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