Issue 101 February 2015NHDmag.com

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS

BRIGHTON & HOVE

Louise DickieSpecialist Stroke Dietitian

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

ISSN 1756-9567 (Online)

dieteticJOBS • web watcH • New reSearcH

Lauren McCormack p9

aduLt food aLLergy

LaCtose intoLeranCe

CoeLiaC disease

Cows’ MiLk vs goat MiLk

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from the editor

Chris rudd nHd editor

Chris rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCt medicines management team, as a dietetic Advisor.

Numerous people will be well into their New Year resolutions by now, many of which would have had a theme around getting fitter or losing weight.

Editor chris rudd rDFeatures Editor Ursula arens rDDesign Heather DewhurstSales richard Mair richard@networkhealthgroup.co.ukPublisher Geoff weatePublishing Assistant Lisa Jackson

Address Suite 1 Freshfield Hall, the Square, Lewes road, Forest row, east Sussex rH18 5eSPhone 0845 450 2125 (local call rate)Fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.NHDmag.com

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all rights reserved. errors and omissions are not the responsibility of the publishers or the edito-rial 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 info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contribu-tions will not receive payment if published. all paid and unpaid submissions may be edited for space, taste and style reasons.

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Did any of you get involved in the Nation-al Obesity Awareness Week, 12-18 January 2015? It aimed to highlight the impact of obesity on the NHS and why we need to take action now to lead healthier lifestyles. The NHS spends between £5 billion and £9 billion treating obese patients and re-lated complications such as Type 2 diabe-tes. Hospital admissions with a primary diagnosis of obesity among people of all ages rose from 1,019 to 11,763 in a decade. There were some interesting ‘infographics’ given during the Awareness Week. Did you know that the NHS employs approxi-mately 1.35 million people and it seems likely that a quarter of these staff would be classified as obese and a further one third as being overweight! If all NHS staff took steps to be healthier and more physically active, it would have a big impact and show ‘a lead by example approach’ to our patients. However, around 75 percent of NHS Trusts do not have an obesity plan or policy implemented. And so to the articles that we have for you in issue 101. A fascinating project that has dealt with several difficult challenges is a community food strategy across Brighton and Hove. Lauren McCormack tells us how communities, businesses, statutory agen-cies and individuals worked together to help create a healthy, fair and sustainable food system which led to the implementa-tion of this strategy. There were many chal-

lenges faced, including obesity, food pov-erty and malnutrition, so please delve into this report to find out more. In the UK, 15 people every hour suffer a stroke and up to 50 percent of these will have dysphagia. Dysphagia and nutritional interventions in stroke care by Louise Dickie tells us the importance of optimising the nutritional care provided to assist in pro-moting the best patient outcomes. If you are considering offering dietetic-led clinics for people with coeliac disease, may I direct you to Fiona Moor’s article? Fiona shares with us how it is done in Southern Derbyshire and how the dietitian manages these clinics and patients. Last year, Carina Venter told us about paediatric food allergies. This month it’s the turn of adult food allergies. Such allergies have complex symptoms and it is important to diagnose and manage these well. Carina explains how, and reminds us that, from 12 December 2014, all major food allergens need to be clearly identified on food labels. And we have more too, as Jacqui Lowden looks at The nutritional qualities of goat milk as an alternative to cows’ milk in infant formulae. She concludes that ‘Goat milk infant formula, however, is not suit-able for infants with a cows’ milk protein allergy, unless directed by a healthcare professional’. I hope you enjoy reading this first of the next 100 issues of NHD!

NHDmag.com February 2015 - Issue 101 3

Chris ruddDietetic advisor

neil donnellyFellow of the bDa

ursula arenswriter, Nutrition & Dietetics

dr Carrie ruxtonFreelance Dietitian

dr emma derbyshireNutritionist, Health writer

dr anita Macdonaldconsultant Dietitian in IMD

kate Harrod-wildSpecialist Paediatric Dietitian

Jacqui LowdenPaediatric Dietitian

Lauren McCormackHealth Promotion Dietitian

tak ChinSpecialist registrar

Carina venter Phd, rdSenior Lecturer, University of Portsmouth

dr Justine Butler,Senior researcher and writer

Louise dickieSpecialist Stroke Dietitian

fiona MoorHead of Dietetic Services, royal Derby Hospital

6 News

15 Adult food allergy

23 Lactose intolerance

29 Dysphagia in stroke care

37 Coeliac disease

40 Book review

41 Subscribe to NHD Magazine

43 Infant feeding: dairy

48 Web watch

50 NHD app for easy download

52 dieteticJOBS

53 Events and courses

54 The final helping

9COVER STORYCOMMUNITY FOOD STRATEGY

editorial Panel

Contents

NHDmag.com February 2015 - Issue 1014

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dr emma derbyshire is a freelance nutritionist and former senior academic. her interests include pregnancy and public health.

NHDmag.com February 2015 - Issue 1016

news

NEw ‘SUPER’ REVIEwWhat we eat and drink can affect chronic disease risk, although studies are not al-ways consistent in their findings. Now, a new paper has pooled results from a substantial number of meta-analysis and systematic review papers, provid-ing evidence of the highest quality. The review included 304 papers published between 1950 and 2013. Find-ings showed that plant foods were par-ticularly effective at protecting against diet-related chronic diseases, especially grain products. Tea was also found to help protect against major chronic dis-eases risk, while soft drinks were found to be least protective. Finally, it should be considered that most of these papers focused on chronic diseases such as overweight/obesity, Type 2 diabetes, heart disease and can-cer. Other chronic diseases such as men-tal, skeletal and digestive health, were slightly under-represented and need to be studied further. For more information, see Fardet A & Boirie Y (2014). Nutrition Review Vol 72 (12), pg 741-62.

wHOLEGRAINS, FIBRE AND HEALTHThere is a growing body of new evi-dence looking at how wholegrains and fibre may help to support health. Now a new review has collated findings from latest research. The review published in Nutrition & Food Science gathered evidence from 49 scientific studies. Results from ob-servational studies showed that higher wholegrain and dietary fibre intakes were associated with a significantly lower risk of cardiovascular disease, diabetes, abdominal obesity and certain cancers. Equally, intervention studies suggested benefits for appetite control, digestive health, improved blood lipid levels and glycaemic control. Given these findings, Government and industry should work to help the public identify foods rich in wholegrains, e.g. breakfast cereals and dietary fibre (especially insoluble fibre) and commu-nicating the health benefits of these. For more information, see: Ruxton CHS & Derbyshire EJ (2014). Nutrition & Food Science Vol 44 (6), pg 492-519.

PREGNANCY, IRON AND CHILDHOOD wHEEzEIt is well known that low iron status in pregnancy can lead to anaemia in the mother and, if uncorrected, in the child. Now, a new study has looked at the role that iron has to play in relation to childhood wheeze. Scientists used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) study; a cohort of children born in the 90s. Informa-tion about iron intake, status and child health from 157 mother-child pairs was analysed. Higher serum Transferrin Recep-tor (TfR) levels (an indicator of re-duced iron status) were linked to in-creased wheeze while higher ferritin levels were linked to improved lung function.

These are interest-ing findings, suggest-ing that pregnancy iron status possibly has broader roles to play in child health. Further studies, ideally as randomised trials, are now needed. For more i n f o r m a -tion, see Nwaru BI et al (2014). British Journal of Nutrition Vol 112 (12), pg 2018-27.

NHDmag.com February 2015 - Issue 101 7

news

NEw IRISH wATER INTAkE DATAAround 60 percent of an adult’s bodyweight is water, performing key roles such as nutrient transport, waste removal and temperature regu-lation. Given this, new survey data in Ireland has now estimated daily water intakes. The Irish National Adult Nutrition Survey (NANS) analysed four-day semi-weighed food records from 1,500 free-living adults aged 18 to 90 years. Total water intake (i.e. drinking water plus water from other beverages, along with food moisture) was 2.3 litres per day, with 67 percent of water coming from beverages and 33 percent from foods. Overall, mean intakes and the proportions of water coming from foods and beverages were generally in line with European guidelines. How-ever, intakes were found to be lowest amongst the elderly, those with less education, of lower social class, who were less active, had a higher body mass index or level of body fat. These findings highlight the need to target these particular groups, helping to ensure that they drink enough water to support health. For more information, see: Connor LO et al (2014). Journal of Human Nutrition & Dietetics Vol 27 (6), pg 550-56.

LATEST ON OBESITY

Irregular eating is often linked to poor health but this has not been widely studied. A new study has now looked into this. Energy intake data was analysed from five-day estimated food diaries (n=1,768), forming part of the National Survey of Health and Development; one of Britain’s’ oldest cohort studies, collecting birth and health data from people born in 1946 to date. Results showed that energy intakes were highest between meals. Irregular energy intakes at breakfast and between meals were significantly associated with increased risk of metabolic syndrome (a clus-ter of metabolic and cardiovascular risk factors). Waist circumference was also significantly higher for those having irregular energy intakes at break-fast, at evening meals and on a day-to-day basis. A second study has also now looked into whether high-protein and low glycaemic index di-ets could be beneficial for weight management. The European DIOGENES study, a ran-domised controlled trial, recruited 256 overweight or obese adults (BMI >27kg/m2). Once they had taken part in an eight-week low-calorie diet they were allocated to five different ad libitum (eating in an uncontrolled environment) diets, each vary-ing in their protein content and glycaemic index. This took place over 12 months. When on the low-calorie diet, mean weight loss was 11.2kg (about 24.6lbs). Weight regained over the 12 months was significantly lower in the high-pro-tein compared with the low-protein diet group (2.0 versus 2.8kg). High and low glycaemic index diets did not affect levels of weight regained. Overall, irregular eating could have broader effects on metabolic profile and health, while high-protein diets appear to have a role in weight management. Further studies are now needed. For more information, see Pot GK et al (2014). International Journal of Obesity Vol 38, pg 1518-24 and Aller E et al (2014). Internation-al Journal of Obesity Vol 38, pg 1511-17.

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NHDmag.com February 2015 - Issue 101 9

Brighton & Hove Food Partnership is all about food - bringing together communi-ties, businesses, statutory agencies and in-dividuals, to help create a healthy, fair and sustainable food system across the city. In 2006, Brighton & Hove was one of the first cities in the UK to launch a food strategy, which encompassed sus-tainability, health, cooking and growing (1). Through working with a range of partners and community groups, over 90 percent of the aims outlined in the food strategy were achieved. Building on the success of this, Brighton & Hove is now delivering on the revised strategy ‘Spade to Spoon: Digging Deeper’ (2). It’s an action plan which sets out how the city intends to address health inequalities, reduce food poverty, support local food businesses

and reduce the environmental impact of the way we produce, consume and dis-pose of food. Meeting these aims is no mean feat. The challenges of obesity, food poverty, climate change and food waste are vast and the causes are multidimensional. The role of the Food Partnership is to coordinate the delivery of the food strat-egy. This includes bringing other organ-isations together, sharing best practice and encouraging partnerships, as well as directly delivering some services. The Food Partnership also holds a seat on a number of strategic boards in the city to help influence other local policies and strategies which have an impact on the food system. Twenty members of staff bring a range of expertise to the organisation,

imPLemeNtiNG A CommUNitY food StrAteGY ACroSS BriGhtoN & hoVe

Lauren McCormackHealth Promotion dietitian

Lauren specialises in weight management and is interested in the environmental impact of food and how sustainability messages can be incorporated into health promotion guidance.

The work of the Brighton & Hove Food Partnership in coordinating a community food strategy, which encompasses health, sustainability, cooking and food growing.

Cover story

Vision and aims of the food strategyA healthy, sustainable and fair food system for Brighton & Hove

• Residentseatahealthierandmoresustainablediet.

• Residentshavebetteraccesstonutritious,affordablesustainablefood.

• Thecityhasavibrantsustainablefoodeconomywithlocalbusinesses,local products and employment opportunities.

• Publicorganisationshavehealthy,ethicalandenvironmentallyresponsible foodprocurementpoliciesandpractices.

• Morefoodconsumedinthecityisgrown,producedandprocessedlocally usingmethodsthatprotectbio-diversityandrespectenvironmentallimits.

• Morepeopleengagedincommunalactivitiesaroundfood.

• Wastegeneratedbythefoodsystemisreduced,redistributed,reusedand recycled.

• Localandsustainablefoodispromotedandcelebratedbyresidentsand visitors.

• Highqualityinformation,supportandtrainingonsustainablefoodand nutritionissuesisreadilyavailableandtherearenetworkingopportunitiesto encourage links between sectors.

• Localplanningandpolicydecisionstakeintoaccountfoodissuesandthe city is engaged with national campaigns.

NHDmag.com February 2015 - Issue 10110

MaLnutrition

including dietitians; nutritionists; a food waste expert; community gardener; food poverty cam-paigners and community cooks. Each team de-liver specialist services, but cross-organisational working is fundamental.

CoMMunity nutrition teaMCommissioned by Public Health Brighton & Hove, the community nutrition team deliver a city-wide weight management service; led by registered dietitians and nutritionists. Adults are offered the opportunity to attend a series of one-to-one appointments, or to attend a community group programme ‘Shape Up’, which includes nutritional advice, behaviour change strategies and exercise. Specific groups have been designed for women post pregnancy, as well as a male only group which takes place at Brighton and Hove Albion football stadium. “My body confidence has increased and my cho-lesterol is going down, so thank you for the support and information.” - Shape Up participant. The Family Shape Up programme is a weight management programme for children aged six to 13 years old. Sessions emphasise practical, hands-on learning using specially designed games, visu-al demonstrations and activities. This is delivered in partnership with Albion in the Community - the charity branch of Brighton & Hove Albion Football Club. Combining their exercise exper-tise alongside The Food Partnership’s nutritional knowledge has proved to be highly effective; av-erage completion rates have been 80 percent since the programme began in 2013.

“I can move faster now and I have more energy and feel happier about myself.” - Family Shape Up participant, aged six. Another programme for children is Zip Zap which is a year-long after school club for five- to seven-year olds. Children learn the value of healthy eating, alongside games that encourage activity and movement. Once a term, parents and carers are invited to join in and learn new skills together. The topics extend beyond the usual healthy eating messages to include cook-ery, gardening and reducing food waste. Zip Zap is currently in its first year, but the intention is to roll it out to every primary school in the city. In addition to these programmes, the Food Partnership delivers Baby Buffet, Weaning Well and Eat Well workshops for a range of groups. The Food Partnership also offers training to support workers, early years’ providers and kitchen staff.

Cookery teaMThe cookery team run a range of courses and workshops across the city. Linking with the community nutrition team, ‘Shape Up in the Kitchen’ has been designed for adults with a BMI over 25kg/m2, who are looking to improve cookery skills and learn how to make healthier recipes. ‘Family Shape Up in the Kitchen’ is a cookery group for children and their parents, which encourages families to cook healthy meals together. Adults with learning disabilities can join the ‘Cooking Together Lunch Club’ which teaches

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basic cookery skills in a supportive environment; as well as improving confidence in the kitchen, this course also aims to promote independence. In collaboration with MIND, a cookery group for people who suffer with anxiety and depression was also successfully piloted earlier this year. In all cookery courses, healthy eating advice is incorporated with visits from one of the Food Partnership dietitians. Cookery leaders also provide participants with practical tips around cooking on a budget and reducing food waste. Ingredients used at the cookery courses meet the Food Partnership’s buying standards (which consider the environmental and local economic impact of ingredients). “I really enjoyed the ‘First Time Cook’ course. The friendliness of the staff and participants was fantastic and the actual practical side of the cooking was fun! I am looking forward to making these recipes at home to improve my eating habits.” - First time cook participant. The cookery team run ‘Pick and Cook’ ses-sions which take place at community growing projects. These are open to all members of the public and aim to connect people with where food comes from and how it is produced. They are also designed to inspire people to cook local, seasonal produce and spend more time outdoors.

sHaring tHe Harvest ProJeCtThe health benefits of gardening and food grow-ing are well documented (3). A growing body of evidence now recognises the impact of gar-dening on improving both physical and mental wellbeing (4-12). The work carried out by our Harvest team over the past four years has helped triple the number of community gardens from 25 to 75 and there are now over 4,000 residents in-volved in community gardening across Brighton & Hove. Be it to increase activity levels, spend more time outdoors, learn new skills or meet new peo-ple, volunteering at a community garden brings lots of benefits. The Food Partnership has recent-ly been awarded £500,000 from the Big Lottery to support people with learning disabilities, or those with experience of homelessness, mental health issues, abuse and addiction to access gar-dening to improve their health and wellbeing. Services are evaluated using the ‘five ways to wellbeing’ model, an evidenced based ques-

tionnaire developed by the New Economics Foundation (13). A recent evaluation found that since joining a community garden, 44 percent of volunteers reported wasting less food and 36 percent of volunteers reported buying more lo-cal food. Further benefits were acknowledged by those who identified themselves as having a mental health problem or learning difficulty: 48 percent reported improved mental wellbeing, 35 percent reported improved physical health and 38 percent reported improved confidence and social skills since joining a community garden. “You probably don’t realise how much the orchard has changed my life. Just being able to go to a group where people understand your problems and you don’t have to explain anything. Just to have a group of sup-portive and understanding people around you. I can’t believe that I hadn’t even noticed that my (anxiety and depression) issues had gone away so quickly!”

Love food Hate waste CaMPaignFood waste is a big issue in the UK and in Brigh-ton & Hove food makes up 35 percent of the city’s domestic waste. The Food Partnership co-ordinates the Love Food Hate Waste programme and speaks to hundreds of people each year through public outreach workshops and com-munity events. An example of successful partnership working between the Food Partnership, Brighton & Hove City Council and members of the community, is the Community Composting scheme, set up to di-vert domestic food waste from landfill. There are now 1,000 households taking part and a network of 30 neighbourhood compost sites across the city. “Some people might argue that our contribution to-wards reducing waste is a drop in the ocean, however, I think it is amazing to see how much waste 30 households can turn into a useful resource.” - Community composter. Food waste reduction messages are threaded throughout all of the Food Partnership servic-es - from meal planning tips and advice about healthy portion sizes to practical cookery skills.

ProJeCtsCoordinating the food plan involves working with a range of organisations and lobbying for change. This includes working with large cater-ers to establish healthy and environmentally re-sponsible food procurement policies and practic-

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es. A real milestone was reached this year when Brighton & Hove City Council agreed to intro-duce minimum buying standards for all their catering contracts (including primary schools). The standards cover animal welfare, nutritional content and the use of local, seasonal produce. Food Poverty is another growing campaign area for the Food Partnership and it recently sub-mitted evidence to the All Parliamentary report Feeding Britain. There has been a sharp increase in food poverty both locally and nationally (14). One major concern is that people experiencing food poverty are more likely to skip meals and compromise nutritional intake. To support people experiencing financial hard-ship, the Food Partnership runs ‘Eating well on a budget’ sessions. For workers and volunteers, the Food Partnership offers food poverty awareness training which teaches people how to recognise food poverty, as well as providing advice on sign-posting individuals to emergency food aid and support with underlying financial issues. The Food Partnership also helps co-ordinate a food bank net-work, which helps bring together groups across the city working to support people in hunger.

“I just wanted to say that I found the training session re-ally insightful and in depth. I went into the session know-ing very little about food poverty, its causes and options that are out there, but I left with a breadth of new knowl-edge.” - Food poverty awareness session attendee.

Having seen an increase in the number of food banks in the city from two to 12, the City Council has just committed to an action plan on food poverty in 2015.

ConCLusionWith increasing populations and finite resources, considering sustainability of the food system is be-coming paramount. Looking at how we produce, consume and dispose of food as a community and working together on all aspects of the food chain is an effective way to promote healthier choices for the individual and for the planet. In short, food issues cannot be looked at in isolation. With great challenges ahead, such as rising obesity levels and food poverty, it’s now more important than ever to take a joined-up ap-proach to food. The work in Brighton & Hove shows how useful and important a focus on food can be, in dealing pressing social, economic and environmental challenges. Inspired by Brighton & Hove’s pioneering model, many UK cities have now adopted their own unique food strategies, and the launch of the national Sustainable Food Cities network in 2013 is helping bring this thinking into the mainstream. There is still plenty of work to do, but significant groundwork has been done. If we continue to look for practical solutions, share best practice and keep these messages high on the political and personal agenda, we can help make change happen.

references1 Spade to Spoon. brighton & Hove Food Partnership. available online at: http://bhfood.org.uk/downloads/downloads-publications/19-spade-to-spoon-strategy-

2003/file2 Spade to Spoon: Digging Deeper. a food strategy and action plan for brighton & Hove. brighton & Hove Food Partnership. available online at: http://bhfood.org.uk/

downloads/downloads-publications/18-spade-to-spoon-strategy-2012-print/file3 Garden Organic and Sustain (2014). the benefits of gardening and food growing for health and wellbeing. ISbN: 978-1-903060-60-5. Sustain, UK. available online

at: www.sustainweb.org/publications/?id=2934 alaimo K, Packnett e, Miles r, Kruger D (2008). Fruit and vegetable intake among urban community gardeners. Journal of Nutrition education and behaviour, 40(2),

94-1015 Hawkins Ja, thirlaway KJ, backx K and clayton Da (2011). allotment gardening and other leisure activities for stress reduction and healthy aging. Horttechnology,

21(5) 557-5856 Mccormack La, Laska MN, Larson NI and Story M (2010). review of the nutritional implications of farmers’ markets and community gardens: a call for evaluation

and research efforts. J am Diet assoc,110 (3), 399-4087 Nelson JM, erens b, bates b, church S and bosher t (2007). Low income diet and nutrition survey. Volume 3 Nutritional status, physical activity, economic, social

and other factors. London: Food Standards agency, the Stationary Office, UK8 Sempik J and aldridge J (2005). Health, wellbeing and social inclusion: therapeutic horticulture in the UK. Loughborough University Institutional repository. ccFr

evidence Papers. Issue 119 Sempik J, aldridge J and becker S (2003). Social and therapeutic Horticulture: evidence and messages from research. thrive, in association with the centre for

child and Family research, Loughborough University10 Stigsdotter Ua and Grahn P (2004). a garden at your workplace may reduce stress. In: Dilani, a (ed.), Design and Health III - Health Promotion through

environmental Design, research centre for Design and health, Stockholm, Sweden, 147-157.11 ratcliffe MM, Merrigan Ka, rogers bL and Goldberg JP (2011). behaviours associated with vegetable consumption. the effects of school garden experiences on

middle school-aged students’ knowledge, attitudes and behaviours associated with vegetable consumption. Health Promotion Practice, 12,1, 36-4312 Zick cD, Smith Kr, Kowaleski-Jones L, Uno c, and Merrill b (2013). Harvesting more than vegetables: the potential weight control benefits of community

gardening. american Journal of Public Health, 103(6), 1110-111513 New economics foundation (2011). Five ways to wellbeing. New applications, new ways of thinking. written by Sam thompson and Jody aked. commissioned

jointly by the National Mental Health Development Unit (NMHDU) and the NHS confederation, nef, London, UK14 cooper N and Dumpleton S (2014). walking the breadline: the scandal of food poverty in 21st-century britain. Oxfam and church action on Food Poverty, UK. ISbN

978-1-78077

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In clinical practice, the offending food(s) causing IgE-mediated food allergy can of-ten be identified by taking a careful clinical history. Important elements of the history include the type of food involved, quantity of food ingested, time between ingestion to reaction, symptoms/signs of the reaction, other occasions when similar reactions oc-curred, time since last reaction and other factors involved (e.g. exercise). In complex cases, a food-symptom diary may be re-quired as an adjunct to the history. The usual first-line diagnostic tests, routinely used in conjunction with the clinical history, to establish the diag-nosis of IgE-mediated food allergy, are skin prick tests (SPT) (which can be performed with commercially-prepared standardised solutions of food allergen extracts, or with fresh foods (prick-to-prick (PTP) testing) and serum specific IgE (sIgE) to food allergens. SPT is generally preferred as it offers a quick and reproducible method for detect-ing IgE sensitisation. Although it is a safe procedure, severe and fatal anaphylactic reactions have been reported in those with highly severe allergies (1). It is, therefore, recommended that SPT is performed by experienced personnel in an appropriate setting with access to emergency medica-tions and equipment. sIgE offers an in vitro method for quantifying IgE sensitisation and may be useful when SPT is not pos-sible (e.g. limited skin surface for SPT, der-matographism, suppressed skin reactivity due to antihistamines, needlephobia). Sensitivity and specificity varies de-pending on the food, as well as other fac-tors (e.g. allergen extract, commercial test system, age of the patient). In general, a negative SPT result has an excellent nega-

tive predictive value, while a positive SPT result only indicates the possibility of symptomatic IgE-mediated food allergy. One exception to this is IgE-mediated food allergy to certain fruits/vegetables (par-ticularly those associated with pollen-food allergy syndromes), which may sometimes not be detected using commercially-pre-pared extracts/reagents due to the labile nature of the allergenic epitope involved. For some of the common major food allergens (e.g. hen’s egg, cows’ milk, pea-nut), decision points based on SPT size and also sIgE titre cut-off values have been described which have a >95 percent positive predictive value for IgE-mediated food allergy. However, decision points have not been successfully established for other major food allergens (e.g. soy, wheat) and the less common food allergens. A potential issue with both SPT and sIgE is the possibility of cross-reactivity to common allergenic epitopes in related foods, unrelated foods and pollens which may result in false positives to food aller-gens that are not clinically relevant. For certain foods - component- resolved diagnostics (CRD) - which in-volves the measurement of sIgE against purified individual proteins within the food - may be useful in determining the risk of severe allergic reactions. Numer-ous food proteins have been identified and knowledge of their allergenic significance continues to evolve. In general, sensitisation to seed storage proteins and non-specific lipid transfer proteins (nsLTP) is usually associated with a higher risk of severe allergic reactions. In contrast, sensitisation to Bet v 1-related PR-10 proteins is usually associated with mild allergic reactions to fruits and vegetables

diAGNoSiS of ige-mediAted food ALLerGY iN AdULtS

tak Chinspecialist registrar in allergy Medicine, southampton general Hospital

dr tak Chin is a Specialist registrar in Allergy medicine at Southampton General hospital

Adult food allergy presents with a range of complex symptoms. A good diagnostic work-up is required, followed by appropriate dietetic advice.

aduLt food aLLergy

Carina venter Phd, rdsenior Lecturer, UniversityofPortsmouth

As well as being a Senior Lecturer at the University of Portsmouth, Carina is an Allergy Specialist dietitian with the david hide Asthma and Allergy research Centre on the isle of Wight. She is also a food Allergy module Leader at the University of Southampton.

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due to cross-reactivity with birch pollen. For exam-ple, the seed storage protein Ara h 2 has a very high positive predictive value for severe allergic reac-tions to peanut (2). The other seed storage proteins Ara h 1 and Ara h 3 have also been associated with severe reactions - severe reactions, however, have been described in patients who are negative to these allergens (3). Exceptions have been reported where Bet v 1-related PR-10 proteins have been associated with severe allergic reactions (e.g. Gly m 4 in soy al-lergy) (4). Furthermore, sensitisation patterns may be different for populations in different countries - a study evaluating CRD in European patients with severe allergy to hazelnuts demonstrated that sensi-tisation was mainly to the major hazelnut allergen Cor a 1.04 (Bet v 1-related PR-10 protein) in Switzer-land and Denmark, whereas it was mainly to Cor a 8 (nsLTP) in Spain (5). More recently, Cor a 9 and Cor a 14 (seed storage proteins) have been shown to be associated with severe allergy to hazelnuts in a Dutch population (6). CRD appears to be useful in the more unusual clinical manifestations of IgE-mediated food allergy - such as when used in selected cases where wheat-dependent exercise-induced anaphylaxis (WDEIA) is suspected (e.g. omega-5 gliadin (Tri a 19))(7) and in the evaluation of delayed anaphylaxis to red meat (e.g. galactose-α-1,3-galactose (α-gal)) (8). At the time of writing, a systematic review assessing the diagnostic accuracy of SPT, sIgE and CRD in supporting the clinical diagnosis of IgE-mediated food allergy is under way (9). Oral food challenges (OFCs) may be neces-sary to establish the diagnosis of IgE-mediated food allergy or to determine the clinical relevance of SPT, sIgE and/or CRD results. The double-blinded placebo-controlled food challenge (DBP-CFC) is considered the ‘gold standard’ diagnostic test. OFCs can also be performed single-blinded or open. However, the potential risk of severe al-lergic reactions, as well as the time-consuming and resource-intensive nature of the procedure, limits their use. International consensus and standards have been developed to standardise various aspects of DBPCFCs to allow comparison between research studies (10). These variables in-clude pre-challenge assessment, safety measures, type/quantity of the food allergen to be adminis-tered, timings between doses, intra-challenge as-sessment, managing subjective symptoms, objec-

tive criteria for a positive challenge, observation periods and outcome reporting. Elimination diets are not usually diagnostic of food allergy on their own - while resolution of symptoms during an elimination diet supports a diagnosis of food allergy, this may be accounted for by other factors and so OFC should be performed to confirm the diagnosis. Elimination diets may be performed in several ways: (i) elimination of one or several suspected foods, (ii) elimination of all except a defined group of foods and (iii) elemental diet (e.g. hydrolysed formula, amino acid-based formulas). The basophil activation test (BAT) appears to be a promising area of future development for diagnostic tests in food allergy with one recent study demon-strating that it can significantly reduce the require-ment for OFC to peanut (11, 12, 13). However, this test is not yet routinely available in clinical practice. A number of unproven tests are often used by complementary/alternative medicine practitioners (e.g. Vega testing, hair analysis, iridology, kinesiol-ogy, specific IgG/IgG4, cytotoxic test) and cannot be recommended for diagnosing food allergy.

diagnosis of non-ige-Mediated food aLLergy in aduLtsThe principles behind the diagnosis of non-IgE-mediated food allergy do not significantly differ from those for IgE-mediated food allergy - the main difference is that clinical history, SPT and sIgE often do not correlate as well in non-IgE-mediated food allergy due to the immune mechanisms involved. As a result, elimination diets and modified OFCs (tailored to the individual and clinical reaction) are required more often in order to demonstrate if a sus-pected food is clinically relevant. This is particularly the case in atopic eczema/dermatitis (AE) where multiple IgE sensitisation without proven clinical relevance is commonly seen. Reactions to classical food allergens (e.g. hen’s egg, cows’ milk) in adulthood are not as common as in childhood (17) - adult studies have shown that foods cross-reactive to birch pollen can worsen AE (18, 19). Three different reaction patterns may be seen in food-induced AE: (i) non-eczematous reactions (usually IgE-mediated causing pruritus, urticaria, flushing but also other immediate-type gastrointes-tinal, respiratory or anaphylactic symptoms); (ii) ec-zematous delayed reactions (usually after hours to

days) and (iii) combination of early non-eczematous and eczematous delayed reactions. It is, therefore, recommended that the skin should be evaluated after 24 hours and later ideally using a validated score (e.g. SCORAD, EASI) fol-lowing OFC for AE, as otherwise delayed reactions may be missed. It is also recommended that OFC is preceded by a diagnostic elimination diet of sus-pected food items over a period of up to four to six weeks (rather than the usual two to four weeks for IgE-mediated symptoms). Full details discussing the diagnostic approach in eczematous reactions to foods in AE are available in a position paper (20). Atopy patch testing (APT) may be considered as an additional diagnostic test in suspected food-induced AE. However, they are not in widespread clinical use since standardised reagents, methods for performing APTs and interpretation of their re-sults have not been established. The use of APT has been evaluated (primarily in children), but did not result in a significant reduction in OFCs required where food-induced AE was suspected (21) - as a result, APT is not generally recommended for the routine diagnosis of food-induced AE. For non-IgE-mediated gastrointestinal food al-lergies, a consensus diagnostic guideline is avail-able for eosinophilic oesophagitis (EoE), which the most common form of eosinophilic gastrointesti-nal disease (EGID) (22). The diagnostic criteria for EoE includes: (i) clinical symptoms related to oe-sophageal dysfunction and exclusion of secondary causes of oesophageal eosinophilia, (ii) eosinophil-predominant inflammation on oesophageal biopsy (≥15 eosinophils per high-power field; two to four biopsies should be obtained from both the proximal and distal oesophagus), (iii) mucosal eosinophilia isolated to the oesophagus which persists after a proton pump inhibitor trial and (iv) a response to treatment such as dietary elimination or topical cor-ticosteroids can further support the diagnosis.

The diagnostic approach to identifying the causative food(s) in patients with EoE is challeng-ing. The usual strategy for this involves two phases: the elimination phase(s) of four to six weeks (rather than the usual two to four weeks for IgE-mediated symptoms) followed by the reintroduction phase(s). The general principle behind this is to initially in-duce resolution (of symptoms and ideally also oe-sophageal eosinophilic inflammation on histology) through the elimination phase, so that causative and non-causative food(s) can be identified when they are re-introduced - a food is considered causative if it results in recurrence of the above. The main elimi-nation strategies may be broadly categorised as fol-lows: (i) elemental diet free of food allergens (e.g. complete liquid amino-acid based formula); (ii) em-piric food elimination diet which excludes the most common causative foods allergens (e.g. six food elimination diet: dairy, soya, eggs, wheat, peanuts, fish/shellfish) and (iii) targeted elimination which removes food allergens based on history and the re-sults of allergy testing (e.g. SPT, sIgE, APT). Food protein-induced enterocolitis syndrome (FPIES) was previously thought to occur primarily in infants and young children only - however, it has been reported to also occur in adults (with the pre-dominant trigger being shellfish) (23). As with the other non-IgE-mediated food aller-gies, SPT and sIgE are often negative and so OFC re-mains the only diagnostic test and is considered the gold standard. There is currently no standardised protocol for OFC for FPIES - however, this is usu-ally done by experienced personnel as an open chal-lenge with a long observation period after the last dose (minimum four to six hours) in a facility that can manage dehydration and allergic reactions. Pre- and post-challenge (six hours) blood samples for complete full blood count with differential counts can be taken to look for an increase in peripheral blood neutrophil counts - this has been proposed as

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The cornerstone in the management of food allergies in adults, requires avoidance of the offending food and prescription of emergency mediation when required.

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one of the major criteria for a positive challenge in acute FPIES. However, in clinical practice, the diagnosis of FPIES is often made on the basis of a suggestive clinical history and resolution of symptoms on elimination of the causative food. APT in FPIES has been evaluated in children (24, 25) - at pres-ent APT is not recommended for routine diagno-sis of FPIES. For completeness, coeliac disease (CD) is technically classified as a non-IgE-mediated food allergy - the diagnosis of CD is primarily by serol-ogy (e.g. specific endomysial antibodies (EMA/AEA), IgA anti-tissue transglutaminase antibod-ies (IgA-TG2/a-TTG/TTA), deamidated anti-gliadin antibodies (IgA-DGP or IgG-DGP); IgG-TG2 is primarily useful in patients with known IgA deficiency) and duodenal biopsy when the patient is on a normal (gluten-containing) diet. It may also involve HLA testing (e.g. HLA-DQ2, HLA-DQ8 haplotype). The diagnostic algorithm for CD in adults is available in a guideline (26). Dermatitis herpetiformis is a related cutaneous condition associated with CD - diagnosis is by skin biopsy and demonstrating the presence of granular IgA deposits in the dermal papillae of uninvolved perilesional skin as shown by direct immunofluorescence (27).

ManageMent of aduLt food aLLergiesThe cornerstone in the management of food al-lergies in adults, requires avoidance of the of-fending food and prescription of emergency me-diation when required.

DietaryavoidanceissuesAvoidance of allergenic foods can be complex, leading to nutritional deficiencies and can affect

quality of life. Ideally, all adults presenting with a suspected or proven food allergy, should be re-ferred for a dietetic consultation (28). A dietitian can provide individualised advice regarding the foods that should be avoided, the level of avoid-ance required and suitable substitute foods (29, 30). In addition, advice on required nutritional supplements can be provided. Advice on a range of lifestyle issues, such as shopping, eating at school or in the workplace, socialising and eat-ing out and going on holiday will also be pro-vided (31, 32). A challenging factor in dealing with patients with FHS is to establish each patient’s tolerance level or degree of avoidance required. This will mainly be determined by the type of food allergy the patient is suffering from and the underlying mechanisms. Some people with food allergies, particularly those which are IgE mediated, need to completely avoid an allergic food - even in trace amounts. Others may be able to include small amounts of the food in their diet with no adverse effects. There are no clear guidelines for avoidance levels, but some patients may be aware of their own tolerance levels by trial and error. It is also known that some individuals be-come tolerant to baked forms of milk and egg, whilst they may still be allergic to less cooked forms. The level of avoidance required should, therefore, also be reviewed at regular intervals. In terms of fruit of vegetables and nuts, it is also important to understand if the patient is suffering from a primary fruit, vegetable and nut allergy, or if the patient is suffering from a cross-reaction to pollens such as birch and grass. For those with primary food allergies, strict avoid-

ance may be required, whereas those suffering from aero-allergen cross reactive reactions, often tolerate cooked versions of the food. In terms of avoiding the major food allergens, EU labelling covers all the major food allergens, which, as from 12 December 2014, all need to be clearly identified on food labels in either bold, un-derlined or italic type. The major food allergens include: • Cereals containing gluten (i.e. wheat, rye,

barley, oats, spelt, kamut or their hybridised strains) and products thereof

• Crustaceans and products thereof• Eggs and products thereof• Fish and products thereof• Peanuts and products thereof• Soybeans and products thereof• Milk and products thereof (including lactose)• Nuts i.e. Almond (Amygdalus communis L.),

Hazelnut (Corylus avellana), Walnut (Juglans regia), Cashew (Anacardium occidentale),Pecan nut (Carya illinoiesis (Wangenh.) K. Koch), Brazil nut (Bertholletia excelsa), Pistachio nut (Pistacia vera), Macadamia nut and Queen-sland nut (Macadamia ternifolia) and products thereof

• Celery and products thereof• Mustard and products thereof• Sesame seeds and products thereof• Sulphur dioxide and sulphites at concentra-

tions of more than 10mg/kg or 10mg/litre expressed as SO2.

• lupin and products thereof• Molluscs and products thereof.

In the UK, The Food Standards Agency have information available on their website: www.food.gov.uk

May contain labellingManufacturers often use phrases such as ‘may contain nut traces’ or ‘made on a production line using soya and milk’ or ‘produced on a line handling egg’ to show that there could be accidental traces of another food in a manu-factured product, from the production pro-cess. This labelling is completely voluntary and, therefore, not legally binding, but many manufacturers choose to label their products in this way.

Current advice from the BDA Food Aller-gy and Intolerance Support group, regarding the management of precautionary labelling in those with more severe food allergies or nut allergies: (taken directly from the FAISG Nut avoidance diet sheet): It is important to take these warnings seriously and consider the following points:• Just because a particular food with a nut warning

has been eaten safely in the past, does not mean that it will always be safe; it may contain nut traces next time. Recipes and manufacturing processes can change.

• All nut warnings should be treated with the same level of risk regardless of the wording used.

• Patients may be more sensitive to nut protein if they are unwell, have been doing strenuous exercise or drinking alcohol, so having a nut trace during these times is more risky.

• Chocolate and chocolate covered items pose a higher risk of nut contamination because chocolate dripping off one product may be used on another during manufacturing. Therefore, chocolate with nut warnings should always be avoided (lists of peanut free or all nut free products are available from chocolate manufacturers).

The safest approach is to avoid all foods with ‘may contain’ nut warnings. However, if a food with a nut warning is to be eaten, the following advice should always be followed:1. Always have in-date emergency medication to

hand.2. Be within easy reach of a phone or mobile that

has charge and reception.3. Only eat if someone is with you who can help if

a reaction occurs.4. Avoid if in a remote location, far from emergency

services.5. Avoid if unwell or asthma is not well

controlled.6. Avoid after strenuous exercise or drinking

alcohol.7. Avoid if previously had an anaphylactic reaction

to nut traces or ‘may contain’ products.

Discuss your approach to managing ‘may con-tain nut’ products with your dietitian or allergy team, as they can give you specific advice.

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suMMaryIn summary, the manifestations of food allergy in adults in varied diagnosis can be complex and any tests performed should be interpreted by a competent clinician. The management of adult food allergy will necessitate a referral to a dietitian in most cases. Important information can be provided during a dietary consultation such as foods to avoid, suitable foods to eat, supplementation of nutrients, label reading and lifestyle advice.

Sensitivity(‘truepositiverate’)=thepercentageofsickpeoplewhoarecorrectlyidentifiedashavingthe condition

Specificity(‘truenegativerate’)=thepercentageofhealthypeoplewhoarecorrectlyidentifiedasnothavingthecondition

Positive predictive value (PPV)=probabilitythatthediseaseispresentwhenthetestispositive

Negative predictive value (NPV)=probabilitythatthediseaseisnotpresentwhenthetestisnegative

references1 bernstein DI, wanner M, borish L et al. twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. JacI 2004; 113: 11292 Klemans rJb, Otte D, Knol M et al. the diagnostic value of specific Ige to ara h 2 to predict peanut allergy in children is comparable to a validated and

updated diagnostic prediction model. JacI 2013; 131: 1573 Nicolaou N, custovic a. Molecular diagnosis of peanut and legume allergy. current Opinion in allergy & clinical Immunology 2011; 11: 2224 berneder M, bublin M, Hoffmann-Sommergruber K et al. allergen chip diagnosis for soy-allergic patients: Gly m 4 as a marker for severe food-allergic

reactions to soy. International archives of allergy & Immunology 2013; 161: 2295 Hansen KS, ballmer-weber bK, Sastre J et al. component-resolved in vitro diagnosis of hazelnut allergy in europe. JacI 2009; 123: 11346 Masthoff LJN, Mattsson L, Zuidmeer-Jongejan L et al. Sensitisation to cor a 9 and cor a 14 is highly specific for a hazelnut allergy with objective symptoms in

Dutch children and adults. JacI 2013; 132: 3937 Morita e, Matsuo H, chinuki Y et al. Food-dependent exercise-induced anaphylaxis-importance of omega-5 gliadin and HMw-glutenin as causative antigens

for wheat-dependent exercise-induced anaphylaxis. allergology International 2009; 58: 493-88 commins SP, Platts-Mills ta. anaphylaxis syndromes related to a new mammalian cross-reactive carbohydrate determinant. JacI 2009; 124: 6529 Soares-weiser K, Panesar SS, rader t et al. the diagnosis of food allergy: protocol for a systematic review. clinical and translational allergy 2013; 3: 1810 Sampson Ha, Gerth van wijk r, bindslev-Jensen c et al. Standardising double-blind, placebo-controlled oral food challenges: american academy of allergy,

asthma & Immunology-european academy of allergy and clinical Immunology PractaLL consensus report. JacI 2012; 130: 126011 Sato S, tachimoto H, Shukuya a et al. basophil activation marker cD203c is useful in the diagnosis of hen’s egg and cows’ milk allergies in children.

International archives of allergy & Immunology 2010; 152: 5412 Glaumann S, Nopp a, Johansson SG et al. basophil allergen threshold sensitivity, cD-sens, Ige-sensitisation and DbPcFc in peanut sensitised children.

allergy 2012;67:242–24713 Santos aF, Douiri a, bécares N et al. basophil activation test discriminates between allergy and tolerance in peanut-sensitised children. JacI 2014; 134: 645-

65214 Muraro a, werfel t, Hoffmann-Sommergruber K et al. eaacI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. allergy 2014;

69: 100815 boyce Ja, assa’ad a, burks aw et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIaID-sponsored

expert panel. JacI 2010; 126: S116 chafen JJ, Newberry SJ, riedl Ma et al. Diagnosing and managing common food allergies: a systematic review. JaMa 2010; 303: 184817 werfel t, ahlers G, Schmidt P et al. Milk-responsive atopic dermatitis is associated with a casein-specific lymphocyte response in adolescent and adult

patients. JacI 1997; 99: 12418 reekers r, busche M, wittmann M et al. birch pollen related food trigger atopic dermatitis with specific cutaneous t-cell responses to birch pollen antigens.

JacI 1999; 104: 46619 worm M, Forschner K, Lee H et al. Frequency of atopic Dermatitis and relevance of Food allergy in adults in Germany. acta Dermato Venereoligica 2006;

86: 11920 werfel t, ballmer-weber b, eigenmann Pa et al. eczematous reactions to food in atopic eczema: position paper of the eaacI and Ga2LeN. allergy 2007; 62:

72321 Mehl a, rolinck-werninghaus c, Staden U et al. the atopy patch test in the diagnostic workup of suspected food-related symptoms in children. JacI 2006;

118: 92322 Liacouras ca, Furuta Gt, Hirano I et al. eosinophilic esophagitis: updated consensus recommendations for children and adults. JacI 2011; 128: 323 Fernandes bN, boyle rJ, Gore c et al. Food protein-induced enterocolitis syndrome can occur in adults. JacI 2012; 130: 119924 Fogg MI, brown-whitehorn ta, Pawlowski Na et al. atopy patch test for the diagnosis of food protein-induced enterocolitis syndrome. Pediatric allergy &

Immunology 2006; 17: 35125 Jarvinen KM, caubet Jc, Sickles L et al. Poor utility of atopy patch test in predicting tolerance development in food protein-induced enterocolitis syndrome.

annals of allergy, asthma & Immunology 2012; 109: 22126 Ludvigsson JF, bai Jc, biagi F et al. Diagnosis and management of adult coeliac disease: guidelines from the british Society of Gastroenterology. Gut 2014;

63: 121027 Seah PP, Fry L. Immunoglobulins in the skin in dermatitis herpetiformis and their relevance in diagnosis. br J Dermatol 1975;92:157-6628 Venter c and Meyer r. allergic disease: the challenges of managing food hypersensitivity. Proceedings of the Nutrition Society 2010, 69, 11-2429 Mackenzie H, Grundy J, Glasbey G, Venter c. Information and support from dietary consultation for mothers of children with food allergies. accepted for

publication annals of asthma, allergy and Immunology. 201430 Maslin K, Meyer r, reeves L, Mackenzie H, Swain a, Stuart-Smith w, Loblay r, Groetch M & Venter c. Food allergy competencies of dietitians in the United

Kingdom, australia and United States of america. clinical and translational allergy (accepted. awaiting publication)31 Skypala IJ, Venter c (2009). Food Hypersensitivity. Oxford. wiley blackwell32 wright t (2006). Food allergies. class Publishing

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NHDmag.com February 2015 - Issue 101 23

Milk is frequently referred to as a fun-damental component of a healthy diet. Why is this? Is milk the only source of some essential nutrient, or is milk unique in that it contains all the nutri-ents that we require? No other animal on the planet continues to drink milk beyond weaning and, not just that, drinking milk taken from another spe-cies that is often pregnant. This unusual practise has become a concern for some scientists.

tHe origins of dairy farMingSheep, cattle and goats were domesti-cated in parts of the Middle East and central Asia over 9,000 years ago, but it is thought that the use of animals for milk was not practiced until between 6,000 to 8,000 years ago in Asia Minor or Turkey (1). Although this sounds like a long time ago, in evolutionary terms it is very recent history. Hominid (mod-ern human) fossils date back to nearly seven million years ago. If this is rep-resented as a 12-hour clock, starting at midday, humans would have started dairy farming less than one minute be-fore midnight!

dairy farMing todayLike humans, cows don’t produce milk unless they have recently given birth. However, the modern dairy cow is rou-tinely impregnated whilst she is still producing milk (this ensures that the

milk yield is kept high). At least two-thirds of cows’ milk in the UK is taken from pregnant cows (2). This inevitably affects the levels of hormones found in milk. There are 35 hormones and 11 growth factors in milk (3). Some scien-tists are particularly concerned about the oestrogen content of cows’ milk (4), suggesting that cows’ milk is one of the important routes of human exposure to oestrogens. Milk production is big business, es-timated to be worth £3.8 billion in the UK (5). Although the numbers of dairy cows in the UK have fallen year by year, the milk yield has continued to rise. Over the last 10 years, selective breeding and high protein feed has increased the yield per cow from just under 18 litres per day to over 20 litres per day. The in-crease in milk yield far offsets the fall in the number of dairy cattle (6). There is a clear trend; fewer cows are being forced to produce more milk, what the cost is to human health remains to be seen.

wHat Lies BeneatH…?The composition of mammalian milk reflects the requirements of the species producing it, be it buffalo, badger, dog or rat - the best milk for them is that of their own species. While whole cows’ milk contains four percent fat, milk from the grey seal contains over 50 percent fat because seals need a lot of body fat to survive in cold water (7). Whole cows’

dr Justine Butler,senior researcher and writer

dr Justine Butler is a Senior researcher and Writer at Viva!Health. Justine holds a Phd in molecular Biology, BSc Biochemistry and diploma in Nutrition. She has published an extensive list of reports, guides and factsheets for Viva!Health and written many articles for health journals, regional and national press.

This article looks at the history of milk consumption, evolution and lactose intolerance. The links between dairy and a range of other illnesses are examined along with the role cows’ milk in bone health.

LaCtose intoLeranCe

rethiNKiNG CoWS’ miLK: iS it reALLY Good for US?

for article referencespleaseemail:info@networkhealth group.co.uk

NHDmag.com February 2015 - Issue 10124

LaCtose intoLeranCe

milk contains nearly a third more saturated fat, twice as much protein and four times as much calcium as human milk which makes it ideal fuel for the rapid growth of new born calves. Human babies grow much slower, but brain develop-ment is rapid, so breast milk contains five times as much polyunsaturated fat as cows’ milk. Milk also carries important chemical ‘messenger’ mol-ecules that instruct the infant’s immune systems. These features have evolved over thousands of years and are vital in terms of health and disease. Some of the consequences of consuming cows’ milk (and, therefore, signalling hormones) with a nutrient balance not well-suited to human bio-chemistry are only just becoming apparent.

aCneDespite the general dismissal of diet as a pos-sible factor underlying the development of acne, a substantial body of evidence demonstrates how certain foods (especially cows’ milk) may adversely influence hormones and cytokines that influence the causes of acne (8). Research suggests that the hormones in milk (or compo-nents of milk that increase hormone levels) can indeed cause acne in some people (9, 10, 11). Whey protein supplements, favoured by body-builders, have also been found to increase the risk of acne (12, 13). Because of this, when taking history from teenage males suffering with acne, the use of whey protein supplements should be screened for.

aLLergiesFood allergy is increasingly widespread and the most common of these is cows’ milk allergy, af-fecting around two percent of infants under the age of one. Symptoms include excessive mucus production resulting in a runny nose and blocked ears. More serious symptoms include asthma, eczema, colic, diarrhoea and vomiting. Food al-lergies cause around five percent of all asthma cases (14) and 10 percent of eczema cases (15).

The most common foods that trigger allergies are cows’ milk and eggs (16). A hypersensitivity reaction to milk proteins can also cause gastro-intestinal bleeding in infants (17). This can lead to iron deficiency anaemia in infants and young children. Cows’ milk-induced gastrointestinal bleeding affects about 40 percent of otherwise healthy infants (18). The only reliable treatment for cows’ milk allergy is to avoid all exposure to cows’ milk proteins. This means avoiding all cows’ milk and dairy products, including: milk, milk powder, milk drinks, cheese, butter, marga-rine, yoghurt, cream and ice cream.

artHritisThe possible effects of diet on the symptoms of arthritis are often overlooked too. While certain foods, such as milk products and food colouring (19), may make the symptoms of rheumatoid ar-thritis worse for some people, a vegan diet may help, possibly because of the types of polyunsat-urated fats included in the diet (20). Indeed, both gluten-free and low-fat vegan diets have been shown to help combat the symptoms of arthritis (21, 22). Chemicals called sulforaphanes (found in cruciferous vegetables such as broccoli, Brus-sels sprouts or cabbage) have anti-inflammatory properties that could help protect against the cartilage damage that occurs in osteoarthritis (23). These effects are certainly worth investigat-ing, but more research is needed to confirm the preliminary findings.

Bone HeaLtHIn their recommendations for preventing osteo-porosis the World Health Organisation (WHO) state that: ‘The paradox (that hip fracture rates are higher in developed countries where calcium intake is higher than in developing countries where calcium intake is lower) clearly calls for an explanation. To date, the accumulated data indicates that the adverse effect of protein, in particular animal (but not vegetable) protein,

Food allergy is increasingly widespread and the most common of these is cows’ milk allergy, affecting around two percent of infants under the age of one.

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might outweigh the positive effect of calcium in-take on calcium balance.’ (24). This makes the recommending of milk and especially cheese a somewhat controversial area that some scientists are beginning to challenge. Osteoporotic fracture rates are highest in coun-tries that consume the most dairy, calcium and animal protein (25). In fact, most studies of frac-ture risk provide little or no evidence that milk and dairy products benefit bone health. Some evidence suggests that dairy products can actu-ally increase the risk of bone fracture (26, 27). So it can be argued that milk is not the best source of calcium and our bone health might benefit if we switch to plant-based sources. Professor Amy Lanou, Chair and Associate Professor of Health and Wellness for the University of North Caro-lina Asheville, says that bones are better served by attending to calcium balance and focusing ef-forts on increasing fruit and vegetable intakes, limiting animal protein, exercising regularly, get-ting adequate sunshine or supplemental vitamin D and getting 500mg of calcium per day from plant sources (25). In a paper in The British Medical Journal, Lanou says that it is time to revise our calcium recommendations for young people and change our assumptions about the role of calcium, milk and other dairy products in the bone health of children and adolescents. Lanou argues that while the policy experts work on revising rec-ommendations, doctors and other health profes-sionals should encourage children to spend time in active play or sports and to consume a nutri-tious diet made from whole plant-based foods to achieve and maintain a healthy weight and build strong bones (28).

CroHn’s diseaseIt has been proposed that the pathogenic bacteri-um that causes Johne’s disease in cattle, Mycobac-terium avium subspecies paratuberculosis (MAP), may also lead to Crohn’s disease in humans. MAP

infection is widespread among cattle and is also found in retail pasteurised cows’ milk (29). Infec-tion may occur from inhaling MAP in fine water spray from rivers contaminated with infected cow manure. This could explain the clusters of Crohn’s that occur around cities with rivers run-ning through them, like Cardiff in Wales (30) and Winnipeg in Minnesota (31). MAP can be diffi-cult to detect in humans, but when appropriate methods are used, most people with Crohn’s dis-ease are found to be infected (32). Professor John Hermon-Taylor at St George’s Hospital Medical School in London has found MAP in patients with Crohn’s disease from the UK, Ireland, US, Germany and United Arab Emirates (29). Avoid-ing dairy products alone may not be enough to ensure avoiding exposure to MAP, although if everyone reduced their intake of animal prod-ucts, there would be fewer cattle and, therefore, less MAP present in the environment.

LaCtose intoLeranCeIn 1836, after returning from the Beagle, Charles Darwin wrote: ‘I have had a bad spell. Vomiting every day for eleven days, and some days after every meal.’ Darwin suffered for over 40 years from long bouts of vomiting, stomach cramps, headaches, severe tiredness, skin problems and depression. A number of researchers now think that he may have suffered from lactose intoler-ance (32). This condition is often overlooked or mistaken for something else. Professor William H Durham, Professor in Human Biology at Stanford University describes how most North Americans (and indeed most Europeans) are surprised to learn that the major-ity of the world’s population is unable to digest cows’ milk (33). Durham describes how we live in a culture strongly committed to the concept that cows’ milk is an ideal food; we tend to think of adult milk consumption as normal and healthy. The dairy industry invests much time and money reinforcing this view. In the 1970s this ‘nutritional

. . . most studies of fracture risk provide little or no evidence that milk and dairy products benefit bone health. Some evidence suggests that

dairy products can actually increase the risk of bone fracture.

ethnocentrism’ resulted in milk powder being sent abroad as food aid to places where the lo-cal population could not digest it. The intended beneficiaries were forced to find other uses for the milk powder; so it was used in whitewash for buildings and distributed in small amounts to be used as a laxative (33). Sadly, in those who could not digest the milk, it disrupted normal digestion and actually increased malnutrition.

wHo Has tHe wHite stuff?Overall, around 70 percent of the world’s popu-lation is lactose intolerant (34, 35). At around the age of two (around the time of weaning), most people stop producing the enzyme lactase and so lose the ability to digest lactose, the sugar in milk. As stated, lactase persistence only devel-oped around 8,000 years ago. In evolutionary terms, this is very recent history. The ability to digest lactose can be traced back to a minority of pastoral tribes who gained a selective advantage from the genetic mutation that enabled persistent lactase (36). This includes the Tutsi and Hutu of Rwanda; the Fulani of West Africa; the Sindhi of North India; the Tuareg of West Africa and some European tribes (33). De-scendants of these people are able to consume dairy milk today without suffering the symp-toms of lactose intolerance (bloating, wind, dis-comfort etc). In Northern Europe, the prevalence of lactose intolerance is relatively low, varying between one to18 percent (37). The highest lev-els of milk consumption in the world are seen in Finland, Sweden, the Netherlands, Albania, Ger-many and Norway. Lactose intolerance is most prevalent in Asian and African countries with 80 to 100 percent fre-quency in some cases. People who have retained the normal intolerance of lactose include the Chi-nese, Japanese, Inuit, native Americans, Australian Aborigines, Iranians, Lebanese and many African tribes including the Zulus, Xhosas and Swazis. These people, generally, do not have a history of pastoralism and many don’t consume any milk products at all. The lowest rates of milk consump-

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The obvious treatment for lactose intolerance is to avoid all cows’ milk and dairy products.

tion in the world are seen in Thailand, Vietnam, the Democratic People’s Republic of Korea, Mo-zambique, the Congo and Liberia (38). It could be argued that the lower level of consumption seen in some developing countries reflects the fact that people can’t afford to buy milk products. How-ever, in Japan, which is not a developing country, consumption is very low. Whether the reason is cultural, economic, historical or biological (lactose intolerance), the fact remains that most people in the world don’t drink milk. The obvious treatment for lactose intoler-ance is to avoid all cows’ milk and dairy prod-ucts. This means checking labels for lactose in bread, chocolate and other processed foods including meats. In addition, lactose is used in some types of medication, so patients should check with their GP or pharmacist (although symptoms of lactose intolerance rarely occur as a result of taking medication containing it). An increasing amount of lactose-free products are appearing to cater for the lactose intolerant and boost sales of dairy foods. Plant-based milks (soya and nut milks) are naturally lactose-free. Although there is no evidence of calcium defi-ciency in people eating a diet with no lactose (39), patients cutting out dairy foods may need some help and advice on how to ensure that they still get plenty of calcium. This may be im-portant for young children who need calcium for healthy growth and development. In conclusion, it can be argued that cows’ milk is neither normal nor natural. The health implica-tions of being the only mammal to consume milk as adults (and not just that, milk from another species too) are becoming clearer and may soon force the government to reconsider how cows’ milk and dairy products are promoted. This article presents a summary of an ex-tensive fully-referenced scientific report called White Lies. All the facts presented are based on peer-reviewed published research. To find out more or to access the full references, see the full report online at: www.viva.org.uk/resources/campaign-materials/reports/whitelies

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Dysphagia is a common side effect of strokes, with between 27 percent and 50 percent of stroke patients being diag-nosed (2, 3, 4), and requires clinical and nutritional management. Nutritional consequences linked to dysphagia in-clude compromised dietary intake, leading to malnutrition and dehydra-tion, which in turn may lead to reduced scope to rehabilitate, prolonged hospital stay and increased mortality.

dysPHagiaDysphagia is the impairment of the swallow process during transit of solids or liquids from the mouth to the stom-ach. Depending on the site and extent of brain injury following stroke, different muscles and nerves used in the swal-lowing reflex may not be triggered or functioning properly, leading to dys-phagia. Strokes that damage the cer-ebella are more likely to lead to swallow problems. Dysphagia is classified into four categories based on the location of the swallow impairment: Oro-pha-rangeal, oesophageal, oesophagogastric and paraoesophageal dysphagia. It is oro-pharangeal that affects the stroke population (5). Within four hours following admis-

sion, it is recommended that stroke pa-tients have their swallow screened for a dysphagia diagnosis with a validated screening tool by appropriately skilled professionals (6). Fifty percent of stroke patients will recover full swallow capac-ity in the first two weeks, although 15 percent will still have swallowing prob-lems after one month (7). As strokes are more common in elderly patients, age-related swallow deterioration and other stroke symptoms can further complicate managing stroke-related dysphagia.

MaLnutrition riskProtein energy malnutrition (PEM) (either pre-existing or during stroke recovery) is an independent indicator of poorer outcome and mortality after stroke (8, 9, 10, 11, 12). Malnutrition risk is increased in el-derly patients (65 years and over) due to reduced lean body mass and many other factors that compromise nutri-ent and fluid intake. Since restoration of lean body mass is more difficult as age increases, preventive nutritional support is important in the elderly (13). Most strokes occur in those over 65 years; with mean ages in the UK be-ing 72.6 years in men and 78.8 years in females (14). Malnutrition figures vary with up to 60 percent of patients being mal-nourished post stroke (15) and in 25 percent of the post-stroke population weight loss will persist for up to 12 months (16). The odds of stroke patients becom-ing malnourished increases with the

dYSPhAGiA ANd NUtritioNAL iNterVeNtioNS iN StroKe CAre

Louise dickiespecialist stroke dietitian in hyperacute/acute stroke care, imperial College HealthCare trust

Louise is currently working as a Specialist dietitian in inpatient stroke care. Previously, Louise worked as a Specialist Nutrition Support dietitian in gastroenterology, iCU, parenteral nutrition and care of the elderly.

Every fourth minute, someone somewhere in the Uk endures a stroke (1). Stroke survival is on the increase and post-stroke care needs are rising, with stroke treatments from acute to recovery phase to managing stroke side effects, showing improvements in patient outcomes.

dysPHagia

Dysphagia is the impairment of the swallow process during transit of solids or liquids from the mouth to the stomach.

NHDmag.com February 2015 - Issue 10130

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presence of dysphagia, and with prolonged periods of inadequate dietary intake during hospitalisation being a possible cause. This sug-gests more structured monitoring of nutritional status is needed during stoke admission (17).

nutritionaL sCreening for tHe dysPHagiC stroke PatientThe National Stroke Guidelines for England and Wales recommend that every patient with nu-tritional problems, including dysphagia and re-quiring food of a modified consistency, should be referred to a dietitian and an ongoing nutri-tional plan should be in place (6, 14). Screening is recommended to be carried out on admission and then repeated weekly. (RCP, 2014). There are now two validated screening tools for the stroke population: Malnutrition Universal Screening Tool and The Guys and St Thomas Nutrition Screening Tool, although there are currently no stroke-specific validated screening tools. Dys-phagia is not a criterion to trigger scoring on many screening tools.

nutritionaL interventions in dysPHagia CareNational recommendations for post stroke pa-tients at risk of malnutrition are to provide spe-cialist dietary advice with the consideration of either oral nutrition support or enteral feeding. The research into nutritional interventions in dysphagia stroke care is becoming stronger to provide us with guidance on the best use of these different nutritional interventions. Interventions include dietary counselling, food texture modi-

fication, oral nutritional supplements and tube feeding, sometimes with various interventions used together to supplement one another. Areas such as palliative care with dysphagia and other common ethical dilemmas are beyond the scope of this article.

oraL nutritionaL interventionsModifiedfoodsThe rationale for the use of texture-modified diets (TMDs) within stroke care is to enable the safe transition of food and fluids to the oesopha-gus, therefore avoiding penetration or aspiration into the trachea and chest, whilst enabling those with a partial dysphagia to safely continue oral diet. Further research is needed to establish the efficacy of TMDs in clinical and nutritional man-agement of dysphagia. The NHS stipulates that nationally recogn-ised terminology is used for food textures by all health and care settings providing TMDs (NHS 2011). These were developed under the auspices of the National Patient Safety Agency (2011) as a result of clinical incidents. They define the types and textures of foods needed by individuals who have oro-pharangeal dysphagia. Specific stan-dards are provided in a guideline document for four food textures that are to be used with check-lists to enable measurement against these stan-dards, in terms of texture consistency. All clini-cal care settings are recommended to provide at least texture C and texture E (NPSA, 2011), and hospital caterers are advised to provide these as an a la carte menu (The Nutrition and Hydration Digest, BDA/NHS 2011).

The National Stroke Guidelines for England and Wales recommend that every patient with nutritional problems, including dysphagia and requiring food of a modified consistency, should be referred to a dietitian and an ongoing nutritional plan should be in place

NHDmag.com February 2015 - Issue 101 31

Use of TMDs is associated with malnutrition; however, causality is difficult to demonstrate due to confounding factors such as the require-ment for feeding assistance, particularly in the post-stroke elderly patient. Many patients with dysphagia find eating uncomfortable and an un-pleasant experience. This can lead to early satiety and refusal of food and beverages (14) and lower energy and protein intakes when compared to those taking normal diets (18). TMDs are not always nutritionally adequate (19, 20, 21). Some nutritional composition analy-ses have shown some to provide as little as 45 percent of average daily energy needs (22). There are no separate regulations to assure that the nutritional composition of TMDs are adequate in health and care settings. However, guidance for catering services is getting better on how to optimise the nutritional content and appeal of TMDs. The Hospital Caterers Association pro-vides practical guidance for provision of TMDs, such as how to best thin puree without detriment to the nutritional value and optimising cooking methods and food presentation. Outsourced food services are also improving the provisions available. There is now a recommendation for a dedi-cated catering liaison dietitian in every hospital department (Nutrition and Hydration Digest, BDA 2012); however, they are not solely focused on TMDs. Stroke specialist dietitians are likely to have the largest proportion of patients requiring the TMDs, so working with the catering liaison dietitian and hospital catering team is invalu-able. Each catering service should provide a

dysPHagia

nutritional break down of their TMDs and, by using the Nutrition and Hydration Digest as a guide, the nutritional composition can be de-duced. Strategies to maximise provisions of ap-petising nutrient-dense foods (including snacks) and fluids of suitable textures can increase nutri-ent intakes (19, 23). Targeted feeding assistance with dysphagic patients has also been seen to be beneficial to nutritional intakes (24).

Modified fluidsAs well as TMDs, thickened fluids are also used as a method of safely consuming oral intake dur-ing dysphagia. Dysphagic stoke patients who are restricted to thickened fluids are at high risk of dehydration (25, 26). Stroke-associated reduced thirst sensations and cognitive impairments, as well as non-stroke related risk indicators, such as age and physical disabilities, further increase the potential of dehydration risk for this patient group (28). Other risk factors for dehydration include the low acceptance rates of thickened fluids (29). It is currently unclear whether thickened fluids induce early satiety. Although studies agree that increasing the thickness of a liquid reduces the amount consumed when compared to unthickened fluids. Assessment of the com-parison between thickened fluids, food, enteral and parenteral nutrition on fluid intake in stroke dysphagic patients has suggested that there is a greater contribution of fluid provided from food, than beverages (31). Therefore, designing menus and promoting fluid dense foods rather than thickened beverages is an important way

Assessment of the comparison between thickened fluids, food, enteral and parenteral nutrition on fluid intake in stroke dysphagic patients has suggested that there is a greater contribution of fluid provided from food, than beverages

NHDmag.com February 2015 - Issue 10132

of improving fluid intakes in patients with dys-phagia. Enteral or parenteral supplementation may be needed. Although costly, some settings use pre-thickened beverages, which may help to improve fluid and nutrient intakes for our dys-phagic stroke patients (31, 32). There are also now pre-thickened ONS available which may be of some benefit for our patients requiring nutri-tional supplements. Initial observational studies using them in in non-stroke patients with dys-phagia requiring ONS, demonstrated achieve-ments in nutritional aims being met in ease of use and palatability (14).

additionaL suPPort for stroke Patients on oraL interventions/oraL dietsStroke patients should be provided with appro-priate equipment and assistance. The use of a plate guard, specialist cutlery and adhesive place mats are examples of such equipment (34). In ad-dition, the red tray system is a simple strategy that alerts healthcare staff that a patient requires assistance and is useful for patients who require a level of physical or cognitive support. Stroke patients can vary in their need for support with eating and drinking due to other stroke side effects. The use of dining areas have been shown to improve energy intake in elderly patients. With much of post stroke dysphagic population being within this bracket, it may have a positive improvement on nutritional in-takes (33).

using oraL nutritionaL suPPLeMents (ons)Oral nutritional supplements may be helpful for dysphagic patients on oral diets and are recom-mended for malnourished stroke patients re-gardless of swallow difficulties (13). A recent Co-

chrane review concluded that, although we need more studies, the present studies suggest that we should be using oral nutrition supplements for our at-risk patients as their use is associated with increased energy and protein intake and reduc-tion in pressure sores for the dysphagic stroke patient (7) compared to diet alone.

tuBe feedingTube feeding may be a chosen method of nutri-tional intervention either to wholly supplement nutritional needs or to supplement intake in those with partial dysphagia. Currently, ESPEN recommend enteral feeding for elderly neurolog-ical patients with severe dysphagia, and the RCP 2014 guidelines advise to start within 24 hours via a nasogastric tube for any patient deemed in need of artificial feeding (13, 14). There have been few evaluation studies made regarding tube feeding to supplement TMDs to see how they impact on outcomes and to guide clinical practice. No significant difference to mortality rates or pneumonia has been found between the use of NGTs or PEGs in the short term (7). However, when longer-term artificial feeding support is required, then PEG feeding is seen as advanta-geous, with a significantly lower probability of feeding failure (14). Post-pyloric feeding should be considered if upper gastrointestinal dysfunc-tion is suspected, once medical and pharmaco-logical treatment approaches have been tried or considered. Available evidence suggests that neither the gastric nor post-pyloric route is seen to be su-perior to the other, with no advantage in terms of reduction in aspiration pneumonia, tube dis-placements or nutritional intake (7).

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NHDmag.com February 2015 - Issue 10134

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nasaL BridLes, Mittens or otHer restraining deviCesResearch is sparse in guiding us with the use of these devices, with no randomised trials evalu-ating the effects of mittens or other forms of restraint. One two-week study involving 104 dysphagic stroke patients found that the use of nasal bridles significantly increased the amount of enteral nutrition and fluid delivered, ame-liorated electrolyte disturbances and improved incidence of NGT failures (35). No difference in mortality, morbidity, PEG placements, functional outcomes, or length of stay was seen. If patients are not tolerating NGTs, the cur-rent RCP guidelines recommend the use of nasal bridles or early gastrostomy placement with lo-cally agreed protocols (14) and recommend that locally agreed protocols and training is in place if mittens are used.

weaningVery few studies focus on this transition and there are no national recommendations available for guidance. Some papers suggest as a minimum that a patient must be able to consume adequate oral nutrition and demonstrate a safe and effective swallow on a consistent basis (36). Buchholz (37) proposed a two-step process. Firstly, initiating a intermittent feed schedule as step one and only once a patient is able to consume 75 percent or more of their nutritional needs consistently for at least three consecutive days should the tube then be removed. Reliance on food and fluid charts for assessment of calorie, protein and fluid intake is essential, particularly for patients with impaired memory, or communication barriers, while review of anthropometric and blood results can help to guide if your nutritional plans are working.

suMMaryAs stroke survival is on the increase and the successes of rehabilitation are becoming more evident, we need to strive to optimise the nutritional care that we provide to assist in promoting the best patient outcomes we can. The forms of nutritional intervention used for dysphagic patients are in need of more research to establish their impact on stroke patient outcomes, including nutritional status, and on what the best strategy is for achieving weight gain, nutritional maintenance or improvements and measurable benefits. Each patient should be holistically assessed to ensure that the most suitable nutritional intervention is used at each step of their post stroke care, with the available current evidence and recommendations guiding your current practice, weighing up of the risks and benefits and thinking about the impact between using the intervention or not on the patient’s quality of life. Whilst the medical aims of active dysphagia management are to continue oral feeding whilst reducing the risk of clinical harm, the nutritional aims are to maintain a good nutrition and hydration status with the most suitable nutritional intervention. More research needs to be done to evaluate the benefits and most suitable nutritional intervention available to maintain or improve nutritional status in our growing dysphagic stroke population. Recent updates in guidance of stroke patients and dysphagic patients should contribute to improved care for these patients and research questions have been asked to add to the current evidence and help strengthen our knowledge for clinical practice.

As stroke survival is on the increase and the successes of rehabilitation are becoming more evident, we need to strive to optimise the nutritional care that we provide to assist in promoting the best patient outcomes we can

NHDmag.com February 2015 - Issue 101 35

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references1 the Stroke association2 Gordon c. Hewer rL. wade Dt. Dysphagia in acute Stroke. bMJ 1987.3 wolfe c. rudd t. beech r. the burden of Stroke, Stroke Services and research. London: the Stroke association. 19964 Odderson Ir. Keatin Jc. McKenna bS. Swallow management in patients on an acute stroke pathway: quality is cost effective. arch Phys Med

rehabil 1995 Dec;76(12):1130-35 Mann G. Hankey GJ. caeron D. Swallowing functions after stroke: prognosis and prognostic factors at 6 months. Stroke 1999 30(4): 744-7486 Stroke Quality Standards. NIce 20107 Geeganage c. beevan J. ellender S. bath PMw. Interventions for dysphagia and nutritional support in acute and subacute stroke. cochrane

Database of Systematic reviews 2012, Issue 10. 8 Dávalos a1, ricart w, Gonzalez-Huix F, Soler S, Marrugat J, Molins a, Suñer r, Genís D. effect of malnutrition after acute stroke on clinical

outcome. Stroke. 1996 Jun; 27(6):1028-32.9 Dennis, M. Nutrition after Stroke. british Medical bulletin. 2000; 56 (No 2) 10 Davis J wong a. Schluter P. Henderson r. Philip J. Henderson r. O’Sullivan. read Stephen. Impact of Premorbid Undernutrition on Outcome in

Stroke Patients. Stroke. 2004; 35: 1930-193411 Martino, r et al. Dysphagia after Stroke. Incidence, Diagnosis, and Pulmonary complications. 2005. american Heart association.12 Yoo SH. Kim JS. Kwon SU. Yun, Sc. Koh JY. Kang Dw. Undernutrition as a Predictor of poor clinical Outcomes in acute Ischemic Stroke

Patients. arch Neurol. 2008;65(1):39-4313 eSPeN Guidelines on enteral Nutrition: Geriatrics. 2006. 14 National clinical Guideline for Stroke. Intercollegiate working Party for Stroke. royal college of Physicians. 2010. 4th edition.15 Norine c. Foley, rD, MSc1, ruth e. Martin, PhD2, Katherine L. Salter, ba3 and robert w. teasell, MD1,3. a review of the relationship between

Dysphagia and Malnutrition Following Stroke. J rehabil Med 2009; 41: 707–71316 Jönsson ac. Lindgren I. Norrving b. Lindgren a. weight loss after stroke: a population-based study from the Lund Stroke register. Stroke 2008

Mar;39(3):17 Gariballa S. Parker S taub N. castleden c. Influence of nutritional status on clinical outcome after acute stroke. am J clin Nutr 1998;68:275–81.18 bath PMw, bath-Hextall FJ, Smithard DG Interventions for dysphagia in acute stroke. cochrane 1997 and physiological burden of dysphagia; its

impact on diagnosis and treatment. Dysphagia april 2002, Volume 17, Issue 2, 19 eckberg, O. et al. 2002. Social pp 139-14620 wright L, cotter D, Hickson M, Frost G. comparison of energy and protein intakes of older people consuming a texture modified diet with a

normal hospital diet. Journal of Human Nutrition and Dietetics. 2005 Jun; 18(3); 213-9. 21 bannerman e, McDermott K. Dietary and fluid intakes of older adults in care homes requiring a texture modified diet: the role of Snacks J am

Med Dir assoc. 2011 Mar;12(3):234-9. 22 Foley N, Finestone H, woodbury MG, teasell r, Greene Finestone L. energy and protein intakes of acute stroke patients. J Nutr Health aging.

2006 May;10(3):171-5. 23 Moreno, c, Garcia MJ, Martinez c & Grupo GeaM. analisis de situacion y adecuacuin de dieta para disfagia en un hospital provincial. Nutr Hosp

2006; 21: 26-3024 wilkinson tJ. thomas K. MacGregor S. tillard G. wyles c. Sainsbury r. 2002. tolerance of early diet textures as indicators of recovery from

dysphagia after stroke. Dysphagia 17, 227-232.25 Hotaling DL. Nutritional considerations for the pureed texture in dysphagic elderly. Dysphagia 1992 (7) 81-85.26 wright L. cotter D. Hickson M. the effectiveness of targeted feeding assistance to improve the nutritional intake of elderly dysphagic patients in

hospital. Journal of Nutrition and Dietitics 2008 21; 6. 27 Finestone HM. Foley Nc. woodbury MG. Greene-Finestone L. 2001 Quantifying fluid intake in dysphagia stroke patients: a preliminary

comparison of oral and non-oral strategies. arch. Phys. Med rehabil. 82, 1744-1746. 28 Vivanti a, campbell K. Suter M. Hannan-Jones M. Hulcombe J. contribution of thickened drinks, food and enteral and parenteral fluids to fluid

intake in hospitalised patients with dysphagia. Journal of Nutrition and Dietitics. 2009. Volume 22, Issue 2, pages 148–15529 axelsson K. asplund K. Norberg a. alafuzoff I. Nutritional status in patients with acute stroke. 1998 acta Medica Scandinavica 224 (3) 217-224.30 Scharver, c. Hammond c. Goldstein L. “Post-stroke malnutrition and dysphagia,” in Handbook of clinical Nutrition and aging, c. w. bales and

c. S. ritchie, eds., pp. 479–499, Humana Press, New Jersey, NJ, USa, 2nd edition, 2009. 31 whelan K. Inadequate fluid intakes in dysphagic acute stroke. 2001. clinical Nutrition. 20. 423-428.32 Mccormick Se. Stafford KM. Saqib G. chroinin DN. Power D. the efficacy of pre-thickened fluids on total fluid and nutrient consumption among

extended care residents requiring thickened fluids due to risk of aspiration. age ageing. 2008 Nov;37(6):714-533 Macleod M. blackie L. Humphrey S. an investigation into the nutritional efficacy, tolerance and patient acceptance of pre-thickened nutritional

supplements in dysphagic patients. Proceedings of the Nutrition Society 2010. 69 34 wright L. Hickson M. Frost G. eating together is important: using a dining room in an acute elderly medical ward increases energy intake. J Hum

Nutr Diet. 2006 Feb;19(1):23-6.35 beevan J et al. Is looped nasogastric tube feeding more effective than conventional nasogastric tube feeding for dysphagia in acute stroke?

bioMed central. trials 2007, 8: 1936 Mann G, Hankey GJ, caeron D. Swallowing functions after stroke: Prognosis and prognostic factors at 6 months. Stroke 30 4 744-74837 buchholz ac. weaning patients with dysphagia from tube feeding to oral nutrition: a proposed algorithm. can J Diet Pract res. 1998: 59;

208-214. 38 corrigan, ML et al. Nutrition in the Stroke Patient. Nutrition in clinical Practice. 26, No 3, June 2011. 242-252. 39 Gomes F, Hookway c, & weekes c.e (2014) royal college of Physicians Intercollegiate Stroke working Party evidence-based guidelines for the

nutritional support of patients who have had a stroke. J Hum Nutr Diet. 27, 107-121. 40 the Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals. DofH. august 2014. 41 the Nutrition and Hydration Digest: Improving Outcomes through Food and beverage Services. July 2012. the british Dietetic association. 42 Dysphagia Diet Food texture Descriptors. april 2011. NSPa/royal college of Speech and Language therapists/the british Dietetic association/

National Nurses Nutrition Group/Hospital caterers association43 withholding and withdrawing Life-prolonging Medical treatment. Guidance for Decision Making. Second edition 2001. bMa. 44 FOOD trial collaboration. Poor nutritional status on admission predicts poor outcomes after stroke: observational data from the FOOD trial.

Stroke 2003 34. 1450-1456.

NHDmag.com February 2015 - Issue 101 37

This however, is extremely challenging for the patient, particularly, for those who have very mild symptoms or are asymptomatic. The follow-up care of patients with coeliac disease (after the diagnosis) var-ies hugely within the UK, ranging from patients with coeliac disease being seen in specialist clinics, to the other extreme of being discharged back to the commu-nity without any provision of a specialist service (either in primary or secondary care). In addition, the individuals pro-viding the follow-up care could be fam-ily practitioners, gastroenterology con-sultants, nurse specialists or dietitians. The British Society of Gastroenterol-ogy recommends that patients should receive life-long follow up through an annual review (2) because of poten-tially serious long-term complications such as lymphoma (3) and osteoporotic fractures (4), although the risk of these is small (5). The dietitian is best placed to provide this, to ensure that even ex-perienced patients with coeliac disease do not inadvertently consume gluten. The Annual review is also essential to promote an overall balanced diet and discuss any nutritional issues or pos-

sible deficiencies which may arise. Evi-dence suggests that patients seen in a dietetic-led coeliac clinic have improved outcomes (6) and that dietetic follow-up is the method of management preferred by the patient (7). Within Southern Derbyshire, the di-etitian takes the lead for the management of patients with coeliac disease across the whole of the patient pathway.

new Patient PatHwayFollowing discussions with Southern Derbyshire CCG and the gastroenterol-ogy consultants at the Royal Derby Hos-pital, major changes have been made to the local pathway for diagnosis and management of patients with coeliac disease. This has resulted in less hos-pital appointments, less unnecessary endoscopies and direct referral into di-etetic services reducing the time to treat-ment implementation. There is emerging evidence which indicates that if a coeliac serology blood test is over five times the normal range (above 50u/ml), then an endoscopy is not required. We have used this infor-mation to structure our new pathway (Figure 1).

dietetiC-Led mANAGemeNt of CoeLiAC diSeASe

fiona MoorHeadofDieteticServices,Royalderby Hospital

fiona moor is head of dietetic Services for the derby hospitals NhS foundation trust. She has a special interest in coeliac disease and runs the coeliac service for patients within Southern derbyshire.

Coeliac disease affects approximately one percent of the western European population (1) and is one of the most common gastrointestinal conditions seen. The only treatment for this condition is the strict life-long exclusion of gluten from the diet.

CoeLiaC disease

figure 1:

NHDmag.com February 2015 - Issue 10138

CoeLiaC disease

dietetiC-Led grouP Patient eduCation sessionsWe have been offering dietetic-led group patient education sessions, as an alternative to individ-ual outpatient clinic consultations, for our new-ly diagnosed coeliac patients since 2010. This was initiated to accommodate the increased number of referrals that we were receiving into the department for newly diagnosed patients. Due to capacity problems at that time, we were unable to offer these patients a one-to-one con-sultation. Group sessions run every three weeks for 90 minutes; they are very informal and designed for patients to share their experiences. During the session, the condition and dietary management is introduced in detail, covering subjects such as hidden sources of gluten, cross contamina-tion, the use of prescribable products and how to maintain a healthy gluten-free diet. Additional guidance is provided on the importance of en-suring adequate intakes of calcium and iron, how and when to introduce pure gluten-free oats and the appropriate use of barley malt extract. Group members are encouraged to ask questions throughout. A pack of written information is provided to each attendee which contains our Gluten Free Diet Sheet, starter pack cards from various man-ufacturers, up-to-date prescription list and cur-rent guidance on units, as well as information regarding calcium and iron intakes. A display, consisting of gluten-free food packages (both prescribable and supermarket free from ranges) is arranged for patients to look at and discuss. Occasionally, a representative from one of the gluten-free manufacturers will attend and sam-ples will be provided for the patients. Individu-

als are also encouraged to join Coeliac UK - the associated charity for patients with the coeliac condition. Those who were felt not to be appropriate for the group, e.g. requiring interpreter servic-es, or those not wishing to attend a group ses-sion, are given an appointment for a one-to-one consultation. At the group session, the dietitian has access to all patients’ biochemistry, so individual dis-cussions regarding coeliac serology levels, along with iron, vitamin B12 and vitamin D can take place and, if necessary, supplementation can be discussed. There is also a check to see if referral for DEXA scan has been made. A patient evaluation rounds the session off at the end of the 90 minutes. Feedback has always been positive (Table 1).

Table1:Patientfeedbackfrompatientevaluationofcoeliac group education sessions - 2014

“very well presented.”

“IfounditmoreusefulthanIhadexpected.”

“Veryhelpful.”

“I’vethoroughlyenjoyedthesession.”

“Ifoundtodayreallyhelpful,nicetotalktoothers

in the same situation.”

The group sessions not only offer practical advise on how to maintain a gluten-free diet, but help patients with the social and psycho-logical elements associated with any long-term condition. Following on from the group session, as per the pathway above, patients are offered ap-pointments to be followed up at eight weeks, six months and 12 months post diagnosis.

The group sessions not only offer practical advise on how to maintain a gluten-free diet, but help patients with the social and psychological elements associated with any long-term condition

NHDmag.com February 2015 - Issue 101 39

CoeLiaC disease

foLLow-uP dietetiC-Led CLiniCsWe have been operating follow-up dietetic-led coeliac clinics since 2007, with a clinic scheduled every week. Patients attending are those return-ing for their six-week, six-month, or 12-month follow-up, or annual review, unless more fre-quent attendance has been identified. All care is managed by the dietitian, including the monitor-ing and interpretation of biochemistry and the requesting of DEXA scan and analysing of the results. This meets national guidelines for the surveillance of these patients with coeliac dis-ease and is in line with the BSG guidelines for the management of the condition (2). Prior to the appointment, all patients will have had the following blood tests: full blood count, ferritin, vitamin B12, folate, calcium, co-eliac serology and vitamin D. Each clinic appointment is a one-to-one con-sultation lasting 20 minutes. There is a review of adherence to the gluten-free diet, assessment of changes to symptoms, discussion of blood re-sults, along with weight check and thorough di-etary assessment, including adequacy of calcium intake in light of DEXA results. At the six-month appointment, consideration will be made to the introduction of pure gluten-free oats and there will be a review of the gluten-free prescription process to ensure there are no outstanding issues or problems. If any red flag symptoms (unintentional weight loss, altered bowel habits, blood in stools) are identified at the clinic appointment, then dis-cussion will take place with a gastroenterologist and referral made as appropriate.

references1 Dube c, rostom a, Sy r et al. the prevalence of celiac disease in

average-risk and at-risk western european populations: a systematic review. Gastroenterology 2005; 128 (4 Suppl. 1): 57-67

2 ciclitira PJ, Dewar DH, McLaughlin SD, Sanders bS. british Society of Gastroenterology. the management of adult coeliac disease. 2010

3 catassi c, Fabiani e, corrao G et al. risk of non-Hodgkin lymphoma in celiac disease. JaMa 2002; 287: 1413-9

4 west J, Logan rF, card tr, Smith c, Hubbard r. Fracture risk in people with celiac disease: a population based cohort study. Gastroenterology 2003; 125: 429-36

5 catassi c, bearzi I, Holmes GK. association of celiac disease and intestinal lymphomas and other cancers. Gastroenterology 2005; 128 (4 Suppl. 1): 57-67

6 wylie c, Geldart S and winwood P. Dietitian led coeliac clinic: a successful change in working practice in modern healthcare. Gastroenterology today 2005; 15: 11-12

7 bebb Jr, Lawson a, Knight t and Long rG. Long-term follow-up of coeliac disease - what do patients want? aliment Pharmacol ther 2006; 23: 825-831

8 Hill PG and Holmes GKt. coeliac disease: Is biopsy still required for diagnosis at all levels of Iga tissue transglutaminase antibody? Gut 2006; 55 Suppl 2: a11

Following on from the group session, as per the pathway above, patients are

offered appointments to be followed up at eight weeks, six months and 12 months

post diagnosis.

NHDmag.com February 2015 - Issue 10140

Book review

The book covers nutrition from precon-ception to adolescence up to the age of 18. It addresses some of the common nutritional and feeding problems at dif-ferent stages of a child’s development. The cultural, physical, emotional, social and psychological factors that may play a part in why feeding can be challeng-ing are also considered and discussed. A section devoted to the social and cultural influences on food choices pro-vides information about common food traditions within different religions and geographical regions. This is particularly useful to those working with diverse ethnic populations. Other highlights in-clude the section on breastfeeding which is covered in more detail than most di-etetic texts. There is an example of a feed-ing routine and tips for good positioning and attachment. The obesity section is a useful tool for health professionals see-ing overweight and obese children in the community, recommending discussion points to explore with a family. Through-out there is plenty of practical advice, examples and reference information in easy-to-read tables and illustrations. The text includes case studies, key points and activities to help readers learn.

My only criticism is that the topics in the last section covering nutrition for children with chronic diseases and syndromes, are too complex to set out and fully explain in 15 pages. Although this section acts as an introduction to chronic diseases and specific conditions, the content should not be relied on by healthcare professionals to provide nu-tritional advice to parents. This book would be useful to nu-trition and dietetics students requiring an overview of nutrition and develop-ment for children aged 0 to 18 years. It may also be interesting reading for other healthcare professionals involved in the nutritional health of children in primary care and community settings. This text would certainly be useful to those working in food provision and meal planning in childcare settings. Al-though the preface describes this book as helpful to parents, the language used and textbook style of writing makes it less accessible to the general public. Instead, healthcare professionals could use the tips and examples in this book as a base to help parents manage meal time behaviour and to suggest suitable nutritious meals and snacks.

Judy More is a registered dietitian who has specialised in paediatric nutrition for over 15 years. Here she has written an evidence-based and concise guide to the key principles of paediatric dietetics, in which she explains the theory behind the basics of a balanced and nutritious diet and describes growth and development throughout childhood.

iNfANt, ChiLd ANd AdoLeSCeNt NUtritioN:A Practical handbook

By Judy MoreCrC Press; 1 edition (22 Jan. 2013)isBn- 978-1444111859 - Cat# k18762PaPerBaCk £19.99

Review by Gemma Ransome, Specialist Dietitian, Paediatric Intensive Care/ Cardiology,The Harley Street Clinic

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Issue 101 February 2015NHDmag.com

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS

BRIGHTON & HOVEADULT FOOD ALLERGY

LACTOSE INTOLERANCE

COELIAC DISEASE

COWS’ MILK VS GOAT MILKLouise DickieSpecialist Stroke Dietitian

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

ISSN 1756-9567 (Print)

WEB WATCH NEW RESEARCH

Lauren McCormack p9

IMPORTANT NOTICE: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breast-fed. The decision to discontinue breast feeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breast feeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional. Goat milk formula is not suitable for a cow milk protein allergy except under the supervision of a suitably qualified health care professional.

REFERENCES: 1. PINTADO, M. E. & MALCATA, F. X. (2000). Hydrolysis of ovine, caprine and bovine whey proteins by trypsin and pepsin. Bioprocess Engineering, 23, 275-282. 2. ALMAAS, H et al (2006). In vitro digestion of bovine and caprine milk by human gastric and duodenal enzymes. International Dairy Journal, 16, 961-968

For more info visit nannycare.co.uk

or email us: enquiry@nannycare.co.uk or call our helpline UK: 0800 328 5826

Better digestibilityThe immaturity of a new-born infant’s digestive tract requires the proteins in formula to be readily digestible. Goat milk proteins are digested more completely than cow’s milk proteins1.

These factors contribute to the better digestion of goat milk and suggest why a goat milk formula may be beneficial and may simply suit some babies better than cow’s milk formulas.

NANNYcare First infant milk:

• Behaves more like breast milk in the infant stomach forming looser, softer and more porous curds than cow’s milk formula

• This aids digestion by allowing easier access by stomach enzymes

• Nearly 3-fold more beta-lactoblobulin is digested in goat milk compared with cow’s milk2

Goat milk has a smaller proportion of s1-casein than cow’s milk and a greater proportion of -casein, similar to the casein profile of human milk.

Casein profile

Comparison of Casein profile between human, goat and cow’s milk

0%

25%

50%

75%

100%

Human milk Goat milk Cow milk

K-Casein s1-Casein

s2-Casein

-Casein

-Casein

-CaseinK-Casein

s1-Casein

s2-CaseinK-Casein

% o

f tot

al C

asei

n

Pictorial representation of species variation in Casein curd ‘density’

Why consider a whole goat milk formula?

BREASTFEEDING IS BEST FOR BABIES

Cow’s milk is commonly used to manufacture infant formula,

generally because it is the most widely available source.

NANNYcare is made from whole goat milk which is now fully regulated and approved for use in infant formula

Method: Samples were reconstituted with water and pH was dropped to 4.5 with HCl

Cow’s milk infant formula1 - Cow milk infant formula, whey dominant (40% casein, 60% whey)2 - Cow milk infant formula (80% casein, 20% whey)3 - Cow hypoallergenic infant formula

Whole goat milk infant formula

Human milk

NC_network health 160x223_ad1.indd 1 21/12/2014 21:24

NHDmag.com February 2015 - Issue 101 43

There is now substantial evidence to indicate that early nutrition also has fundamental implications for long-term health, by programming aspects of ensuant cognitive function, thereby preventing obesity and anaemia, as well as reducing the risk of serious diseases such as diabetes, cardiovas-cular disease, osteoporosis, cancer and atopy (1, 2, 3). To achieve these outcomes, breast-feeding is recommended (4). Where breastfeeding is not possible, or breast milk is insufficient, infant formulas are used. Traditionally, infant formu-las made with cows’ milk are the first line choice for formula-fed infants. Until recently, most of the conclusive studies in human infants published in the international literature have been limited to the evaluation of cows’ milk or soy protein-based infant formu-lae. Proteins from the milk of animals other than cows, or from various plant sources, have also been considered potentially suitable for use in infant formulae (5, 6). However, the suitabil-ity and safety of goat milk has only recently been approved, despite the fact that goat milk has a history of use for human nutrition in many cultures (7, 8, 9) and that there has always been

demand for goat milk infant formulas, with reports of home-made goat for-mula and raw goat milk being used (10, 11, 12, 13). The Dietetic Products, Nutrition and Allergies of European Food Safety Authority (EFSA) panel (14) concluded that protein from goat milk is suitable as a protein source for infants and for follow-on formulae (as long as the fi-nal products comply with the compo-sitional criteria as per the EU Directive 2006/141/EC). From March 2014 goat milk infant formula has now become al-lowable throughout the EU. But is it any different from cows’ milk formula? Table 1 outlines the main differenc-es between cows’ milk and goat milk formulae. CoMPositionaL ProPertiesnucleotidesIn young infants, rapid growth can in-crease the need for nucleotides, which are important constituents of RNA and DNA. It is well documented that nucleotide supplementation increases weight gain and head growth in for-mula-fed infants. Therefore, nucle-otides may be conditionally essential for optimal infant growth in some formula-fed populations (19).

the NUtritioNAL QUALitieS of GoAt miLK AS AN ALterNAtiVe to CoWS’ miLK iN iNfANt formULAe

During infancy, appropriate nutrition is required for normal growth and development.

infant feeding: dairy

Table1:Howgoatmilkdiffersfromcows’milk

Goatmilkissecretedbyanapocrineprocess,similartothatofbreastmilk(15)

Goatmilkhasalowerlevelofalphas1-caseinandgreaterproportionofbeta-caseincomparedtocows’milkand is more similar to human milk (16)

Goatmilkhasmoremediumchainfattyacidsthancows’milk(17)

Goatmilkhasfivetimesmorenucleotidesthancows’milk,similartohumanmilk(18)

Jacqui LowdenPaediatric dietitian - team Leader Critical Care, therapy & dietetics, rMCH

Presently team leader for critical care and burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis. although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

NHDmag.com February 2015 - Issue 10144

infant feeding: dairy

Cows’ milk infant formulas are now rou-tinely supplemented with nucleotides. How-ever, goat milk formula already contains an array of nucleotides and so requires no supple-mentation (20).

Protein and amino acidsGoat milk infant formula has amino acids in amounts similar to human milk reference val-ues, when expressed on a per-energy basis (21). The protein content of infant formula has, in the past, been set higher than human milk. This was due to concerns regarding protein quality and insufficient amounts of some ami-no acids. However, there now exists evidence that the protein content has been set too high, resulting in a greater than normal weight gain and stress on a young infants immature kidneys (22, 23). With this ‘growth acceleration hypothesis’, suggesting that early and rapid growth during infancy programs the infant metabolic profile to be susceptible to obesity and the other com-ponents of metabolic syndrome, it is essential that any infant formulas are brought in line with human milk reference values.

whey proteinsInfant milk formulas often have whey pro-teins added to improve the quality of protein available as essential and semi-essential amino acids (24, 25). Goat milk infant formula, how-ever, has been shown to have sufficient quan-tities of all essential and semi-essential amino acids, without added whey proteins and so has an amino acid profile compatible with in-ternational standards for infant formula (21). It has also been demonstrated that this type of goat milk formula has amino acid digestibility and absorption properties similar to those of a cows’ milk infant formula, with added whey, in an animal model (26).

nutritionaL adeQuaCyAs well as meeting international composition-al standards, it is also essential that the suit-ability and nutritional adequacy of infant for-mulas containing new sources of protein are established (27, 28). Until recently, there has only been one pre-vious randomised controlled trial using a goat milk infant formula to feed infants (29), dem-onstrating that the growth in 30 infants fed

Cows’ milk infant formulas are now

routinely supplemented with

nucleotides. However, goat

milk formula already

contains an array of

nucleotides and so

requires no

supplementation.

NHDmag.com February 2015 - Issue 101 45

infant feeding: dairy

a goat milk formula was similar to that of 32 infants fed a whey-based cows’ milk formula, but the study was criticised for lack of blood biochemical data and numbers (30). Since then, however, a study published in 2014 has demonstrated that in infants, the growth and nutritional outcomes provided by the goat milk formula did not differ from those provided by a standard whey-based cows’ milk formula. The study of 285 infants fed goat or cow formula or breast milk, provided the necessary evidence leading to the recent change allowing goat milk as a base in infant formula (31).An earlier study by Zhou et al 2011 (16) high-lighted an interesting aspect, in that they mea-sured how many times an infant was offered an alternative formula or non-formula foods before the age of four months, as a measure of compliance. In the group randomised to re-ceive the cows’ milk formula, almost 40 per-cent of the infants were offered either another formula or a non-formula food for more than 12 days before the age of four months. The rates in the infants fed the goat milk formula were far less and more similar to the breast milk fed infants. When parents change their baby’s formulas or introduce solids earlier than the recommen-dation, a common reason given is because they feel that the baby is not satisfied. This does need to be investigated further, but could pos-sibly suggest that they were more satisfied on the goat milk formula.

wHat aBout Cows’ MiLk Protein aLLergy?The World Allergy Organisation estimates that 1.9% to 4.9% of children suffer from cows’

milk protein allergy (32). It has previously been suggested that goat milk could be used as a possible nutritional alternative to cow’s milk for these infants. However, clinical stud-ies have demonstrated a risk of cross-reactivity between the proteins in cows’ milk and in goat milk (33, 34). There have also been reported cases of infants with cows’ milk allergy devel-oping anaphylaxis after the ingestion of goat milk (35). In the 2012 EFSA publication, it was con-cluded that, ‘There is insufficient data on the allergenicity of goat milk protein, with no con-vincing data to support the conclusion that the incidence of allergic reactions is lower when feeding goat milk-based infant formula when compared with cows’ milk-based infant for-mula.’ It also concluded that, ‘Substituting goat milk protein for cows’ milk protein in infant formula intended for cows’ milk allergic infants cannot be considered safe, unless proven to be so in clinical and in vitro studies.’ (36) Government advice at present is, therefore, that, ‘Goat milk infant formula and follow-on formula is not suitable for infants with a cows’ milk protein allergy unless directed by a healthcare professional.’

suMMaryOptimum nutrition during infancy is not only important for normal growth and develop-ment, but also for long-term health. Where breast milk is not available, it is essential that infant formulas can provide, as close as pos-sible, the equivalent nutritional and health outcomes for babies as for those infants who are breastfed.

Government advice at present is .

. . ‘Goat milk infant formula and

follow-on formula is not suitable

for infants with a cows’ milk

protein allergy unless directed by a

healthcare professional.’

NHDmag.com February 2015 - Issue 10146

infant feeding: dairy

references1 Lucas a. Programming by early nutrition: an experimental approach. J Nutr 1998;128 (suppl 2):401-6S2 wHO Diet, Nutrition, and the Prevention of chronic Disease. report of a joint wHO/FaO expert consultation. 20033 SacN (2011 a). the influence of maternal, fetal and child nutrition on the development of chronic disease in later life (online). London SacN. available at www.

Gastroenterology and Nutrition 41:584–599, November 2005. eSPGHaN committee on Nutrition6 codex alimentarius commission (2007). Standard for infant formula and formulas for special medical purposes intended for infants cODeX StaN 72-1981

(amended 2007)7 Silanikove N, Leitner G, Merin U et al (2010). recent advances in exploiting goat milk: quality, safety and production aspects. Small rum res 89, 110-1248 Haenlein GFw (2004). Goat milk in human nutrition. Small rum res 51, 155-1639 razafindrakoto O, ravelomanana N, rasolofo a et al (1994). Goat milk as a substitute for cows’ milk in undernourished children: a randomised double-blind

clinical trial. Pediatrics 94, 65-6910 Ziegler DS, russell SJ, rozenberg G et al (2005). Goat milk quackery. J Pediatr child Health 41, 569-57111 basnet S, Schneider M, Gazit a et al (2010). Fresh goat milk for infants: myths and realities - a review. Pediatrics 125, e973-e97712 taitz LS and armitage bL (1984). Goat milk for infants and children. br Med J (clin res ed) 288, 428-42913 baur La and allen Jr (2005). Goat milk for infants: yes or no? J Paediatr child Health 41, 54314 european Food Safety authority (2012). Opinion of the Scientific Panel on Dietetic Products, Nutrition and allergies on a request from the commission relating

to the suitability of goat milk protein as a source of protein in infant formula and in follow-on formula. the eFSa Journal 10 (3):260315 wooding FbP, Peaker M, Linzell JL (1970). theories of milk secretion: evidence form electron microscopic examination of milk. Nature, 226, 762-416 Zhou SJ, Sullivan t, bibson ra, Makrides M (2011). How does goat milk infant formula compare to cow milk formula? a randomised controlled trial. Journal of

Pediatric Gastroenterology and Nutrition, 52, e20817 Lindquist S and Hernell O (2010). Lipid digestion and absorption in early life: an update. curr Opin clin Nutr Metab care, 13, 314-2018 Prosser cG, McLaren rD, Frost D, agnew M, Lowry DJ (2008). composition of the non-protein nitrogen fraction of goat whole milk powder and goat milk-

based infant and follow-on formulae. Int J Food Sci Nutr, 59, 123-3319 Singhal a et al (2013). Dietary Nucleotides and early Growth in Formula-Fed Infants: a randomised controlled trial. Published online September 13, 2010

Pediatrics Vol 126 No 4 October 1, 2010 pp e946 -e953 (doi: 10.1542/peds.2009-2609)20 Prosser cG, McLaren rD, Frost D, agnew M, Lowry DJ et al (2008). composition of the non-protein nitrogen fraction of goat whole milk powder and goat

milk-based infant and follow-on formulae. Int J Food Sci Nutr, 59, 123-3321 rutherfurd S, Moughan P, Lowry D et al (2008). amino acid composition determined using multiple hydrolysis times for three goat milk formulations. Int J Food

ci Nutr 59, 6709-69022 Koletzko b, von Kries r, closa r, escribano J, Scaglioni S, Giovannini M, beyer J, Demmelmair H, Gruszfeld D, Dobrzanska a et al. Lower protein in infant

formula is associated with lower weight up to age two: a randomised clinical trial. am J clin Nutr.2009;89:1836-4523 escribano J, Luque V, Ferre N, Mendez-riera G, Koletzko b, Grote V, Demmelmair H, bluck L, wright a, closa-Monasterolo r. effect of protein intake and

weight gain velocity on body fat mass at six months of age: the eU childhood Obesity Programme. Int J Obes (Lond) 2012; 36:548-5324 Janas LM, Picciano MF and Hatch tF (1987). Indices of protein metabolism in term infants fed either human milk or formulas with reduced protein

concentration and various whey casein ratios. J pediatr 110, 838-84825 Janas LM, Picciano MF and Hatch tF (1985). Indices of protein metabolism in term infants fed human milk, whey predominant formula or cows’ milk formula.

Pediatrics 75, 775-78426 rutherford SM, Darragh aJ, Hendriks wH et al (2006). true ileal amino acid digestibility of goat and cows’ milk infant formulas. J Dairy Sci 89, 2408-241327 Global Standard for the composition of Infant Formula: recommendations of an eSPGHaN coordinated International expert Group. Journal of Pediatric

Gastroenterology and Nutrition 41:584-599, November 2005. eSPGHaN committee on Nutrition28 Koletzko b, ashwell M, beck b et al (2002). characterisation of infant food modifications in the european Union. ann Nutr Metab 46, 231-24229 Grant c, rotherham b, Sharpe S et al (2005). randomised double blind comparison of growth in infants receiving goat milk formula versus cows’ milk infant

formula. J Paediatr child Health 41, 564-56830 eFSa Panel on Dietetic Products Nutrition and allergies (2004). Scientific opinion on the suitability of goat milk protein as a source of protein in infant formulae

and in follow-on formula. eFSa J 30, 1-1531 Zhou SJ et al (2014). Nutritional adequacy of goat milk infant formulas for term infants: a double-blind randomised controlled trial. british Journal of Nutrition

111, 1641-165132 Fiocchi a, brozek J, Schunemann H, bahna SL, von ba, beyer K et al. world allergy organisation (waO) diagnosis and rationale for action against cows’ milk

allergy (DracMa) guidelines. world allergy Organ J, 2010, 3(4):57-16133 ballabio c, chessa S, rignanese D, Gigliotti c, Pagnacco G, terracciano L, Fiocchi a, restani P and caroli aM (2011). Goat milk allergenicity as a function of

alphas-casein genetic polymorphism. Journal of Dairy Science, 94, 998-100434 Infante Pina D, tormo carnice r and conde Zandueta M (2003). Use of goat’s milk in patients with cows’ milk allergy. anales de Pediatria, 59, 138-142.35 Pessler F, Nejat M. anaphylactic reaction to goat’s milk in a cows’ milk-allergic infant. Pediatr allergy Immuno, 2004,15(2):183-536 eFSa Journal (2012) 10(3):2603. Scientific Opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow-on formulae

Until recently, most of the conclusive stud-ies in human infants published in the inter-national literature have been limited to the evaluation of cows’ milk or soy protein-based infant formulae. However, there is now pub-lished evidence that goat milk infant formula is a safe and suitable alternative to cows’ and soy-based formulas and is approved for use.

Goat milk has several features that have great-er similarity to human breast milk than cows’ milk. There is no evidence to suggest that there is any advantage to including extra whey pro-teins in goat infant formula. Goat milk infant formula, however, is not suitable for infants with a cows’ milk protein allergy, unless directed by a healthcare professional.

sacn.gov.uk/pdfs/sacn_early_nutrition_final_report_20_6_11.pdf (accessed July 2014)4 aaP (2012). breastfeeding and the use of human milk. Pediatrics 129, e827-e8415 Global Standard for the composition of Infant Formula: recommendations of an eSPGHaN coordinated International expert Group. Journal of Pediatric

Staying well-nourished can be a challenge for patients who have difficulty chewing or swallowing. Those on a puréed diet are faced with:

• Messy and dissatisfying results

• Reduced nutritional content

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• Reduced choice – unable to enjoy high risk foods, such as peas

Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether. The good news is there is a more appetising alternative.

Made in a blender at home

Staying well-nourished can be a challenge for patients who have difficulty chewing or swallowing. Those on a puréed diet are faced with:

• The danger of not blending to a safe consistency

• Messy and dissatisfying results

• Reduced nutritional content

• Time-consuming food preparation

• Reduced choice – unable to enjoy high-risk foods like peas

Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether.

The good news is there is a more appetising alternative…

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Beef & Gravywith mashed potato and peas

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NHDmag.com February 2015 - Issue 10148

weB watCH

WeB WAtCh

Online resources and useful updates.

TRANSFERRING RENAL DIALYSIS AND MORBID OBESITY SURGERY SERVICES TO CCGS

NEw INVESTMENT FOR TREATING EATING DISORDERS

EVIDENCE UPDATE: HYPERPHOSPHATAEMIA IN CHRONIC kIDNEY DISEASE

VITAMIN D GUIDANCE FOR PROFESSIONALS AND PUBLIC

NICE CG189NICE has issued new clinical guidance: ‘Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (CG189)’. This guideline updates and replaces section 1.2 of NICE clinical guide-line 43 (published December 2006). It offers evidence-based advice on the care and treatment of obesity. New recommendations have been added about low-calorie and very-low-calorie diets, bariatric surgery and follow-up care. www.nice.org.uk/guidance/CG189

The new investment aimed at reform-ing the treatment of children and young people with eating disorders paving the way for new waiting time standards has been announced by the Deputy Prime Minister. The investment, which will be rolled out over five years, is part of an ongoing campaign by the government to bring mental health services on a par with physical care. It comes just a month after research revealed that an increas-ing number of young people, from as young as five, are being admitted to hospital for treatment of eating disorders, with those aged 14 to 25 most likely to be affected. www.gov.uk/government/news/deputy-pm-announces-150m-investment-to-trans-form-treatment-for-eating-disorders

NICE has published a new evidence update ‘Hyperphosphataemia in chronic kidney disease’ (Evidence update 72). It provides a summary of selected new evidence relevant to NICE clinical guideline 157: ‘Management of hyperphospha-taemia in patients with stage 4 or 5 chronic kidney disease’ (2013). www.evidence.nhs.uk/about-evidence-services/bulletins-and-alerts/evidence-updates/evidence-updates-by-date

The Department of Health has launched ‘A consultation on ar-rangements for the transfer of com-missioning responsibility from NHS England to Clinical Commissioning Groups: Renal dialysis services and morbid obesity surgery services’. The Department wants to know what type of support CCGs will need from NHS England to be able to commission these two services safely and effectively. They are also asking whether the transfer should happen from 1 April 2015, if they can put that support in place. The results will be analysed and used to inform decisions on when and how the transfer in commission-ing responsibility should be made.www.gov.uk/government/consul-tations/transferring-services-from-nhs-england-to-ccgs

START wELL, LIVE BETTERThe Faculty of Public Health has published its 12-point action plan for public health. ‘Start well, live better’ is the culmination of an extensive consultation with fac-ulty members about the top public health priorities for this govern-ment and the next. It is not a defini-tive list of what needs to change; instead, it represents what members believe to be those priority areas where specific and urgent action is needed. Action that will improve people’s health and wellbeing, save lives, and give children and young people the best possible chance of achieving a healthy future are included. www.fph.org.uk/start_well%2c_live_better_-_a_manifesto

Public Health England has published guidance, aimed at both health professionals and the public, highlighting awareness of the risks of vitamin D deficiency. ‘Vitamin D information for health-care professionals’ aims to make health professionals aware of the significant difference they can make to people’s health be ensuring that those people most at risk, are aware of the implications of vitamin D deficiency, and most importantly, what they can do to prevent it. ‘Vitamin D: All you need to know’ is aimed at the general public and explains how vital Vitamin D is in keeping bones and teeth healthy and its importance in helping the body absorb calcium. www.gov.uk/government/publications/vitamin-d-for-healthcare-professionals-and-the-public

…created by Wiltshire Farm Foods’ award-winning chef

Our award-winning Puréed, Pre-Mashed & Fork Mashable meals make a genuine difference to the people who use them. We ensure each recipe is:

• Made to the specific requirements of Category C, D or E diets

• Great-tasting and visually appealing

• Nutritionally balanced

• Quick and easy to prepare

• Increased choice – prepared to safely include high-risk foods like peas

Visit www.wiltshirefarmfoods.com/dysphagiadiets or call 0800 066 3169 to request our free dysphagia brochures and help your patients put the meal back into mealtimes.

Created by our chef for people with dysphagia

Beef & Gravy with mashed potato and peas

WFF045_TM_NHD_160x223_Ad_v01.indd 2 29/09/2014 18:49

Issue 101 February 2015NHDmag.com

IMPLEMENTING A COMMUNITY FOOD STRATEGY ACROSS

BRIGHTON & HOVEADULT FOOD ALLERGY

LACTOSE INTOLERANCE

COELIAC DISEASE

COWS’ MILK VS GOAT MILKLouise DickieSpecialist Stroke Dietitian

DYSPHAGIA AND NUTRITIONAL INTERVENTIONS IN STROKE CARE . . . p29

ISSN 1756-9567 (Print)

WEB WATCH NEW RESEARCH

Lauren McCormack p9

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NHDmag.com February 2015 - Issue 10152

Career

To place a job ad here and on www.dieteticJOBS.co.uk

please call 0845 450 2125 (local rate)

d i e t e t i c J O B S . c o . u k

Band 6 dietitian - HoMe Based - soutH westWe are currently looking for a Band 6 Dietitian who would like to move away from clinical work and into a commercial position within a leading service provider. This position is home based with travel once a week to client sites. This specific area of the business provides frozen meals to the healthcare industry and is based within the South West region, so applicants must be able to travel once a week within this area, including NW, Midlands etc. Interviews are to be held as soon as possible, so if you feel you may be interested, or would like to see a full Job spec, then please either call Hayley at Elite on 01277 849 649 or email hayley@eliterec.com

renaL dietitian, Band 6/7 - CHesHireWe are looking for a Renal Dietitian Band 6/7 to com-mence mid-February for a period of three to four months, preferably a car owner/driver as some cover will be needed at a satellite unit. Hours negotiable full time/part time. Please call 01277 849649 or email hay-ley@eliterec.com www. elitedietitians.com

Band 6 CoMMunity dietitian - BerksHireBand 5/6 Community Dietitian required to cover GP clinics, inpatient community wards, nursing homes and local clinics. Please call 01277 849649 or email hay-ley@eliterec.com www.elitedietitians.com

Band 5/6 PaediatriC CoMMunity dietitian - HertfordsHireBand 5/6 Paediatric Community Dietitian required four days a week covering general clinics. Case load will include: allergies, weight management, faltering growth and fussy eating. Experience in children’s dia-betes and paediatric home enteral feeding would be an

advantage. Case load is all outpatient based so ability to travel between bases and places of work is needed. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com

Band 5/6 CoMMunity dietitian - nw engLandNorth West England Band 5/6 Community Dietitian is required to cover a nutrition support role cover-ing clinics and home visits, applicant must have own transport. Starting as soon as possible, full time until the end of March. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com

Band 6 PaediatriC CoMMunity dietitian - essexBand 6 Paediatric Community Dietitian required to cover either a full- or part-time role. A car will not nec-essarily be required as this role could be based at one site doing clinics. To start ASAP until end of March. Please call 01277 849649 or email hayley@eliterec.com www.elitedietitians.com

sPeCiaList dietitian - eating disordersBand 6 Specialist Dietitian with experience of eating dis-orders for an ongoing contract. This is a hospital-based post in the South of England. For this and similar jobs, please contact Patrice at PJ Locums on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accom-modation. We provide you with a current CRB, full occupational health check and can organise your man-datory training. PJ Locums is an NHS Government Pro-curement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate)

dieteticJOBS.co.ukThe UK’s largest dietetic jobsite

NHDmag.com February 2015 - Issue 101 53

Career

0800 023 2275info@eliterec.com www.elitedietitians.com

Elite Recruitment are a specialist supplier to private hospitals & commercial companies. We are a preferred

supplier to NHS trusts nationwide and are the only agency dedicated to dietetic recruitment.

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JOB OF THE MONTH PAEDIATRIC DIETITIANS URGENTY REQUIRED

We are urgently looking for experienced paediatric dietitians to cover posts in Hertfordshire, London

and Essex. We have Full and Part Time Posts available in both Acute and Community. Excellent

rates of pay – up to £30.00ph.

UNIVERSITY OF NOTTINGHAM - SCHOOL OF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals• IBS & the Use of the FODMAPs Diet Study Day -

18th March 2015• Nutrition Support Module - 22nd & 23rd April, 27th MayFor further details please contact Marie Coombes via e-mail on marie.e.coombes@nottingham.ac.uk or check out the University website at www.nottingham.ac.uk/biosciences and click on ‘Study with us’ and then ‘short courses’ which will take you to ‘for practising dietitians’.

twitter for CLiniCians & HeaLtHCare Managers

25th February A Practical Guide to developing your skills in Social Media Hallam Conference Centre, London www.healthcareconferencesuk.co.uk/social-media-twitter-nhs

aso ConferenCe: satiety - froM origins to

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3rd March Association for the Study of Obesity Institute of Child Health, London www.aso.org.uk/conferences/

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We urgently require dietitians for immediate vacancies

To find out your options call or email

Freephone: 0800 032 0454 Registration@pjlocums.co.uk

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• We offer inpatient and community UK & NI coverage

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www.pjlocums.co.uk

NHDmag.com February 2015 - Issue 10154

For me, this has always been a very use-ful and beneficial exercise. This year, it in-cludes the regular birthdays, anniversaries, holiday dates, Preston North End FC home games, Wales Rugby Union matches, mu-sic festival (last year it was the Secret Gar-den Party in Abbots Ripton, Huntingdon, Cambridgeshire; this year we are heading off to Festival Number 6 in Portmeirion, North Wales) etc. Where is this heading I hear you ask? Well, my diary will also include a few tasks, hopes and professional activities that I would wish to consider either un-dertaking or maintaining. One of these has always been to look after my own health, which includes weight, as much as I can. For someone who has always en-joyed participating in sport and has spent all his professional life working under a weight management umbrella, (my final year University dissertation in 1970 was entitled ‘fitness and fatness’), I understand and appreciate the huge health benefits that this gives which echo through all my activities and also forms the backbone of my diary, if not my life. So, my agenda for the first couple of months of 2015 is to declutter my ‘stuff’. This is going well. I also set myself the small task of addressing the obesity prob-lem, particularly with reference to its de-mands on the NHS, through the pages of this publication and the possibility of a United Kingdom Obesity Party (UKOP). This hybrid seedling has failed to germi-nate. Without going into any details, I guess

it’s no surprise. As I write, I hear that four out of five adults who listed losing weight as their New Year’s resolution have al-ready thrown in the towel. Why should we expect anything other than a half-hearted whim to elicit a change in behaviour that needs to last months if not years? What was I thinking? We are in second place behind Hungary (very apt) of the 26 nations in Europe’s Obe-sity League. Individuals and institutions are groaning under the weight of ‘feast-ers, emotional eaters and constant cravers’ who are barricading our hospital beds. It’s a no go political nightmare when you are likely to alienate at least 25 percent of the population. I returned home last Thursday evening and listened to Question Time on the BBC which of course will now have a question about the NHS every week up to the election in May. Obesity is mentioned, but never dare to question that it forms part of an individual’s responsibility to manage their weight and reduce their likelihood for future demands on the service. I take my hat off to the work of the Na-tional Obesity Forum and their representa-tives, usually Tam Fry and David Haslam, who are saying what the politicians daren’t say. “As a country we need to do more. We should be under no illusions. Obesity has the potential of breaking the NHS.” I have just checked my diary and see that we have a weekend in London booked in February. Must make sure I go on the recently renamed Coca-Cola London Eye! “Keep dancing”.

the fiNAL heLPiNG

I have a plan. To be fair, ever since I can remember, I have gathered my thoughts at the very end of one year and put them, together with any plans for the next, in my new diary. This year has been no exception, except that social activities and events now seem to be well catered for in the ‘working’ week.

neil donnelly

Neil is a Fellow of the bDa and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders

Neil Donnelly’s

Diary

2015

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References 1. WHO World Health Organisation. Report of a Joint WHO/FAO/UNU Expert consultation. WHO Tech Rep Ser 2007(935): 1-265. 2. Clarke SE et al. J Hum Nutr Diet 2007; 20: 329-339. 3. Van Waardenburg DA et al. Clin Nutr 2009; 28: 249-255. 4. de Betue CT et al. Arch Dis Child 2011; 96: 817-822. 5. Bueno AL et al. Euro J Clin Nut 2010; 64(11): 1296-1301. 6. Black RE et al. Am J Clin Nut 2002; 76: 675-680. 7. Greer FR, Krebs NF Pediatrics 2006; 117(2): 578-585. 8. Leach JL et al. Am J Clin Nut 1995; 61: 1224-1230.

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