) MSc RGN TCH Queens Nurse Cholesterol is an abundant fundamental lipid molecule in mammalian cells which also plays a critical role in the manufacture of steroid hormones, vitamin D and in the production of bile acids (14). It is well documented that excessive cholesterol accumulation in the arterial intima can lead to the development of atherosclerosis (22) which is most commonly associated with an increased risk in the development of coronary heart disease (CHD) (8). However, it is also important to note that atherosclerosis can accumulate in many other arteries causing cerebral vascular accident (CVA), damage to the aorta and renal problems (23). High levels of cholesterol can also result in the formation of gall stones (6). . . . it is currently considered best practice in the UK and Europe for individuals who may be at risk of CHD to limit their intake of saturated fats and trans fat which are the major determinants of blood cholesterol concentrations. Alison Burton Shepherd is a Nurse Tutor at Florence Nightingale School of Nursing and Midwifery, Kings College University London. She is a Registered Nutritionist lecturing in nutrition and adult nursing with specialist interest in childhood obesity and clinical nutrition. Given the plethora of data which supports the adverse relationship between dietary cholesterol and its role in the development of CHD (19), it is currently considered best practice in the UK and Europe for individuals who may be at risk of CHD to limit their intake of saturated fats and trans fat which are the major determinants of blood cholesterol concentrations (12). A recent review (11) has questioned the role of dietary cholesterol in the increased risks of developing CHD or increasing mortality from CHD. Cholesterol transport and disease Lipoproteins are particles which transport cholesterol and triglycerides, both of which are not soluble in aqueous solutions (5). Very Low density lipoproteins (VLDL) are produced by the liver with a primary function of supplying free fatty acids to tissues and are normally the predominant carriers of circulating triglycerides. Low density lipoproteins (LDL) are by-products of VLDL metabolism and, in the normal state, are the primary carriers of plasma cholesterol which supply the body cells where required (23). VLDL and LDL are often referred to as ‘bad cholesterol’ (13) and high levels of both of these lipoproteins in the plasma are associated with an increased risk of CHD (28). High density lipoproteins (HDL) are manufactured by the liver and on their release, this ‘empty vessel’ collects any excessive cholesterol in the peripheral tissues and transports this back to the liver (33). This is anecdotally referred to as ‘good cholesterol’ and data from several clinical trials suggests that raising HDL cholesterol may be beneficial in reducing the risks of CHD (25). Furthermore, HDL cholesterol confers antioxidant, anti-apoptotic, anti inflammatory and anti proteolytic protection in endothelial cells (33). However, these lipoproteins should not be considered as separate entities as it is well documented that it is the maintenance of a healthy LDL/HDL cholesterol ratio which is considered to be a key marker of CHD risk (11). Should we restrict dietary cholesterol? The current recommendation in the UK and Europe is that the individual total blood cholesterol levels should be four millimoles (mmol)/litre or less (9). The most recent dietary guidelines from the USA recommend an intake of 300mg or less of cholesterol per day in healthy individuals with a further restriction of less than 200mg per day in those individuals classified as a greater risk of heart disease (34). However, according to Spence et al (32), dietary cholesterol should be restricted in all populations and not just in those with CHD. This advice is somewhat equivocal and confusing and begs the question as to whether there should be a ‘carte blanche’ dietary restriction of cholesterol applied to those who are otherwise healthy, or in those with an increased risk of developing CHD without a genetic predisposition. For those individuals with familial hypercholesterolemia (FH) it is suggested that reducing dietary cholesterol is an effective adjunct when combined with statins (7). Given such individuals increased risk of developing premature CHD, this is a sensible safe practice (28). However, the data from the Spence report (32) was based on animals which were fed an equivalent of 9,500mg of cholesterol per day and therefore application of such results to a NHDmag.com May 2013 - Issue 84 13 cholesterol Box 1: Cardio protective dietary guidelines adapted from the European Society of Cardiology (10) • Saturated fats to account for <10% of total energy intake • Limit trans fats to <1.0% of total energy from natural origin • Avoid trans fats from processed meats and other foods • <5.0g of salt per day • Encourage at least 35g to 45g of fibre per day from wholegrain foods • Two to three servings of fruit per day • Two to three servings of vegetables per day • At least one portion of oily fish a week • Limit alcohol consumption to two glasses per day for men and one glass per day for woman human population is both unethical and controversial (35). Other evidence considered in the report was from epidemiological studies in which no adjustments were made for the contribution of saturated fat in the diet which is a confounding factor, thus altering the reliability and validity of the study (11). However, nutritional epidemiological studies form the scientific basis on which public health nutrition information is devised and implemented (20). Therefore, data from epidemiological studies per se, although not deemed to be the ‘gold standard’ of clinical research, plays an important role in informing evidenced based practice. Extensive research originating from early 20th century epidemiological studies, including the Framingham study (21) and the Nurses study (18), does not support a relationship between dietary cholesterol and CHD. More recently, a review from Fernandez (11), which analyses both epidemiological studies and data from randomised clinical controlled trials, noted to be the gold standard in research (27), also reports that dietary cholesterol has no effect on blood cholesterol levels CHD risk or CHD mortality. But these results should be interpreted with caution as there is now a growing body of evidence which highlights a significant association with dietary cholesterol and an increased risk of CHD in the diabetic population (17). What is best practice? Hayward and Krumholz (15) suggest that there is no firm data to support the theory that patients at risk of CHD should be treated according to LDL targets. In contrast, the British Dietetic Association (3) argues that it is better to encourage individuals at risk of CHD to decrease the amount of saturated fat in their diet as opposed to concentrating solely on the reduction of LDL cholesterol. This is because diets high in saturated fat are said to not only increase the amounts of LDL cholesterol but can also decrease the levels of HDL cholesterol, suggesting that saturated fats are potentially more atherogenic than cholesterol alone (1). However, the evidence surrounding the atherogenicity of saturated fat is equivocal (30) with recent studies suggesting that some dairy products, for example cheese which is high in saturated fat, can actually lower LDL cholesterol, when compared to butter with the same amount of saturated fat (16). Moreover, as egg yolk has a high cholesterol concentration, limited egg consumption has been recommended 14 NHDmag.com May 2013 - Issue 84 in the past to lower the risk of ischaemic heart disease (24). But there is now a growing body of evidence refuting this atherogenic relationship with egg consumption and more recent data from a randomised controlled trial asserts that eating eggs on a daily basis can lead to increased levels of plasma HDL and improvements in HDL profiles in those with metabolic syndrome when compared to those consuming a yolk-free egg substitute (2). Furthermore, consuming eggs on a daily basis is not thought to be associated with an increased risk of CHD or stroke in healthy individuals (29). More research is required, however, before this recommendation is made for diabetic individuals (26). Healthcare professionals should also be aware that, although some foods such as shellfish and in particular prawns and other cuts of offal, contain high amounts of cholesterol, these foods have a lesser effect on raising plasma cholesterol levels when compared to a diet which is high in foods containing saturated fat (3). It is also important to recognise that there are some individuals in whom blood cholesterol rises as a response to a high cholesterol intake by increasing both LDL and HDL cholesterol, but with no subsequent changes to the LDL/HDL cholesterol ratio (11), which, as previously stated, is a more sensitive marker and predictor of increased risk of CHD (31). The European Society of Cardiology (10), however, asserts that a ‘healthy diet’ is the cornerstone of CHD prevention and has produced some dietary guidelines for healthcare professionals which are summarised in Box 1. Diet is an integral part of lifestyle and although this will contribute towards improving heart health, it is recommended that adults of all ages should be encouraged to participate in physical activity in conjunction with a healthy eating plan (4). Moreover, the British Dietetic Association (3) suggests that other lifestyle factors, including overweight, obesity and smoking should also be addressed in order to promote a healthy cardiovascular system. Conclusion Despite these equivocal findings, lowering dietary cholesterol might reduce the risk of CHD considerably in a subgroup of individuals who are highly responsive to changes in cholesterol intake (19). Certainly, this advice applies to those individuals who have a genetic susceptibility to hypercholesterolemia and for those individuals with diabetes who also have an increased risk of developing CHD. cholesterol . . .the most recent evidence consistently indicates that dietary cholesterol does not increase the risk for heart disease in a healthy population. However, the most recent evidence consistently indicates that dietary cholesterol does not increase the risk for heart disease in a healthy population. Therefore, it is best practice to advise these individuals to maintain a healthy weight by following a balanced diet incorporated with physical exercise. For any person who wishes to consider restriction of dietary cholesterol, it is advisable to consult their own GP or a qualified dietitian prior to making any dietary changes. References 1 Adams TH, Walzem RL, Smith DR (2009). Hamburger high in total saturated and trans fatty acids decreases HDL cholesterol and LDL particle diameter and increases TAG in mildly hypercholesterolaemic men. Br J Nutr 103 91-98 2 Andersen CJ, Blesso CN, Lee J et al (2013). Egg consumption modulates HDL lipid composition and increases the cholesterol accepting capacity of serum in metabolic syndrome Lipids Mar 15 ahead of print 3 British Dietetic Association (2012). Food Fact Sheet Cholesterol. Accessed online at www.bda.uk/ foodfacts 4 British Heart Foundation (2010). Healthy Eating. Accessed online at www.bhf.org.uk/heart-health/ prevention/healthy-eating.asp 5 Brunzell JD, Davidson M, Furberg CD et al (2008). Lipoprotein management in patients with cardio metabolic risk. Diabetes Care 31 (4) 811-822 6 Cariati A, Piromalli E (2013). Could omega-3 fatty acid prolonged intake reduce the incidence of symptomatic cholesterol gallstones disease? Clin Nutr 8th Feb ahead of print 7 Citkowitz E (2012). Hypertriglyceridaemia. Accessed online at http://emedicine.medscape.com/ article/126568-overview 8 Cohen Tervaert JW (2013). Cardiovascular disease due to accelerated atherosclerosis in systematic vasculitis. Best Prac Res Clin Rheumatol Feb 27 (1): 33-44 9 Cooper A, Nherera L, Calvert N et al (2008). Clinical guidelines and evidence review for lipid modification: cardiovascular risk assessment and the primary and secondary prevention of cardiovascular disease. National Collaborating Centre for Primary Care and Royal College of General Practitioners London 10European Society of Cardiology (2012). Essential Messages from Essential Guidelines CVD prevention www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/Essential_Messages_CVD_ Prevention.pdf 11Fernandez M (2012). Rethinking Dietary Cholesterol. Curr Opin Clin Nutr Metab Care 15: 117-121 12Fernandez ML, Calle MC (2010). Revisiting dietary cholesterol recommendations: does the evidence support a 300mg/d limit? Curr Atheroscler Rep 12: 377-383 13Ginter E, Simko V (2013). New promising potential in fighting atherosclerosis: HDL and reverse cholesterol transport. Bratisi Lek Listy 114(3): 172-6 14Grebe A, Latz E (2013). Cholesterol crystals and inflammation. Curr Rheumatol Rep Mar 15 (3): 313 15Hayward RA and Krumholz HM (2012). Three reasons to abandon low density lipoprotein targets, an open letter to the adult treatment panel IV of the National Institutes of Health. Circ Cardiovasc Qual Outcomes 5: pp 2-5 16Hjerpsted J, Leedo E, Tholstrup T (2011). Cheese intake in large amounts lowers LDL cholesterol concentrations compared with butter intake of equal fat content. Am J Clin Nutr Dec;94(6): 1479-84 17Houston DK, Ding J, Lee JS et al (2011). Dietary fat and cholesterol and risk of cardiovascular disease in older adults: The Health ABC Study: Nutr Med Card Dis 21: 430-437 18Hu FB, Stampfer MJ, Rimm EB et al (1999). A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA 281: 1387-1394 19Kratz M (2005). Dietary cholesterol atherosclerosis and coronary heart disease. Handb Exp Pharmacol (170): 195-213 20Margetts BM, Nelson M (2000). Design Concepts in Nutritional Epidemiology 2nd Ed published by Oxford university Press 21Mc Namara DJ (1997). Cholesterol intake and plasma cholesterol an update. J Am Coll Nutr 16: 530-534 22Montero-Vega MT (2012). The inflammatory process underlying atherosclerosis Crit Rev Immunol 32 (5): 373-462 23Mulryan C (2012). The role of Cholesterol. Clinical Independent Nurse 16th April 2012 24Nakamura Y, Okamura T, Tamaki S et al (2004). Egg consumption, serum cholesterol and cause specific and all cause mortality: The National Integrated Project for Prospective Observation of NonCommunicable Disease and its trends in the Aged 1900 (NIPPON DATA80). Am J Clin Nutr jul;80(1): 58-63 25Pirillo A, Norata GD, Catapano AL (2012). Treating High Density Lipoprotein (HDL-C) Quantity Versus Quality. Curr Pharm Des Dec 26 ahead of print 26 Radzeviciene L, Ostrauskas R (2012). Egg consumption and the risk of Type 2 diabetes mellitus: a case control study. Public Health Nutr Aug 15;(8): 1437-41 27Relton C (2013). Implications of the placebo effect for CAM research. Complement Ther Med Apr;21(2): 121-4 28Robinson JG (2013). Management of familial hypercholesterolemia: a review of the recommendations from the national lipid association expert panel on familial hypercholesterolemia. J Manag Care Pharm 19(2) 139-49 29Rong Y, Chen L, Zhu T et al (2013). Egg consumption and risk of coronary heart disease and stroke: dose response meta-analysis of prospective cohort studies. BMJ Jan 7;346:e8539 30Rosch PJ (2012). Genes and stress cause coronary atherosclerosis not saturated fat. Accessed online at www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60804-5/fulltext 31Sabate J, Wien M (2010). Nuts, blood lipids and cardiovascular disease. Asia Pac J Clin Nutr 19(1): 131-6 32Spence JD, Jenkins DJA, Davignon J. Dietary cholesterol and egg consumption not for patients at risk of cardiovascular disease. Can J Cardiol 26e;336-339 33Tran-Dinh A, Diallo D, Delbosc S et al (2013). HDL and endothelial protection. Br J Pharmacol Mar 14: Epub ahead of print 34USDA Dietary Guidelines 2010. Accessed online at www.cnpp.usda.gov/dietaryguidelines.htm 35Van der Worp HB, Howells DW, Michelle ES et al (2010). Can animal models of disease reliably inform human studies? Plos Med (3): e1000245 A D V E R T I S E M E N T F E AT U R E Making vitamin D a healthy daily habit Dr Carrie Ruxton, registered dietitian Understanding the importance of toddler nutrition Question: “Parents are more likely to discuss eating behaviours rather than nutrition. How can I help parents understand the importance of toddler nutrition?” Answer: The toddler years are a time of great changes in growth and development. The helpless baby is transformed into a walking, talking little person with their own ideas and wishes, particularly when it comes to food! This can put parents and carers under enormous strain as they struggle to please their children while still meeting their distinct nutritional needs. Compared with adults, kilo for kilo, toddlers need more than four times the amount of iron and vitamin C and three times the amount of calcium, zinc and vitamin A. Some parents will raise the issue of nutrition but this is often because their toddler is not eating enough and they are worried about a lack of calories. However, whether or not parents bring up the topic of nutrition, it is worth highlighting that toddler’s needs go way beyond calories. Vitamins and minerals, especially iron, omega-3 fats and vitamin D, are all needed to support normal development. Vitamin D is a nutrient of concern in the UK population and dietary intakes are failing to keep pace. For example, the National Diet and Nutrition Survey found that the average toddler is only getting 27% of their vitamin D recommended intake through their diet1. The evidence shows that parents are struggling to provide the right amounts of key nutrients for their toddlers, but advice and encouragement from health professionals can help. Effective communication about which nutrients are important and how they can be provided can give parents ideas to try at home. These include: For vitamin D: U As part of a varied diet, two beakers daily of Growing Up Milk provides 73% of the daily vitamin D recommendation for toddlers2 U In summer, 10-15 minutes of sun exposure daily without sun cream boosts vitamin D status3 U Good dietary sources include oily fish and eggs For iron: U Iron in red meat is most easily absorbed U Non-meat sources include pulses, soya and spinach U Growing up Milk is fortified with iron For omega-3s U The best dietary source is oily fish, such as salmon, trout and mackerel. Aim for one portion a week U If your child refuses to eat fish, try a fish oil supplement Combining a varied diet with appropriate supplementation and use of fortified foods and milks can help parents to give their toddlers the right amounts of vitamins and minerals for growth. Health professionals can support parents by suggesting simple changes to existing family routines and by providing information on good dietary sources of nutrients. For more on vitamin D – www.in-practice.co.uk/vitamind References 1. Bates B et al (2011). National Diet and Nutrition Survey: Headline results from Years 1 and 2 combined. FSA and the DH: London. 2. Department of Health (1991). Dietary Reference Values for food Energy and Nutrients for the United Kingdom, 2nd edition. Report on Social Subjects no. 41. TSO: London. 3. Scottish Government (2010). Advice on vitamin D. www.scotland.gov.uk/News/Releases/2010/09/17113234 NHDmag.com May 2013 - Issue 84 15 C L I N I C A L Basing practice on evidence… Nutritional intervention and support is crucial for optimal care in cystic fibrosis. Chris Rudd, RD Clinical Editor, Network Health Dietitians Chris is working part time as Dietetic Advisor with Medicines Management NHS West and South Yorkshire and Bassetlaw Commissioning Service Unit. 16 The evidence base is examined in Helen White’s article Evidence based practice for nutrition support intervention in cystic fibrosis. 10,000 people are currently registered as having CF nationally and there are 100,000 individuals worldwide, so as dietitians it is important that our practice is based on evidence and that we offer the most appropriate form of nutritional support. Helen’s article looks at enteral tube feeding as well as oral nutritional supplements and the effect of both on nutritional outcome. Keeping to a gut theme, Arash Assadsangabi and Mark McAlindon report on Inflammatory Bowel Disease in their article Crohn’s and colitis: clinical presentation and medical management. The highest incidence and prevalence of IBD is in Nortehrn Europe, the UK and North America with a higher accumulation in urban areas. Arash and Mark look at the factors involved in the prevalence of IBD and also explain the role that management, surgical intervention, medicines and diet play in each clinical condition. NHDmag.com May 2013 - Issue 84 Have you heard of the European Commissionfunded NUTRIMENTHE project? It sounds fascinating and researches into the effect of diet on the mental performance of children. Claire Horton asks the question, Does prenatal nutrition affect mental performance in childhood? The NUTRIMENTHE project is revealing that subtle changes in biochemistry during pregnancy may have effects on later mental performance. Sounds like we need to ‘watch this space’ in the future! We might need to give more specific advice for mums to be and those during the pregnancy stage. And from newborns to the elderly, nutrition is just as important in late stages of life as in pregnancy. Cathy Forbes and Vittoria Romano discuss Improving diet in the elderly. A complex challenge, but one that can impact positively on the NHS and social care budgets if it is handled correctly. There is a lot of good reading material this month, making sure that the NHD Clinical section continues to be an essential dietetic resource for all our readers. NHD Clinical - cystic fibrosis Evidence based practice for nutrition support intervention in cystic fibrosis Nutritional intervention and support is crucial for optimal care in cystic fibrosis. The evidence base is examined to explore the basis to the guidance we have for nutritional interventions. Helen White Principal Lecturer/ Specialist Dietitian Cystic Fibrosis Leeds Metropolitan University Leeds Teaching Hospitals Trust Helen combines clinical working with a lecturing and research role. She has a particular interest in research into dietary interventions and nutritional complications in adults with cystic fibrosis. Cystic fibrosis is an inherited disease. One in every 2,500 babies born in the UK has the disease, with 10,000 people currently registered as having CF nationally and 100,000 individuals worldwide. Although it has a varied manifestation according to the genotype of the individual, it is predominantly characterised by progressive, irreversible lung disease and pancreatic dysfunction. The latter results in lipase deficiency and fat malabsorption unless adequate pancreatic enzyme replacement therapy is taken. Optimising nutritional status is considered an essential part of lifelong treatment and is inextricably linked with pulmonary status. This important interrelation between nutrition and pulmonary function provides the rationale for dietary interventions and the degree of malnutrition has been shown to predict survival (1). As disease progresses, escalation of nutritional intervention is usually the norm. Dietary supplementation, oral calorie supplements and enteral tube feeding may all be considered routinely within this process. Definitions of nutritional failure The type of intervention chosen is dependent on clear definitions for nutritional failure. At present, these vary according to different national reference standards and the data that has been used as their basis (Table 1) (2,3,4). Standards within the UK were last published in 2002 (3) and continue to guide our clinical management, with the broad aims of increasing energy intake to 120 to 150 percent of estimated average requirements (EAR) and of protein to 200 percent of the Reference Nutrient Intake (RNI) with 40 percent of energy provided by fat (Table 2 overleaf). However, new data arising from national database analysis (5,6) and peer reviewed studies has allowed a more detailed examination of population norms for weight, growth and BMI at na- tional level. The advantage of these large scale population analyses has been their ability to link nutritional and pulmonary status more clearly. In children, those who achieve a BMI centile of 50th or above have associated lung function values of >90 percent predicted (3). For adults a BMI of 22kg/m2 in women and 23kg/m2 in men is associated with lung function values of >65 percent (5,6). These population statistics have therefore provided new information regarding the targets we should be aiming to achieve with patients. High calorie, high fat diets with accompanying pancreatic enzyme replacement therapy, are now well established in the nutritional treatment of those with CF. Early studies that used supplemental drinks using household foods, concluded that absorbed intakes of 100 to 110 percent of the recommended energy requirements could be achieved, resulting in normal growth (7). In the main, however, studies such as this were rare and the literature instead focused on changes in nutritional policy over time and its impact on dietary intake and growth. Various reports have since established that despite the advent of higher fat diets, achieving the dietary recommendations for CF continues to prove difficult. In children with mild lung disease, studies generally show that mean energy intakes are 99 to 116 percent RDA, which remain consistently below the UK guidelines for CF (8-12). It is also significant that only a certain percentage (11 to 39 percent) in any study have been able to achieve the dietary recommendations, suggesting that despite a relaxation of fat restriction, there remains an upper limit to the amount of food that children and adults with CF can consume (11-13). Although such an approach has consistently increased energy intakes in children with CF to above that of healthy controls, the recommended levels of Table 1: Definition of nutritional failure in patients with CF and those at risk ECFS Sinaasappel et al (2) * <2 yrs UK CF Trust (2002)* <5 yrs <2 yrs 2-18 yrs 5-18 yrs 2-20 yrs >18 yrs Normal nutritional state Preventative counselling % Wt/Ht 90-110% % Wt/Ht 90-110% % Wt/Ht 90-110% % Wt/Ht 90-110% BMI 18.5-25or no recent weight loss BMI 19-25 or no recent weight loss Dietetic referral Consider supplements Any degree of FTT** % Wt/Ht 85-89% Wt loss over 4-6 mths Wt plateau over 6 mths ** BMI <18.5 or >5% wt loss over < 2 mths BMI <19 or >5% wt loss over < 2 mths Invasive nutritional support FTT despite oral supplementation** Supplements tried and either % wt/ht <85% or weight fall of 2 centile positions** Supplements tried and BMI <18.5 (<19)* or >5% weight loss over <2 mths BMI percentile ≥50th Woman: BMI ≥22 Man: BMI ≥23 North American CF Foundation Borowitz et al (2008) Defined targets to avoid nutritional failure BMI percentile ≥50th NHDmag.com May 2013 - Issue 84 17 NHD Clinical - cystic fibrosis Table 2: Dietary guidelines in cystic fibrosis 40 percent fat have rarely been achieved. Children with CF generally consume moderate fat intakes and have been shown to simply eat more of all nutrients compared to healthy children of the same age (10,14). Higher energy intakes of 117 to 126 percent have been reported in adult populations, although fat intakes of 35 to 38 percent persist (12,15). Richardson et al compared cross-sectional anthropometric measures collected in an Australian population taken 15 years apart and reported significant improvements in weight, growth and body composition measures, to the extent that growth improvements met the predicted standards for the general population (15). Unfortunately, the authors did not distinguish between various dietary interventions that helped them to meet these targets. A reported mean dietary intake of >120 percent energy following relaxation of dietary restrictions, therefore incorporated several forms of nutritional intervention. A subsequent study supported these findings in an adult age group, but also went on to differentiate between nutritional intakes and status of patients consuming diet alone, oral supplements and enteral tube feeding (12). It is noteworthy that those adults consuming diet alone achieved the best nutritional status and lung function whilst consuming the least energy (100 percent estimated average requirements). It suggests that achievement of the energy recommendations may not be necessary where lung function is adequate and instead emphasises the continual need for individual assessment and monitoring. Oral nutritional supplements There are fewer studies that examine the impact of oral proprietary nutritional supplements in cystic fibrosis (CF). A recent systematic review highlights the lack of evidence to support their use (16), despite their acknowledged benefits within clinical practice 18 NHDmag.com May 2013 - Issue 84 situations. This has been compounded by the ethical limitations of withholding oral supplements in trial designs and the difficulties in assessing adherence to oral calorie supplements over longer time periods. All studies to date have been relatively short term, evaluating efficacy over periods of eight weeks to 12 months and have predominantly aimed to increase caloric intake by 20 percent above pre-trial intakes. Kalnins et al 2005 (17) failed to demonstrate improvement in weight gain or growth over a threemonth period, suggesting that oral supplements may substitute for dietary intake and fail to increase overall energy intakes. The only multicentre longitudinal study that has been published to date, investigated the effect of a novel high fat oral supplement (Scandishake), providing 46 percent energy from fat (18). The aim was to produce an oral supplement that was palatable, fulfilled prescribing criteria and effectively promoted weight gain in patients with CF who were attending centres with established dietetic input. The results of an eight-week intervention programme demonstrated significant weight gain ranging from 1.6 to 4.0kg (mean 1.9kg), successfully highlighting it as a useful adjunct in the treatment of malnutrition. Using a randomised controlled study design Steinkamp et al (19) evaluated the effect of an existing oral energy supplement rich in linoleic acid, on body weight and essential fatty acid status in patients with CF over a three-month period. The supplemented group had significant increases in mean energy intake and weight gain compared to the control group. Despite similar dietary energy intakes derived from fat (38 percent in supplemented group, 35 percent in control group), a pronounced improvement in plasma phospholipid measures, including linoleic acid, was shown in the intervention group. The authors concluded that patients with CF and low body weight have poor essential fatty acid (EFA) status and can benefit from EFA-rich energy supplements. However, in view of their findings including similarities in overall fat intake, one could argue that the crucial factor is overall nutritional intake. Unless energy intake and nutritional status is optimised to promote weight gain for patients with CF, then all nutritional deficiencies including EFA will likely exist. These results were not confirmed in a large multicentre RCT published in 2006, which recruited 102 children from 17 CF centres across the UK (20). All children received the usual dietary advice to maximize nutritional intake, but the 50 children who were randomised to the intervention group additionally received self-selected oral nutritional supplements for a 12-month period. According to the primary outcome measure of ‘change in BMI’, the results showed that there was no improvement in nutritional status or other clinical outcomes and the authors concluded that ‘oral protein energy supplements should not be regarded as an essential part of the management’ for these children. Despite these findings many clinicians observe the beneficial impact of oral calorie supplements at a clinical level. If you can’t count on the weather, you can still count on a boost from Vitasavoury. So Spring has sprung and Summer is on the way but let’s be honest, if last year is anything to go by you’ll probably still want the comforting high energy, low volume, savoury soup boost of Vitasavoury at hand. The perfect alternative to sweet supplement drinks. 100ml Low Volume 204 kcal per serving 4 Great Tasting Flavours 150ml 309 kcal per serving Convenient Presentation New mixed starter pack ACBS Approved It’s easy to get a free sample to try with your patients or more information vita[email protected]o.co.uk 0151 709 9020 www.vitafloweb.com A Nestlé Health Science Company Fill in a sample request form on our website www.vitaoweb.com Remember to quote reference number NHD0513 NHD CLINICAL - cystic fibrosis Enteral tube feeding When dietary education and oral nutritional supplementation fail to reverse nutritional decline, enteral tube feeding is the remaining option. Nasogastric, gastrostomy and jejunostomy feeding are the available routes. To date there is no evidence to show which is the most preferable, although consensus suggests that gastrostomy placement is the method of choice in most cases. Enteral tube feeding has recently been concluded as having the strongest evidence base for benefit, all studies indicating significant weight gain and a reduction in the rate of decline of pulmonary function (16). Early reports examining the potential benefits of enteral tube feeding, were undertaken as individual case studies or single group pre-test, post-test longitudinal studies. All resulted in weight gain or improved growth, but had inherent limitations. They were small in sample size (n = 1-12), encompassed a broad age range and undertook enteral tube feeding for varying time periods of 12 days to eight months (21-24). A number of studies have since confirmed the positive nutritional effects of gastrostomy or jejunostomy feeding in severely malnourished patients (25-30). In almost all cases, significant improvements in nutritional status were observed at six months to one year of follow-up; changes which have been shown to persist for up to four years after insertion (27), with only one study failing to demonstrate the nutritional advantages associated with enteral tube feeding (29). They observed a gradual worsening of nutritional status, accompanied by a high mortality rate of 30 percent, and went on to show that mortality was significantly associated with a WAZ score of <-2.0 and predicted FEV1 <50 percent. This supported an earlier study demonstrating that poorer nutritional outcome was associated with FEV1 < 40 percent (31). It suggests that initiating enteral tube feeding according to nutritional failure alone may be too simplistic. Nutritional and other clinical outcomes may therefore be dependent on the level of lung function at the point of insertion. The nutritional benefits associated with enteral tube feeding, are not yet consistently reflected in pulmonary and clinical measures. Stabilisation of lung function has been demonstrated in the shorter term, but there is only one study that has been able to show an increase in FEV1 (3.9%) after one year of tube feeding (25) and several studies fail to indicate any reduction in hospital admissions or intravenous antibiotic treatment (25,26,28,30). Importantly there are few complications reported. Of those complications that are cited, gastrooesophageal reflux and onset of diabetes are the most frequent. The incidence of gastrooesophageal reflux has been reported as high as 30 percent (29) and the incidence of diabetes ranges from five percent to 50 percent within a one- to two-year follow-up period among tubefed patients (25,29,30,32,33). Further work is now required to determine the optimal content and stage of disease at which enteral tube feeding should be introduced. Weight gain has been demonstrated in almost all cases, but not its impact on body composition or glucose homeostasis. The nutritional parameters used to indicate changes in nutritional status also differ, highlighting the need for standardised reporting of nutritional measures to allow better comparison between studies. In summary, the evidence base gives less guidance for dietary intervention alone, or the use of oral calorie supplementation in CF. The ethical limitations of withholding dietary supplementation, where nutritional status is known to influence clinical outcome, has been a major obstacle in study design and approval. In contrast, enteral tube feeding has been more clearly shown to improve nutritional status, particularly in malnourished patients and has been shown to slow the rate of pulmonary decline in patients with advanced disease. References 1 Sharma R, Florea VG, Bolger AP, Doehner W, Florea ND, Coats AJS, Hodson ME, Anker SD, Henein MY (2001). Wasting as an independent predictor of mortality in cystic fibrosis. Thorax;56:746-750 2 Sinaasappel M, Stern M, Littlewood J et al (2002). Nutrition in patients with cystic fibrosis: a European consensus. J Cystic Fibrosis,1:51-75 3 Littlewood J, Taylor C, Littlewood J, Beckles Wilson N, Morton A, Watson H, Wolfe S (2002). Nutritional management of cystic fibrosis. CF Trust Publication. Bromley, Kent, UK 4 Stallings VA, ,Stark LJ, Robinson KA, Feranchak AP, Quinton H (2008). Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: Results of a Systematic Review J Am Diet Assoc, 108(5):832-9 5 Cystic Fibrosis Foundation (2010). Annual data report. Bethesda, VS; CFF 6 Cystic Fibrosis Registry (2010). Annual data report Kent, UK: Cystic Fibrosis Trust 7 Parsons HG, Beaudry P, Dumas A, Pencharz PB (1983). Energy needs and growth in children with cystic fibrosis. J Pediatr GastrNutr, 2:44-49 8Tomeszko JL, Stallings VA, Scanlin TF (1992). Dietary intake of healthy children with cystic fibrosis compared with normal control children. Pediatrics, 547-553 9 Kawchak DA, Zhao H, Scanlin TF, Tomezsko JL, Cnaan A, Stallings VA (1996). Longitudinal prospective analysis of dietary intake in children with cystic fibrosis. J Paediatr 129: 119-128 10 White H, Wolfe SP, Foy J, Morton AM, Conway SP, Brownlee KB (2007). Nutritional intake and status in cystic fibrosis: does age matter? J Pediatr Gastr Nutr 44:116-123 11 Powers SW, Patton SR, Byars KC, Mitchell MJ, Jelalian E, Mulvihill MM, Hovell MF, Stark LJ (2002). Caloric intake and eating behaviour in infants and toddlers with cystic fibrosis. Pediatrics 109:5;1-10 12 White H, Morton AM, Peckham DG, Conway SP (2004). Dietary intakes in adult patients with cystic fibrosis - do they achieve guidelines. J Cystic Fibrosis 3:1-7 13 Daniels L, Davidson GP, Martin AJ (1987). Comparison of the macronutrient intake of healthy controls and children with cystic fibrosis on low fat or nonrestricted fat diets. J Pediatr Gastr Nutr 6:381-386 14 Anthony H, Bines J, Phelan P, Paxton S (1998). Relation between dietary intake and nutritional status in cystic fibrosis. Arch Dis Child78:443-447 15Richardson I, Nyulasi I, Cameron K, Ball M, Wilson J (2000). Nutritional status of an adult cystic fibrosis population Appl Nutr Inv,16:255-259 16 Woestenenk JW, Castelijns SJ, Vand der Ent CK, Houwen RH (2013). Nutritional intervention in patients with cystic fibrosis: a systematic review. J Cystic Fibrosis 12:102-115 17 Kalnins D, Corey M,Ellis L, Paul B, Pencharz MB, Tullis E,Durie PR (2005). Failure of conventional strategies to improve nutritional status in malnourished adolescents and adults with cystic fibrosis. J Pediatr 399-401 18 Skypala IJ, Ashworth FA, Hodson ME, Leonard CH, Knox A, Hiller A, Wolfe SP, Littlewood JM, Morton A, Conway S, Patchell C, Weller P, McCarthy H, Redmond A, Dodge J (1998). Oral nutritional supplements promote significant weight gain in cystic fibrosis patients. J Hum Nutr Diet11:95-104. 19 Steinkamp G, Demmelmair H, Ruhl-Bagheri I, von der Hardt H, Koletzko B (2000). Energy supplements rich in Linoleic Acid improve body weight and essential fatty acid status of cystic fibrosis patients. J Pediatr Gastroenterol Nutr31(4):418-423 20 Poustie VJ , Russell JE, Watling RM, Ashby D, Smyth RL (2006). Oral protein energy supplements for children with cystic fibrosis: CALICO multicentre randomised controlled trial. BMJ 332:632-636 21 Shepherd RW, Thomas BJ, Bennett D, Cooksley WGE, Ward LC (1983). Changes in body composition and muscle protein degradation during enteral nutritional supplementation in nutritionally growth retarded children with cystic fibrosis. J Pediatr Gastroenterol Nutr 2:439-446 22 Bertrand JM, Morin CL, Lasalle R, Patrick J, Coates AL (1984). Short-term clinical, nutritional and functional effects of continuous elemental enteral alimentation in children with cystic fibrosis. J Pediatr;104:41-6 23 Pencharz P, Hill R, Archibald E, Levy L, Newth C (1984). Energy needs and nutritional rehabilitation in undernourished adolescents and young adults with cystic fibrosis. J Pediatr Gastr Nutr; 3 (Suppl 1):S147-S153 24 Moore MC, Greene HL, Donald WD, Dunn GD (1986). Enteral tube feeding as adjunct therapy in malnourished patients with cystic fibrosis: a clinical study and literature review. Am J Clin Nutr 44:33- 41 25 Steinkamp G, Von der Hardt H (1994). Improvement of nutritional status and lung function after long-term gastrostomy feedings in cystic fibrosis. J Pediatr 124:244-249 26 Williams SG, Ashworth F, McAlweenie A, Poole S, Hodson ME, Westaby D (1999). Percutaneous endoscopic gastrostomy feeding in patients with cystic fibrosis. Gut 44:87-90 27Rosenfeld M, Casey S, Pepe M, Ramsey BW (1999). Nutritional effects of long-term gastrostomy feedings in children with cystic fibrosis. JADA 99:191-194 28 Van Biervliet S, De Waele M, Van Winckel M, Robberecht E (2004). Percutaneous endoscopic gastrostomy in cystic fibrosis; patient acceptance and effect of overnight tube feeding on nutritional status. Acta GastroEnterologica Belgique, 241-244 29Oliver MR, Heine RG, Ng CH, Volders E, Olinsky A (2004). Factors affecting clinical outcome in gastrostomy-fed children with cystic fibrosis. Pediatr Pulmonol 37:324-329 30Efrati O, Mei-Zehav M, Rivlin J, Kerem E, Blau H, Barak A, Bujanover Y, Augarten A, Cochavi B, Yahav Y, Modan-Moses D (2006). Long-term nutritional rehabilitation by gastrostomy in Israeli patients with cystic fibrosis: clinical outcome in advanced pulmonary disease. J Pediatr Gastroenterol Nutr, 42:222-228 31 Walker SA, Gozal D (1980). Pulmonary function correlates in the prediction of long-term weight gain in cystic fibrosis patients with gastrostomy tube feedings. J Pediatr Gastroenterol Nutr 27:53-56 32 Kane RE, Black P (1989). Glucose intolerance with low-, medium- and high-carbohydrate formulas during night time enteral feedings in cystic fibrosis patients. J Pediatr Gastroenterol Nutr, 8:321-326 33 White H, Pollard K, Etherington C, Clifton I, Morton AM, Owen D, Conway SP, Peckham DG (2009). Nutritional decline in cystic fibrosis related diabetes: the effect of intensive nutritional intervention. J Cystic Fibrosis 8:179-185 20 NHDmag.com May 2013 - Issue 84 C AL OG EN NE W EX TR AS HO T S Small but mighty The only high energy* shot with added protein and 36% RNI # of vitamins and minerals …in just 3 shots per day Kcal Protein 160 2g Added Vits & Mins Per shot (40ml) New convenient 40ml shots. 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Tel: 01225 751098. www.nutriciaONS.co.uk -VYMHZ[LMMLJ[P]LTHUHNLTLU[VM *YVOU»ZKPZLHZL[OH[»ZYLHK`^OLU[OL`HYL ,SLTLU[HS,_[YH3PX\PK ,SLTLU[HS,_[YH3PX\PKPZ[OLX\PJRLMMLJ[P]LHUKSVUNSHZ[PUNZVS\[PVU[V*YVOU»ZKPZLHZL LWPZVKLZHUKÅHYL\WZ :\WWSPLKPUYLHK`[VKYPURJHY[VUZ,SLTLU[HS,_[YH3PX\PKPZZOV^U[VPUK\JLYLTPZZPVUPU^LLRZ HUKTH`THPU[HPUYLTPZZPVUMVY\W[V`LHYZ,SLTLU[HS,_[YH3PX\PKPZHJVU]LUPLU[^H`MVY`V\Y WH[PLU[Z[VTHUHNL[OLPY*YVOU»ZLMMLJ[P]LS`OH]PUNHTPUPTHSLMMLJ[VUSPMLZ[`SL >P[OHYHUNLVMÅH]V\YZHUKVW[PVUZ[VHKK]HYPL[`[V[OLPYLSLTLU[HSKPL[JV\SKP[IL^OH[`V\Y*YVOU»Z WH[PLU[ZOH]LILLU^HP[PUNMVY& -VYHZHTWSLWHJRVM,SLTLU[HS,_[YH3PX\PKQ\Z[JVU[HJ[`V\Y5\[YPJPH9LWYLZLU[H[P]LVY :HSLZ:\WWVY[VU 9PVYKHU(4L[HS;YLH[TLU[VMHJ[P]L*YVOU»ZKPZLHZLI`L_JS\ZPVUKPL[!,HZ[(UNSPHUT\S[PJLU[YLJVU[YVSSLK[YPHS3HUJL[ "! ;LHOVU2L[HS;OLLMMLJ[VMLSLTLU[HSKPL[VUPU[LZ[PUHSWLYTLHIPSP[`HUKPUÅHTTH[PVUPU*YVOU»ZKPZLHZL.HZ[YVLU[LYVSVN` "! =LYTH:L[HS6YHSU\[YP[PVUHSZ\WWSLTLU[H[PVUPZLMMLJ[P]LPU[OLTHPU[LUHUJLVMYLTPZZPVUPU*YVOU»ZKPZLHZL+PN3P]LY+PZ" ! 5\[YPJPH3[K>OP[L/VYZL)\ZPULZZ7HYR5L^THYRL[(]LU\L;YV^IYPKNL>PS[ZOPYL)(?8;! ^^^LSLTLU[HSJVT NHD CLINICAL - ibD Crohn’s and colitis: clinical presentation and medical management Arash Assadsangabi Specialist Registrar in Gastroenterology Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Dr Mark McAlindon Consultant Gastroenterologist Royal Hallamshire Hospital Sheffield Teaching Hospitals NHS Foundation Trust Arash is a senior registrar in gastroenterology currently based at the Royal Hallamshire Hospital. His main area of research interest is proteomics in IBD. He is currently undertaking a joint laboratory/ clinical research on the subject attached with the University of Sheffield. Since being appointed as a consultant in Sheffield in 1998, Mark has led endoscopy and nutrition services and developed capsule endoscopy. He is active in research in these areas, has published original research papers and reviews and lectures nationally and internally on capsule endoscopy. Inflammatory bowel disease (IBD) is an idiopathic chronic condition which encompasses two distinct disease categories, namely ulcerative colitis and Crohn’s disease (CD). In ulcerative colitis (UC) the mucosal inflammation starts at the rectum and could spread proximally but always in a continuous fashion. It only affects the colon but could sometimes cause a backwash ileitis. On the other hand, CD can involve any part of the gastrointestinal lumen from mouth to anus. It generally follows a discontinuous pattern. Northern Europe, the UK and North America have the highest incidence and prevalence of IBD. Low incidence areas include southern Europe, Asia and most developing countries, although the rate of the disease is on the rise on these regions (1). Current widely accepted pathogenesis of the disease postulates that IBD results from an inappropriate response to an innocuous antigen in a defective mucosal immune system. Once inflammation begins, the primary difference between patients with IBD and unaffected persons lies in an impaired ability to down-regulate mucosal inflammation. IBD is a multi-factorial disease with various aetiologic risk factors being linked to its development. A positive family history is the largest independent risk factor for the disease (2). There is strong evidence of genetic factors attributed to the high concordance rate of IBD in studies on identical twins (3). A higher accumulation of IBD in urban areas compared with rural communities has been shown in several large epidemiological studies that may reflect the effect of improving hygiene as a risk factor (2). The traditional low incidence of IBD in developing countries, which is now on the rise, also suggests the possible socioeconomic changes such as sanitation, industrialisation and diet as risk factors (4). Excessive sanitation is thought to interfere with the normal functional maturation of the mucosal immune system that requires exposure to various environmental antigens for its normal development and induction of immune tolerance in early stages of intestinal maturity. This in turn results in inappropriate immune responses when exposed to these antigens later in life. Cigarette smoking aggravates the course of CD; on the other hand it is associated with less frequent flares of UC (5). An association between certain diets such as high polyunsaturated fats and high carbohydrate diet and the increased risk of IBD has been shown in several studies (6,7). Breastfeeding helps with intestinal immune system maturity and probably confers immunity to IBD (8). Ulcerative Colitis UC is a chronic inflammatory process of the colonic mucosa. It is a clinical diagnosis, confirmed by other ancillary findings from endoscopic and histological examinations. Acute UC typically presents with gradual onset of bloody diarrhoea, pus or mucus passing, urgency and abdominal cramps during bowel movements. The severity of symptoms correlates with the extent of disease. When the disease extends beyond the rectum, blood is usually mixed with stool. It is worth mentioning that non-IBD causes of colitis and enteritis including bacterial, parasitic, viral, inflammatory, toxic, vasculitic and malignant should be excluded prior to confirmation of diagnosis. Several criteria have been described for better objective assessment of the UC severity. Truelove-Witts criteria is one of the most widely used methods dividing the disease to mild, moderate or severe. A variety of drug therapies is available for induction of treatment during acute flare of UC. Current approved treatment options include 5-aminosalicylic acid (5-ASA), steroids, ciclosporin A, tacrolimus, infliximab and surgery. On the other hand, certain medications such as 5-ASA, E coli Nissle 1917/ VSL#3, azathioprine/mercaptopurine, infliximab (not currently approved by the NICE) are used to maintain UC remission. Generally speaking, the choice of treatment depends on several factors including location, severity, comorbidities and degree of responsiveness to initial medical therapies as well as the patient’s choice. Crohn’s Disease CD is a transmural inflammatory disease of the gastrointestinal mucosa that can affect the entire gastrointestinal tract, but most frequently involves the distal small intestine and proximal colon. At diagnosis, the ileocecal region is involved in about 47 percent of cases, followed by the colon in about 20 percent and the small intestine alone in about 30 percent. The stomach and mouth are rarely affected. The oesophagus is also very rarely involved (9). It can cause complications such as strictures, abscesses, sinus tracts, fistulas or adhesions. These features may also contribute to bowel obstruction. The inflammatory process usually evolves toward one of two pattern of disease: a fibrostenotic-obstructing pattern or a penetrating-fistulatous pattern. The behaviour and anatomical location of the disease can change over time (10). The clinical presentation is largely dependent on disease location and can include prolonged diarrhoea with abdominal pain, low-grade fever, weight loss, generalised fatigability, clinical signs of bowel obstruction, as well as passage of blood, pus and/or mucus. NHDmag.com May 2013 - Issue 84 23 NHD CLINICAL - ibD CD treatment is usually follows a sequential ‘step-up’ approach, in which less aggressive and less toxic treatments are first initiated, followed by more potent medications or surgery if the initial medical therapy fails. The diagnosis is made on the basis of history and physical examination, supplemented with objective findings from endoscopic, radiological, laboratory and histological studies. Multiple scoring systems incorporating the patient’s history, physical examination findings, and laboratory data have been developed to objectively assess disease activity in adults with CD. The Crohn’s Disease Activity Index (CDAI) is one such scoring system that is widely used in research. Another commonly used criterion is the Harvey-Bradshaw Index (HBI) which has more applicability in the clinical ground due to its easy scoring system. CD treatment is usually follows a sequential ‘stepup’ approach, in which less aggressive and less toxic treatments are first initiated, followed by more potent medications or surgery if the initial medical therapy fails. Induction of treatment usually includes 5-ASA, azathioprine/mercaptopurine, steroids, infliximab/adalimumab or surgery depending on the location, severity, disease behaviour (fistulating versus obstructing) and previous drug responsiveness whilst taking in to account the patient’s preference. Azathioprine/mercaptopurine, infliximab/ adalimumab or methotrexate on the other hand can be used to help keeping the disease in remission. There is no good evidence to support any role of probiotics in the maintenance of Crohn’s disease. Role of Nutritional Therapy in IBD Malnutrition is a common occurrence in IBD; hence validated tools such as Malnutrition Universal Screening Tool (MUST) should be used in clinical practice to guide objective assessment of these patients (13,14). Nutritional deficits in calcium, vitamin D, other fat soluble vitamins, zinc, iron and vitamin B12 status (Post terminal ileal resection) is relatively common especially during the disease activity (14). In certain situations, such as short bowel syndrome or peri-operative patients with low BMI or significant weight loss, macronutrients support in the form of total parenteral nutrition (TPN) may be indicated (15). There is no good evidence to support the use of TPN and bowel rest as the main or adjunct induction therapy in IBD (16, 17). Therapeutic liquid feeding is not indicated in the treatment of UC (14, 18). On the other hand, exclusive enteral nutrition (EEN) can be used as an alternative therapy to corticosteroids for treating active CD although EEN has shown to be less effective than corticosteroids in the adult cohort. This could be attributed to tolerability in this group of patients (14). There is no difference in efficacy between elemental and polymeric diets as an induction treatment for active CD (19). There is also little evidence to support the use of liquid feeds as maintenance therapy for CD (20). Extraintestinal Manifestations and Complications Up to about one third of patients with CD and UC will develop extraintestinal disease manifestations or complications (10). Extra-intestinal manifestations include dermatological (erythema nodusum, pyoderma gangrenosum), rheumatological (peripheral arthritis, ankylosing spondylitis), ocular (conjunctivitis, uveitis), hepatobiliary (hepatic steatosis, primary sclerosing cholangitis), urological (calcium oxalate stones), metabolic bone disorders (osteoporosis and osteonecrosis), thromboembolic disorders (venous and arterial thrombosis) and cardiopulmonary (endocarditis, interstitial lung disease). Patients with UC and CD have an increased risk of developing malignancies including colon cancer in patients with UC & CD and small bowel carcinoma in patients with Crohn’s enteritis (11). Index screening colonoscopy is currently advised for all patients about 10 years after the initial diagnosis followed by risk stratification according to disease activity, presence of complications, family history of colorectal cancer and histological findings into low, intermediate and high risk groups; follow up screening colonoscopy will then be in five, three or 10 years respectively as per current British Society of Gastroenterology (BSG) guideline (12). References: 1 Loftus EV Jr. Clinical epidemiology of inflammatory bowel disease: incidence, prevalence, and environmental influences. Gastroenterology 2004; 126: 1504–17 2 Daniel C Baumgart, Simon R Carding. Inflammatory bowel disease: cause and immunobiology. Lancet 2007; 369: 1627–40. 3Tysk C, Lindberg E, Jarnerot G, Floderus-Myrhed B. Ulcerative colitis and Crohn’s disease in an unselected population of monozygotic and dizygotic twins. A study of heritability and the influence of smoking. Gut 1988; 29: 990–96. 4 Desai HG, Gupte PA. Increasing incidence of Crohn’s disease in India: is it related to improved sanitation? Indian J Gastroenterol 2005; 24: 23–24. 5 Cosnes J. Tobacco and IBD: relevance in the understanding of disease mechanisms and clinical practice. Best Pract Res Clin Gastroenterol 2004; 18: 481–96. 6Riordan AM, Ruxton CH, Hunter JO. A review of associations between Crohn’s disease and consumption of sugars. Eur J Clin Nutr 1998; 52: 229–38. 7 Geerling BJ, Dagnelie PC, Badart-Smook A, Russel MG, Stockbrugger RW, Brummer RJ. Diet as a risk factor for the development of ulcerative colitis. Am J Gastroenterol 2000; 95: 1008–13. 8 Schack-Nielsen L, Michaelsen KF. Breast feeding and future health. Curr Opin Clin Nutr Metab Care 2006; 9: 289–96. 9 Louis E, Collard A, Oger AF, Degroote E, Aboul Nasr El Yafi FA, Belaiche J. Behaviour of Crohn‘s disease according to the Vienna classification: changing pattern over the course of the disease. Gut 2001; 49: 777–82. 10 Daniel C Baumgart, William J Sandborn. Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet 2007; 369: 1641–57. 11 Bernstein CN, Blanchard JF, Kliewer E, Wajda A. Cancer risk in patients with inflammatory bowel disease: a population-based study. Cancer 2001; 91: 854–62. 12 Stuart R Cairns, John H Scholefield, Robert J Steele, Malcolm G Dunlop, Huw J W Thomas et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010; 59: 666-690. 13 Stratton RJ, Hackston A, Longmore D, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 2004;92:799-808. 14 Craig Mowat, Andrew Cole, Al Windsor, Tariq Ahmad, Ian Arnott et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2011;60:571-607. 15 National Collaborating Centre for Acute Care. Nutrition Support in Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: National Collaborating Centre for Acute Care, 2006. http://www.rcseng. ac.uk. 16 Greenberg GR, Fleming CR, Jeejeebhoy KN, et al. Controlled trial of bowel rest and nutritional support in the management of Crohn’s disease. Gut 1988;29:1309-15. 17 McIntyre PB, Powell-Tuck J, Wood SR, et al. Controlled trial of bowel rest in the treatment of severe acute colitis. Gut 1986;27:481-5. 18 Lochs H, Dejong C, Hammarqvist F, et al. ESPEN guidelines on enteral nutrition: gastroenterology. Clin Nutr 2006;25:260-74. 19 Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn’s disease. Cochrane Database Syst Rev 2007;(1):CD000542. 20 Akobeng AK, Thomas AG. Enteral nutrition for maintenance of remission in Crohn’s disease. Cochrane Database Syst Rev 2007;(3):CD005984. 24 NHDmag.com May 2013 - Issue 84 NHD CLINICAL - WEB WATCH web watch Meat consumption and mortality Research published in BMC Medicine looked at meat consumption and mortality. The aim of this study was to examine the association of red meat, processed meat and poultry consumption with risk of early death in the European Prospective Investigation into Cancer and Nutrition (EPIC). The results of the study support a moderate positive association between processed meat consumption and mortality in particularly due to cardiovascular diseases, but also cancer. Article: www.biomedcentral.com/1741-7015 /11/63/abstract; BBC News report: www.bbc. co.uk/news/health-21682779 CQC Care Update: dementia The Care Quality Commission (CQC) reports in its latest update that care for people with dementia is not meeting their needs as services are struggling to cope. The second Care Update report also highlights concerns around the quality of services for people with mental health issues and learning disabilities. The findings show people living in a care home and suffering from dementia are more likely to go to hospital with avoidable conditions such as urinary infections. Once there, they are more likely to stay longer, be readmitted or die than those without dementia. CQC: www.cqc.org.uk/our-secondcare-update-published; BBC News report: www. bbc.co.uk/news/health-21747049 Salt strategy The Responsibility Deal Food Network has published its new salt strategy. The approach is purposively designed to take a holistic approach to salt reduction and will enable everyone in the food industry, health organisations and wider to play their part. The strategy comprises four key areas: revising the 2012 salt targets for over 80 categories of food by the end of the year to encourage companies to reformulate recipes; encouraging the out of home sector to do more: by setting new maximum targets for the most popular dishes; asking companies to use their influence in the market; through promotional and other activities; to encourage people to choose lower salt options and getting more companies across the food industry to sign up to salt reduction. DH strategy: http://responsibilitydeal.dh.gov.uk/2013/03/12/salt-strategy/. DH press release: http://mediacentre.dh.gov. uk/2013/03/12/government-drive-to-helpcut-salt-consumption-by-a-quarter/; BBC News report: www.bbc.co.uk/news/health-21712348 NICE guidance NICE has issued guidance on ‘Hyperphosphataemia in chronic kidney disease’ (CG157). This clinical guideline offers best practice advice on the care of adults, children and young people with stage 4 or 5 chronic kidney disease (CKD) who have, or are at risk of, hyperphosphataemia. http://guidance.nice.org.uk/CG157. Diet and nutrition survey of infants and young children The Department of Health and the Food Standards Agency have published ‘The Diet and Nutrition Survey of Infants and Young Children (DNSIYC)’. It provides detailed information on the food consumption, nutrient intakes and nutritional status of infants and young children aged four up to 18 months living in private households in the UK. The survey was carried out by a consortium of organisations: Medical Research Council Human Nutrition Research (MRC HNR), NatCen Social Research (NatCen), the MRC Epidemiology Unit and the Human Nutrition Research Centre at Newcastle University. The survey complements the National Diet and Nutrition Survey (NDNS) rolling programme which covers children and adults aged from 18 months upwards. http://transparency. dh.gov.uk/2013/03/13/dnsiyc-2011/ Smoking cessation and weight change research Research published in the Journal of the American Medical Association (JAMA) has tested the hypothesis that weight gain following smoking cessation does not attenuate the benefits of smoking cessation among adults with and without diabetes. The health gains from giving up were most marked in people who did not have diabetes, but people with the condition were still said to have benefited. Obesity is a risk factor in heart disease, leading past research to examine whether weight gain might cancel out some of the benefits of quitting smoking. BBC News report: www.bbc.co.uk/news/health21757875; JAMA article: http://jama.jamanetwork.com/article.aspx?articleid=1667090 Using the internet to improve health The NHS Commissioning Board has announced plans to help up to 100,000 more people to use the internet to improve their health. The Board is forming a new partnership with the Online Centres Foundation to fund existing UK Online Centres to train and support people to help their health and wellbeing through the internet. The funding will support the Online Centres Foundation to develop at least 50 of their existing centres in public places such as libraries, community centres cafes and pubs to become digital health hubs. These hubs will provide training and support to help people go online for the first time so that they can start using websites such as NHS Choices. They will also be encouraged to do more online, such as provide comments on their use of the NHS or order repeat prescriptions online. www. commissioningboard.nhs.uk/2013/03/13/ internet-health/ Dignity and nutrition inspection programme The Care Quality Commission (CQC) has published its first dedicated review of privacy, dignity and nutrition in both care homes and hospitals. The 2012 Dignity and Nutrition Inspection Programme (DANI) has found that while most older people are having their needs met, a number of hospitals and care homes need to make improvements. It highlights the fact that often small changes can make a big difference to people’s experience of care. CQC inspected 500 care homes and found 84 percent respected people’s privacy and dignity and 83 percent met people’s nutritional needs. This means staff were aware of people’s likes and dislikes and made sure people with dementia were given support to choose and their food. However, there were times when inspectors witnessed people not being given help to eat and drink or given personal care in a way that respected their privacy. CQC: www.cqc.org. uk/media/dignity-and-nutrition-inspectionprogramme-published; BBC News report: www. bbc.co.uk/news/health-21834679 Guidance on commissioning weight management services The Department of Health has published ‘Developing a specification for lifestyle weight management services’. The document aims to support commissioners developing a tier two lifestyle weight management service specification for adults and children. It is intended to be used as the basis for a service tendering process and can be adapted for use in the final contract documentation. www. dh.gov.uk/health/2013/03/guidance-commissioning-weight/ NHDmag.com May 2013 - Issue 84 25 NHD CLINICAL - nutrition & the elderly Improving diet in the elderly Working in partnership with local older people to improve diet Cathy Forbes Registered Dietitian, South Essex Partnership University NHS Foundation Trust Vittoria Romano Registered Dietitian, South Essex Partnership University NHS Foundation Trust In association with NAGE Cathy leads the Food First Project in Bedfordshire and has a keen interest in increasing the awareness and management of malnutrition and dehydration in the community. Vittoria has worked on the Food First project for the past 18 months where she has enjoyed meeting and helping a wide range of professionals and service users. 26 The World Health Organisation states that most developed countries define an elderly person as someone over the age of 65 (1). According to the UK census in 2011, this accounts for 9.2 million people in the UK and is an increase of 10 percent from the previous census a decade ago (2). As a result, the elderly population in the UK is very varied and people may still be working, or may require full-time nursing care. Much has been written about how to improve nutrition for those elderly living in care homes, but this only accounts for five percent of the over-65s in the UK (3). Instead, the vast majority live in their own homes, with varying degrees of support, and they and their families would like to prolong this for as long as possible. Improving diet is one way of supporting this group to keep well and maximise independence and wellbeing. As a team, we work closely with our local Older People’s Reference Group, whose membership is drawn from the local elderly population and those who work to support them. At a recent meeting, their priorities for dietary education for the elderly were: • improving the dietary knowledge and cooking skills of single older men; • clarifying the messages around healthy eating; • increasing awareness of food safety; • information on how to choose healthy pre-prepared meals. These issues are not confined to the Bedfordshire area, but are generally only addressed in a patchy manner - depending on the services available. Age UK have estimated that over 40,000 men living alone or caring for partners no longer able to undertake the main cooking duties, have attended cooking classes across the country, from Norfolk to Somerset and Manchester to Brighton (4). However, this is a tiny figure compared with the potential number who would enjoy and benefit from such sessions. As well as providing an opportunity to learn new culinary skills and improve dietary knowledge, such programmes can NHDmag.com May 2013 - Issue 84 increase confidence and widen social networks in a group of people who are at risk of otherwise entering a cycle of depression and reduced appetite, which in turn leads to worsening health (5). Lack of confidence in achieving a healthy diet is not limited to older men, many older women are also unsure of what the current advice is, especially as much media attention is focused on the diets of children and younger adults. The National Diet and Nutrition Survey results suggest that more work is needed in changing the eating habits of the older generation with only 37 percent of older adults meeting the recommendation of five portions of fruit and vegetables per day and intakes of saturated fat exceeding the dietary reference value of 11 percent of energy intake (6). It is easy to dismiss the importance of a healthy diet in older age as this is considered to be the final stage of life. However, with 3.5 million people expected to be 85 and over in 2035, longer-term health outcomes still need to be considered in the elderly. This could take the form of written dietary information targeted specifically at this population, drawing on familiar foods that are also healthy. For example, recommending cheap and now unfashionable foods such as eels and pilchards for oily fish, or vegetables such as marrows and swedes. Advice also needs to focus on how to manage a diminishing appetite within a healthy, balanced diet. The European Food Information Council has identified a range of issues that make food safety a bigger issue in the elderly (7). These include problems with vision that make it difficult to read expiry dates and cooking instructions, or to spot when food or utensils are discoloured or mouldy. A reduced sense of smell can also mean that an older person may miss the warning signs that food has ‘gone off’ (8). Impaired dexterity, e.g. due to the effects of arthritis, or difficulty standing and bending, make cleaning surfaces, foods and containers demanding tasks and food storage may be impacted as shopping is more infrequent and wrapping a challenge. With just £107 a week available from NHD CLINICAL - nutrition & the elderly the state pension, food is often an easy area to cut the budget. As a result, reliance on short dated, reduced items may also increase the risk of food poisoning in a group already susceptible to this problem due to the reduced stomach acid associated with atrophic gastritis, commonly seen in older adults (8). Pre-prepared meals may also be seen as a way of keeping costs down, with low cost supermarket options starting at approximately £1 for a main meal. Such products are also commonly chosen by those elderly who are struggling with daily tasks and may find food preparation difficult, or who are relying on carers to come in and make their food in a short time frame. Signposting this vulnerable group to choices that are easy to prepare but also nutritious is essential in order to avoid micronutrient deficiencies. Support for those who prepare these meals may be a more cost effective way of achieving this, for example, by educating domiciliary carers on the basics of nutrition, or by reviewing the menus provided by local meals-onwheels services or luncheon clubs which may be run by volunteers with limited knowledge of a balanced diet for their target age group. Improving diet in the elderly is a complex challenge, but by getting it right, it will be possible to impact positively on the budgets of the NHS and social care, while also providing benefit and reassurance to NHDmag.com Issue 84 May 2013 Improving diet in the elderly is a complex challenge, but by getting it right, it will be possible to impact positively on the budgets of the NHS and social care . . . individuals and their loved ones. With such a diverse population though, it is essential that professionals establish the views and priorities of their local elderly population before planning services and interventions intended to improve the diet of this group. References 1 World Health Organisation (2013). Definition of an older or elderly person [online] available from www.who.int/ healthinfo/survey/ageingdefnolder/en/ [08/04/2013] 2Office for National Statistics (2013). Census data [online] available from www.ons.gov.uk/ons/guide-method/ census/2011/census-data/index.html [08/04/13] 3 Cochrane Editorial Unit (2011). Care homes for older people [online] available from www.thecochranelibrary.com/ details/collection/1312113/Care-homes-for-older-people.html [12/12/2012] 4The Guardian (2012). One foot in the gravy: the rise of cookery classes for older men [online] available from www. guardian.co.uk/society/2012/apr/10/cookery-classes-older-men [08/04/2013] 5 Hirsch JM (2004). Food Classes Give Elderly Men Confidence [online] available from www.globalaging.org/ elderrights/us/2004/foodclass.htm [08/04/2013] 6 National Diet and Nutrition Survey (2011). Headline results from Years 1 and 2 (combined) of the Rolling Programme (2008/2009 - 2009/10) [online] available from www.gov.uk/government/uploads/system/uploads/attachment_data/ file/152235/dh_128542.pdf.pdf [08/04/2013] 7European Food Information Council (2003). Food safety and the elderly [online] available from www.eufic.org/article/ en/artid/food-safety-elderly/ [08/04/2013] 8 Whitney EN, Cataldo CB and Rolfes SR (1998). Understanding normal and clinical nutrition. 5th ed. Belmont: Wadsworth Save over 33% exclusive subscription offer PREVENTING AND TREATING BONE LOSS Dr Carrie Ruxton p9 NUTRITION SUPPORT INTERVENTION IN CYSTIC FIBROSIS Helen White Principal Lecturer/Specialist Dietitian Nutritional intervention and support is crucial for optimal care in cystic fibrosis. The evidence . . . p17 COELIAC UK’S AWARENESS WEEK DIETARY CHOLESTEROL ELDERLY NUTRITION CROHN’S DISEASE NUTRIMENTHE: PRENATAL NUTRITION DIETETIC*/"3sNHD CLINICAL sNEW RESEARCH sSUBSCRIPTION OFFER ISSN 1756-9567 (Print) • • • • • • Latest nutrition news Feature articles on public health and community nutrition Nutrition research updates from the world’s leading nutrition institutions NHD Clinical featuring practical features, case studies, guidelines and more Expert columns and comment from the coal face of UK dietetics Career section with live jobs, events and courses Don’t miss out! Be sure to take advantage of this great saving on the full price. For just £3.00 per issue you will be able to keep your professional development up-to-date with the UK’s favourite nutrition and dietetic professional magazine. 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Subscribing is easy at www.NHDmag.com NHDmag.com May 2013 - Issue 84 27 nutrimenthe Does prenatal nutrition affect mental performance in childhood? Dr Claire Horton Beta Technology Ltd Doncaster In scientific literature, there is growing evidence pointing to a link between diet and brain development and later mental performance. Not just the diet of the child, but that of the mother while pregnant. Of all our organs, the brain is one of the slowest to develop and is also one of the most complex structures we know. It begins to form 18 days after conception, develops rapidly during pregnancy and continues to develop into adolescence. This article outlines some of the work of the European Commission-funded NUTRIMENTHE project which is researching the effect of diet on the mental performance of children. The NUTRIMENTHE project aims to provide a greater insight into the extent to which nutritional influences in early life, including prenatal life, programme a person’s mental development. The research is being carried out by a multidisciplinary team of scientists from 20 research centres based mainly in Europe, coordinated by the University of Granada in Spain, and includes research into the influence of a mother’s diet, pre- and postnatal intervention studies and nutritional intervention in children, on later mental performance. The nutrients of interest include long-chain omega-3 polyunsaturated fatty acids (PUFA), B-vitamins, folic acid, iron, zinc, iodine and protein (in breast and formula milk). There are large cohort studies involved in NUTRIMENTHE, based at study centres around Europe and through these, NUTRIMENTHE expects to generate much new information as to how diet affects mental performance. Claire has over 25 years’ experience in the bioscience sector. She graduated in 1985 with a Biology degree and embarked on a career in medical research, culminating in her gaining a PhD in 1996. She then entered the pharmaceutical industry and in 2003 joined Beta Technology where she currently represents Beta on the FP7-funded NUTRIMENTHE project. 28 Measuring cognitive function A major aim of NUTRIMENTHE is to measure cognitive function but, the term ‘cognitive function’ covers many domains of mental performance. IQ, which is usually chosen to measure cognitive function, does not fully capture the complexity of cognitive development, so NUTRIMENTHE has developed a battery of neuropsychological tests which cover the main domains of cognitive function (perception, motor, memory, attention, language, executive functions and emotion). The tests are currently being used by NUTRIMENTHE’s partners to assess the mental performance of the children taking part in the studies. NUTRIMENTHE’s findings to date relate mainly to the influence of maternal diet on mental performance, but much more is due to emerge in the coming months relating mental performance to pre- and postnatal nutritional intervention in children. Maternal folic acid status Folic acid, which should be taken by women wishing to become, or who already are pregnant, is known to reduce the incidence of neural tube defects, but are there any further effects after neural tube closure? This has been investigated by NUTRIMENTHE partners from The Erasmus Medical Centre in The Netherlands using the Generation R cohort from Rotterdam. They have found that failure to use folic acid supplements is associated with a higher risk of behavioural and emotional problems in toddlers aged 18 months. The problems may persist as children observed at NHDmag.com May 2013 - Issue 84 age three, also show an increased risk of emotional problems. For instance, signs of being anxious or depressed, withdrawn behaviour and sleep problems are still present if their mother failed to take folic acid. The mechanism(s) of action can only be speculated at present (1,2). Maternal thyroid hormone status It has been known since the 1970s that thyroid hormones play a crucial role in brain development and that a lack can result in mental retardation. In NUTRIMENTHE, research from the Generation R cohort has shown that children born to women showing severe hypothyroxinaemia, demonstrated a higher risk of developing expressive language delay, which includes the ability to form sentences, use grammar correctly and retell a story or event at 18 months and 30 months (3). Eating fish while pregnant In the UK, women are advised by the Department of Health to eat two portions of fish a week, including one of oily fish. Indeed, the ALSPAC study, a longitudinal cohort study from Bristol, has shown that children born to women who reported the highest fish intake while pregnant, demonstrated better outcomes in tests for verbal intelligence, motor skills and prosocial behaviour (giving, helping and sharing) when measured from six months to 48 months of age. Furthermore, fish eating was positively associated with verbal IQ in the children at age eight (4). In further research involving the ALSPAC cohort, NUTRIMENTHE researchers from the University of Bristol are looking into what constituent of fish might be mediating the effect. The long-chain omega-3 PUFA, docosahexaenoic acid (DHA) is a top candidate. Omega-3 PUFAs receive much attention regarding their possible links to good health. Since humans cannot make these fatty acids de novo they must be obtained from the diet. The long-chain omega-3 PUFAs, DHA and eicosapentaenoic acid (EPA), are important structural components of cells, especially the cell membranes of the brain. Indeed, the EC recently supported health claims that intake during pregnancy of DHA ‘contributes to the normal brain development of the foetus and breastfed infants’ and ‘to the normal development of the eye of the foetus and breastfed infants’ (Commission Regulation No. 440/2011). Oily fish is an excellent source of DHA and EPA and fish eating in pregnancy is associated with maternal plasma levels of DHA which is transferred to the foetus via the nutrimenthe placenta, but are maternal DHA levels related to outcomes in children? In a study of over 2,000 mother-child pairs from the ALSPAC cohort, after adjustment for a number of confounders, no associations were found between the level of maternal DHA and childhood IQ. Thus, DHA did not appear to be the ‘missing link’ and it may be that other nutrients in fish, such as iodine, vitamin D or selenium, may be mediating the effect. Or, it may be that the child’s diet is more important. Or, it may be that IQ was not an optimal measure of mental performance (unpublished). Furthermore, NUTRIMENTHE researchers from The Medical University of Warsaw conducted a systematic review of randomised controlled trials (RCTs) that studied the effect on neurodevelopment and visual function of children born to women supplemented with long-chain omega-3 whilst pregnant or breastfeeding. The evidence from the RCTs included in the review demonstrated that there is not a clear and consistent benefit on either neurodevelopment or visual acuity from supplementation with longchain omega-3 PUFA during pregnancy or breastfeeding. However, the review did highlight the marked heterogeneity of the included studies and the varied approaches to outcome assessment. Also, none of the studies involved children over the age of four and the sample size in some trials was small. This serves to highlight the necessity for well-designed RCTs and the need for more follow-up studies in school-age children and beyond (5). The influence of genetics NUTRIMENTHE is investigating how our genetic makeup influences how we process certain nutrients. The project is investigating how polymorphisms in the fatty acid desaturase (FADS) gene cluster influence how PUFAs are processed during pregnancy. The FADS genes code for the enzymes delta-5 and delta-6 desaturase are involved in the synthesis of omega-3 and omega-6 fatty acids (6, 7). NUTRIMENTHE has published work showing that genetic variants of FADS genes are associated with levels of PUFA in the red blood cells of pregnant women (8) and in breast milk (9). Further work (10) has demonstrated that the composition of omega-3 and omega-6 PUFAs in cord blood is dependent on maternal and child genotypes, such that maternal genotypes are mainly associated with omega-6 precursors and that child genotypes are mainly associated with omega-6 products. The child’s metabolism therefore seems important for its own neonatal supply of n-6 LC-PUFA. In contrast, DHA amounts were equally associated with child and maternal genotypes, suggesting that DHA levels are dependent on both maternal and child metabolism. DHA supplied by the mother may thus be very important to satisfy the high foetal demand of DHA during pregnancy. The future The NUTRIMENTHE project is revealing that seemly subtle changes in biochemistry during pregnancy may have effects on later mental performance. The biological mechanisms will certainly be complex and clearly, much remains to be discovered, especially in terms of the role of long chain omega-3 PUFAs. Although it is accepted that long chain omega-3 PUFAs are required for brain development, the requirements for omega-3 remain to be established. This project has much more to achieve and many more results will emerge leading to further insight into how diet during prenatal and early life affects mental performance. NUTRIMENTHE is funded until December 2013 and will hold its final conference on the 13th and 14th of September, 2013 in Granada, Spain in advance of the 20th International Congress of Nutrition. The NUTRIMENTHE project acknowledges 5.9m€ funding from the European Community’s 7th Framework Programme for Research and Development (FP7/2008-2013) under grant agreement nº 212652 (NUTRIMENTHE Project ‘The Effect of Diet on the Mental Performance of Children’). NUTRIMENTHE website: www.nutrimenthe.eu References 1Roza et al (2010). Maternal folic acid supplement use in early pregnancy and child behavioural problems. The Generation R Study. British Journal of Nutrition 103(3): 445-52 2 Steenweg de Graaff et al (2012). Maternal folate status in early pregnancy and child emotional and behavioural problems: The Generation R Study. American Journal of Clinical Nutrition. June: 95(6):1413-21 3 Henrichs et al (2010). Maternal thyroid function during early pregnancy and cognitive functioning in early childhood: the Generation R study. Journal of Clinical Endocrinology and Metabolism. 95: 4227-4234 4 Hibbeln et al (2007). Maternal seafood consumption in pregnancy and neurodevelopment outcomes in childhood (ASLPAC study): an observational cohort study. Lancet 369: 578-85 5 Dziechciarz et al (2010). Effects of n-3 long-chain polyunsaturated fatty acids supplementation during pregnancy and/or lactation on neurodevelopment and visual function in children: a systematic review of randomised controlled trials. Journal of the American College of Nutrition. 29 (5): 443-454 6 Glaser et al (2011). Genetic variation in polyunsaturated fatty acid metabolism and its potential relevance for human development and health. Maternal and Child Nutrition 7(suppl 2), 27-40 7 Lattka et al (2010). Do FADS genotypes enhance our knowledge about fatty acid related phenotypes? Clinical Nutrition 29: 277-87 8 Koletzko et al (2011). Genetic variants of the fatty acids desaturase gene cluster predict amounts of red blood cell docosahexaenoic and other polyunsaturated fatty acids in pregnant women: findings from the Avon Longitudinal Study of Parents and Children. American Journal of Clinical Nutrition. 93: 211-9 9 Lattka et al (2011). Genetic variants in the FADS gene cluster are associated with arachidonic acid concentrations in human breast milk at 1.5 and 6 months postpartum and influence the course of milk dodecanoic, tetracoenoic and trans-9-octadecanoic acid concentrations over the course of lactation. American Journal of Clinical Nutrition 93: 382-91 10 Lattka et al (2012). Umbilical cord PUFA are determined by maternal and child fatty acid desaturase (FADS) genetic variants in the Avon Longitudinal Study of Parents and Children (ALSPAC). British Journal of Nutrition. Aug 9:1-15. [Epub ahead of print] NHDmag.com May 2013 - Issue 84 29 career To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk HEALTHCARE POLICY LEAD - COELIAC UK Salary range: £25-£30K pa for this 12month maternity contract. Based at: Coeliac UK, High Wycombe This role, which reports to the Research Manager, Evidence and Policy team, will focus on developing the Coeliac UK health agenda, working with the NHS, healthcare professionals and healthcare bodies. You will also be involved in drafting policy positions to inform health campaigns. Coeliac UK represents nearly 60,000 Members by providing information and support to those medically diagnosed with coeliac disease and dermatitis herpetiformis. It also campaigns on behalf of all those living with coeliac disease and undertakes research into the causes of the disease. Closing date: 17th May - to apply, please send your CV with a cover letter to Jean Christopher at [email protected] COMMUNITY BARIATRIC DIETITIAN The Bariatric Consultancy is a private company providing multidisciplinary Tier 3 specialist weight management services to the NHS. We are looking to recruit a full-time Band 6 Community Bariatric Dietitian for a new Kent-wide MDT Tier 3 service for adults with a BMI 35 plus. Based in Dartford, Kent with clinic locations in east and west Kent. This is a challenging post that will offer the successful candidate the opportunity to develop their skills both as a practitioner and also in the training of other healthcare professionals. We are also looking for someone who can contribute to service development. This post involves the assessment of pre Tier 4 patients and delivery of a specialist group programme. CVs with a covering letter should be sent in the first instance to [email protected] Closing date: 21st May. Band 6/7 Paediatric Dietitian - Manchester Band 6/7 Paediatric Dietitian for acute role in Manchester for approximately three months starting at the beginning of May. Clinical areas are high dependency , gen medicine IP and general OP. Accommodation available on site. Pay up to £30 per hour. Call Hayley now for more information on the above position and other excellent roles we have available, tel: 01277 849 649 or 0800 023 2275. Email: [email protected] ITU Dietitian - Bucks Band 6 ITU Dietitian required for four days a week covering ITU, enteral nutrition and surgery, start date is May 2013 for approximately four weeks. Call Hayley now for more information on the above position and other excellent roles we have available, tel: 01277 849 649 or 0800 023 2275. Email: [email protected] 30 NHDmag.com May 2013 - Issue 84 Renal Dietitian Band 6 - Essex Dietitian required for Essex Hospital three days a week starting mid-May, Applicants must have strong renal experience for this role. Call Hayley now for more information on the above position and other excellent roles we have available, tel: 01277 849 649 or 0800 023 2275. Email: [email protected] Locum Band 6/7 Dietitian - North West - pay up to £28ph Locum required for Paediatric Community Nutrition and Dietetic Service. You will need to be a car user and able to travel to various venues around the town. The role involves working in community clinics, seeing a range of paediatric patients. Accommodation is available on site. Duration: six months. For more information contact Daniel on 0207 749 8285 or [email protected] co.uk Visit www.labmedrecruit.co.uk/dietitians Locum Band 6 Dietitian - London, pay up to £28ph Band 6 Dietitian needed to start ASAP, to work on the general medical wards for a large NHS Foundation Trust. Assistance with finding private accommodation can be provided. Duration: three months plus. For more information contact Daniel on 0207 749 8285 or [email protected] co.uk Visit www.labmedrecruit.co.uk/dietitians Locum Band 6/7 Dietitian -North West, pay up to £30ph Hospital Dietitian required for immediate start. The successful candidate will be working with a paediatric caseload in a leading children’s hospital. Start date mid-May. Accommodation is available and the post will be for around three months. For more information contact Daniel on 0207 749 8285 or [email protected] co.uk Visit www.labmedrecruit.co.uk/dietitians Locum Band 5/6 Dietitian - South East, pay up to £27ph Our client in the South East is looking for a Band 5 or 6 Dietitian to cover adult paediatric diabetes caseload. Part-time applicants will be considered. Accommodation is available on site. For more information contact Daniel on 0207 749 8285 or [email protected] co.uk Visit www.labmedrecruit.co.uk/dietitians General Dietitian - Adult Inherited Metabolic Disorders Band 7 General Dietitian with Adult Inherited Metabolic Disorders experience based in London. Start date ASAP until the end of May. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to [email protected] pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Buying Solutions framework approved supplier for Allied health, health science personnel and Nurses. Band 6 Paediatric Dietitian - Eating Disorders We require a Band 6 Paediatric Dietitian with eating disorder experience. This post is based in Leeds. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to me [email protected] Band 7 Dietitian - Allergies - London We require a Band 7 Dietitian with experience as an allergy Dietitian. This post is based in London. For this and similar jobs please contact Patrice on 0800 032 0454 or 020 8874 6111. Email your CV to me [email protected] EVENTS & COURSES Promoted event University of Nottingham - School of Biosciences - Modules for Dietitians and other Healthcare Professionals • Renal Nutrition – start date 11th June • Diabetes 2 – start date 11th July For further details please email: [email protected], tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’. ECO 2013, European Congress on Obesity 12-15 May Arena and Convention Centre Liverpool www.easo.org/eco2013 NICE Annual Conference 2013 14-15 May - ICC in Birmingham www.nice.org.uk/ Vitafoods Europe 2013 14-16 May - Palexpo, Geneva, Switzerland www.vitafoods.eu.com/ career We urgently require dietitians for immediate vacancies s To find out your options call or email s Freephone: 0800 032 0454 [email protected] s s PJ Locums is an NHS Buying Solutions framework approved supplier for allied health Our aim is to find you the right person and the right job We offer inpatient and community UK & NI coverage Competitive rates www.pjlocums.co.uk -RN]R]RJW\ £33 .J[W^Y]X 9N[QX^[ 5JKVNMJ[NL^[[NW]UbUXXTRWPOX[*M^U]9JNMRJ][RL-RN]R]RJW\OX[ YX\R]RXW\`R]QRVVNMRJ]N\]J\RWJ_J[RN]bXOUXLJ]RXW\ =NVYX[J[b9N[VJWNW]?JLJWLRN\]Q[X^PQX^]]QN>48_N[\NJ\ ● <XUN<^YYURN[JP[NNVNW]\`R]Q9[R_J]N<NL]X[,URNW]\ ● ;NON[bX^[O[RNWM\LXUUNJP^N\]X5JKVNMNJ[W^Y]X ● .aLU^\R_N?JLJWLRN\RWX_N[ 71<=[^\]\RWX^[ 6J\]N[?NWMX[,XW][JL]\ ● ]N[V\LXWMR]RXW\JYYUb Tel: 020 7749 8285 Email: [email protected] www.labmedrecruit.co.uk NHDHalf.July10.indd 1 17/6/10 12:07:03 NHDmag.com May 2013 - Issue 84 31 Our range has grown New Fortini 1.0 Multi Fibre NEW Kcal Protein g 200 4.8 200 Fibre g ml 3.0 Fortini 1.0 Multi Fibre adds even more variety to our trusted Fortini range sKCALBOTTLE s3UITABLEASASOLESOURCEOFNUTRITIONFORCHILDRENYEARSORKG s5NIQUE-&™-ULTI&IBREBLENDTOHELPIMPROVEBOWELHEALTH1-6 sCHILDFRIENDLYmAVOURSn3TRAWBERRY6ANILLA"ANANAAND#HOCOLATE s0ARTOFTHE&ORTINI7ALLACE'ROMIT2EWARD3CHEMEENCOURAGINGCOMPLIANCE Fortini knows there’s no such thing as the ‘average child’. That’s why we’re constantly innovating our range, helping you to meet your young patients’ nutritional needs. 1. Trier E. et al. JPGN 1999;28(5):595. 2. Evans S. et al. J Hum Nutr Diet 2009;22:414-421. 3. Hofman Z. et al. Clin Nutr 2001;20(S3)217A:P63. 4. Daly A et al. J Hum Nutr Diet 2004;17:365-370. 5. Guimber D et al. Br J Nutr 2010;104(10); 1514-1422. 6. Grogan J. et al. J Hum Nutr Diet 2006;19:P462.