Issue 108 October 2015NHDmag.com

ISSN 1756-9567 (Online) Dr Mabel Blades p11

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A DAY IN THE LIFE OF A RENAL DIETITIAN...

Heather AlfordRegistered Dietitian, East & North Hertfordshire NHS Trust

NUTRITIONAL ASPECTS OF HIGH FIBRE CEREALINGREDIENTSby Carrie Ruxton

THE FOOD THEORY OF EVERYTHING

by Ursula Arens

NHDmag.com October 2015 - Issue 108 53

The celebrity physicist Professor Stephen Hawking may be trying to find the num-ber or equation that defines ‘time’; but you do not have to understand physics to enjoy the insight into his professional and personal challenges as beautifully portrayed in the film The Theory of Ev-erything. Dr Toni Meier of the Martin Luther University in Halle Wittenberg in Germany, has the more modest ambi-tions of developing a menu system that combines the criteria of both nutrition quality and environmental impacts. Can these chalks and cheeses be combined to form a single menu rating that is mean-ingful and something that every caterer will be able to use to traffic-light menus into red-no or green-yes decisions? The computer algorithm Dr Meier has developed is called susDISH (from the term sustainable dish). More than 1000 menus have been rated, and cater-ers in many public and private institu-tions in Germany will be doing trial runs. Canteens, such as those of the car production sites of BMW, or of the Universities of Berlin, already mandate nutrient scoring systems, and adding eco points or greenhouse gas emis-sion scores is just further fine tuning. “Where’s the Beef?” is a well-known American catchphrase first used by the hamburger chain Wendy’s to pro-mote its claims of more-meat than rival burgers, but now it’s a phrase used by politicians and others in debate want-ing facts and detail. It may also be the question that German canteen users ask after a susDISH menu analysis. There are three aspects to the sus-DISH analysis. Firstly health points, which are based entirely on the nutrient content of the meal. There are 16 macro

and micronutrients included in the cal-culation, with minimum cut-offs calcu-lated to provide one third of reference intakes (for, example, lunch), with mar-gins of 5.0% over or under the cut-offs. For a few nutrients, there are maximum cut-offs (protein/fat/sodium/choles-terol). Only energy contents, which are based on figures of adult Physical Activ-ity Levels (PALs) of 1.6, have the wider margin of 10% over or under cut-offs. The more nutrients there are within the cut-offs, the higher the health points, the top score being 16 for the attain-ment of all the nutrient and energy cri-teria. Health points analysed for sample menus score highest for menus that include meat and lowest for the vegan menus, although the span of about two points indicate minor differences over the full range of zero to 16 (see Table 1). Typical faults for menus are inadequate levels of calcium or vitamin B12, and excess levels of sodium. Meat-contain-ing menus can maintain high nutrition scores with smaller meat portion sizes, so health point optimisation can be more a process of changing recipes rather than changing ingredients. The second aspect is the eco-point score. This method of analysis was de-veloped and is widely used in Switzer-land (Frischknecht, 2013) and uses mea-sures of ecological scarcity. Criteria are based on national targets and capture field-to-fork analysis of a wide diversity of ecological aspects of food production and preparation, such as pesticide use, water use, air pollution, soil degradation, nitrate excess and loss of biodiversity. Eco-points vary very widely per kilo of product; Beef hits 1344 points, but other animal-source foods scatter less predict-

the (food) theory of everything

the susdiSH analysis system for scoring menus

NHD extra - MenU scorinG

review byUrsula arens writer; nutrition & Dietetics

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews

for article information sources please email info@network healthgroup.co.uk

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NHD extra - MenU scorinG

ably (butter 811, cheese 549, milk 131, pork 511, poultry 336, eggs 238 and fish 51-164). Of course the gradient of milk to cheese to butter reflects the concentration of the product from processing, and weight quantities of butter consumed are usually lower than those of milk, so recipe level scores are different (see Table 1). All plant-source foods score below 200 eco points per kilo. The third and final aspect included in the susDISH analysis method, is the calculation of greenhouse gas emissions that can be attributed to food products. Although carbon footprint data is only one component in the assessment of environmental impacts, it has a defined methodology of assessment that allows clear categorisation of products (see Table 1). Dr Meier calculated health and eco points from different menu items, and used traffic light band-ing to illustrate results in a scattergram (see Figure 1). The red zones were dominated by beef dishes on the eco points axis and by a few pork and vegan dishes on the health points axis. This data could be used to cut red menu items from the catering ros-ter, or to present data to consumers to allow their ‘informed choice’ on these issues. It could also be used to schedule red meal items into smaller por-tion size or less frequent offerings on the menu cycle. Obvious and pragmatic conclusions could be drawn, that computer algorithms can only end-lessly fine-tune what are long-established con-clusions, that beef consumption has the greatest adverse environmental impacts, and vegan diets have certain nutrient deficits that benefit from the use of fortified foods or supplementation. Some further analysis of menu data shows that, where recipe adjustments are made to improve scoring for eco points or greenhouse points, there is usually also an added benefit to the caterer of a reduction of the cost of ingredi-

ents. Obviously, this relates to reduced portion sizes of what is usually the most expensive in-gredient (meat). In contrast, adjustments to im-prove the health point scores of vegan recipes may result in increased costs, due to the use of specialist or more expensive ingredients. Another assessment of nutrition and environ-mental impacts has been carried out by the Swiss canteen company SV Group and the World Wide Fund for Nature (WWF) group in Switzerland. Life Cycle Analysis (LCA) of all food purchases made by the catering group was calculated and a 20% reduction in greenhouse gas emissions was identified by the introduction of three measures:1. Reduction of food waste by changes to spec-

ifications, and changes in kitchen practice.2. Reduction in the use of vegetables grown in

heated greenhouses, and increased use of foods that are seasonal and not transported by air.

3. Reduction in the amounts of meat per meal and greater availability and frequency of vegetarian meal choices.

The catering initiative, launched in more than 70 Swiss staff canteens, was branded ‘One Two We’ (meaning One – you the customer, to-gether with SV catering making Two partners, and together We aim to reduce greenhouse gas emissions). The programme was awarded the 2013 Zürich Climate Prize. Nutrient analysis of menus is long estab-lished and assessment of sustainability criteria in catering decisions is also very familiar, if still rather variable and inconsistent in the criteria and weightings used. The ability to integrate such data is an appealing concept for those in-volved in catering (especially for those involved in the marketing of catering services), and dieti-tians should seize the opportunities offered by the demand for nutrition-plus information.

menu n= Health points>=√ eco points>= X greenhouse points >=X

Mixed menu 155 11.8 104 1.6

Beef dishes 19 12.7 273 4.1

pork dishes 34 11.5 114 1.7

poultry dishes 25 12.3 87 1.4

vegetarian 40 11.7 71 1.1

vegan 14 10.6 42 0.8

table 1: sample scores for different menus

NHDmag.com October 2015 - Issue 108 55

According to the Eatwell plate, cereals form part of the starchy food category that should comprise 33% of the diet by volume. Commonly-consumed cereal foods include breakfast cereals, pasta, rice and bread, as well as the more dis-cretionary options of biscuits, cakes and buns. Breakfast cereals contain an array of cereal ingredients, many of which offer nutritional benefits, or which could be classed as ‘wholegrain’. This article will consider some of these ingredients, particularly in the light of EU authorised health claims.

health claiMsSince 2012, all health claims made on food and drink products must be au-thorised based on the available sci-entific evidence. Table 1 presents the health claims that can be made for ce-real ingredients. While it is accepted that manufacturers will present health claims on pack in language more ap-propriate for consumers, it is never-theless recommended that the word-ing remains as close as possible to the original statement in order to avoid misleading consumers. Examples of wording on pack include: ‘to give di-gestion a helping hand’, or ‘to help ac-tively reduce cholesterol’.

wheatWheat is the second most important crop worldwide after rice and is a ma-jor staple in several regions.3 The wheat grain consists of a germ, endosperm (which is the starchy element) and bran

fractions which are high in fibre and make up 14-16% of the grain.4

Wheat contains vitamins: thiamin, riboflavin, vitamin B6, folate and vi-tamin E, as well as sulphur-containing amino acids and phenolic compounds which express antioxidant character-istics. As reviewed by Stevenson et al4, several observational studies have associated wheat fibre with a reduced risk of cardiovascular disease and Type 2 diabetes. In addition, a recent meta-analysis5 confirmed that higher intakes of wheat bran were linked with reduced risk of Type 2 diabetes. However, the few randomised controlled trials (RCT) are contradictory. The discrepancy may be because viscosity of fibre is the key factor in delivering metabolic effects.6

Observational evidence also ex-ists for an inverse association between wheat fibre intake and cancer risk4 This is backed by two large clinical trials (n=3209 combined) which found that men, but not women, with higher in-takes of wheat bran had a 19% lower risk of colorectal adenoma recurrence.7

oatsOats are consumed mainly in Europe and are a source of thiamin, niacin, fo-late, vitamin E, phosphorus, iron, mag-nesium and zinc. They are also rich in the soluble fibre, beta-glucan, which has been proven to lower LDL choles-terol. Beta-glucan works by boosting the transport of bile acids through the gastrointestinal tract which enhances their excretion via faeces. This, in turn,

nutritionAl ASPeCtS of high fiBre CereAl ingredientS

cereals

carrie ruxton phD, freelance Dietitian

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.

Cereals and cereal products are a major part of Western diets, providing in the uk with more than one third of daily energy intakes, around a quarter of protein intakes, 40% of fibre intakes and significant amounts of vitamins and minerals.1

for article references please email info@networkhealth group.co.uk

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stimulates the synthesis of new bile acids from endogenous and dietary cholesterol which low-ers blood cholesterol levels.8

There is consistent evidence to link consump-tion of oats with cardiovascular health via a direct impact on total and LDL cholesterol and, possibly, via changes to post-prandial glycaemia and blood pressure.9 A systematic review evaluated the pub-lished literature on oats and lipid management finding that oats significantly lowered total or LDL cholesterol in most of the 21 RCT included.10 A more up-to-date systematic review confirmed these findings for cholesterol, but disputed whether oats had any impact on blood pressure or glycaemia due to under-powered RCT.11

Oats have been identified as having a role in weight management, but the evidence can be inconsistent. A 12-week RCT in 144 participants found a reduced waist circumference in those giv-en an oat cereal versus a low fibre control cereal.12 However, in two other trials, there was no spe-

cific weight loss attributed to the high oats diet, although metabolic benefits were apparent.13, 14

ryeThe rye grain is related to wheat and barley and is commonly used in Europe for bread flour and muesli. Health aspects of rye include blood lipid reduction, glycaemic control and weight management. An acute trial in 12 healthy subjects found that rye products produced a significantly lower insulin response compared with a control wheat bread, which was not related to the glycaemic index (GI) of the products, suggesting that other bioactive properties were at work.15 In addition, rye had a greater impact on satiety compared with the control food. A four-week trial in 21 par-ticipants confirmed these findings and reported that wholegrain rye was associated with a sig-nificant reduction in post-prandial glucose and insulin, as well as an increase in short-chain fatty

ingredient Claim Amount needed

wheat bran fibre

contributes to an acceleration of intestinal transit

10g wheat bran fibre daily. food must also qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

contributes to an increase in faecal bulkfood must qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

oat grain fibre contributes to an increase in faecal bulk as above

oat beta-glucan

contributes to the maintenance of normal blood cholesterol levels

food must contain at least 1.0g beta-glucan per portion and must state that beneficial effects occur at daily intakes of 3.0g

contributes to the reduction of the blood glucose rise after a meal

food must contain at least 4.0g of beta-glucan for each 30g of available carbohydrates per portion and should be eaten as part of a meal

lowers blood cholesterolfood must contain at least 1.0g beta-glucan per portion and must state that beneficial effects occur at daily intakes of 3.0g

Barley beta-glucan

contributes to the maintenance of normal blood cholesterol levels

as above

contributes to the reduction of the blood glucose rise after a meal

food must contain at least 4.0g of beta-glucan for each 30g of available carbohydrates per portion and should be eaten as part of a meal

Barley grain fibre contributes to an increase in faecal bulkfood must qualify for a ‘high in fibre’ nutrition claim (6.0g per 100g)

rye fibre contributes to normal bowel function as above

table 1: Authorised health claims for cereal ingredients2

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acids, suggesting colonic fermentation of rye con-stituents.16 However, a crossover trial in women with impaired glucose tolerance found no effect of rye on insulin sensitivity, although acute post-prandial insulin excretion was higher.17

Turning to lipid reduction, a crossover trial in 40 adults with hypercholesterolaemia found sig-nificant reductions in total and LDL cholesterol when rye was consumed, but only in men.18 A dose response was also noted. These effects were confirmed by a later trial in 63 healthy adults which noted that LDL cholesterol became more re-sistant to oxidation with each rise in the consump-tion of rye.19 The addition of plant sterols had no observed impact on LDL cholesterol oxidation.

BarleyBarley is a fibre-rich grain that contains signifi-cant levels of beta-glucan and insoluble fibre, and has been classified as low GI.20 Originally used by animal feed and brewing sectors, barley is now being incorporated into a greater variety of food products due to its health benefits. In a five-week RCT, involving 18 men with hypercholesterolaemia, partially replacing usual carbohydrates with barley-rich products, total cholesterol, LDL cholesterol and triglycer-ides were significantly lowered without reduc-ing HDL cholesterol.21 The positive impact was most likely mediated via changes in soluble fibre. Similar findings were reported when an experimental diet containing barley and le-gumes was compared with a healthy control diet matched for fibre content.22 In the 46 fe-male participants, significant reductions were seen over four weeks in total cholesterol, LDL cholesterol and diastolic blood pressure. Un-like the previous study, HDL cholesterol levels did reduce. Further research20 suggests that the beta-glucan content of barley can lower blood glucose and insulin responses, while the overall soluble fibre content appears to stimulate pro-duction of GLP-1, a satiety hormone.

DiscUssion anD conclUsionsThis brief review highlights the benefits associ-ated with increased consumption of fibres from wheat, oats, barley and rye. Studies consistent-ly report associations with lipid management and, in some cases, glycaemic control. Studies on weight loss and blood pressure control are less consistent. The benefits appear to be medi-ated via fibre, often soluble fibre such as beta-glucan and other bioactive compounds. Given the habitual low fibre intakes in the UK at 14g in adults and 12g in children com-pared with the Dietary Reference Value of 18g, it is well accepted that choosing wholegrain op-tions is a positive step. No specific wholegrain targets exist in the UK, but in the US and Can-ada, it is recommended that adults and older children consume three to five 16g wholegrain portions daily. An analysis of the National Diet and Nutrition Survey found that median wholegrain intakes were 20g in adults and 16g in children, i.e. just over one portion daily.23 Only 17% of adults and 6.0% of children met the US/Canadian recommendation. A system-atic review24 confirmed associations between wholegrain foods and reduced risk of chronic conditions. In conclusion, the promotion of wholegrain or high fibre cereals, such as oats, barley, wheat and rye, could significantly benefit health as supported by European health claims. Manu-facturers should be encouraged to include more of these ingredients in products.

acknowledgementThis work was supported by the Breakfast Cereal Information Service, an independent informa-tion body set up to provide balanced information on breakfast cereals. It is supported by a restricted educational grant from the Association of Cereal Food Manufacturers. See www.breakfastcereal.org for more information.

Barley is a fibre-rich grain that contains significant

levels of beta-glucan and insoluble fibre, and has

been classified as low GI.

NHDmag.com October 2015 - Issue 10858

If you had asked me when I was grad-uating university whether I would be a Renal Dietitian in the next few years, I doubt I would have said yes. Although I enjoyed the biochemistry and medical complexities of the kid-ney in my studies, I was still a little bit scared of them before I accepted the job at the Lister Hospital in Ste-venage. I didn’t have any renal expe-rience when I first started in my job, but the benefit of working in a multi-professional environment is that you are always learning from someone.

My workload largely involves the main haemodialysis unit based within the hospital. I also see low clearance and post-transplant patients in clinic and cover the renal ward when need-ed. The dialysis unit has approximately 115 patients, including those who have recently started dialysing and those who have more complex conditions or who are unwell on dialysis needing more nursing care and are unable to dialyse at the satellite units. I normally start my day at 8.30am, unless I am doing a twilight shift to see the patients who dialyse in the evenings.

I prep the dialysis patients to see that day. We tend to see our patients on dialysis, as they are generally here for four hours, three times a week and are understand-ably reluctant to have any more time taken out of their day. When I enter the unit, I am asked to review a patient who has come in 7.0kg over their dry weight and has a high potassium level. She is almost blind, has recently had a below knee amputation due to diabetes and is relying on her partner to shop and pre-pare food for them both (her partner’s cooking skills are limited to reheating ready meals). She is permanently hun-gry and immobile and has gained a lot of weight recently. She had no problems with kidney disease until a few months ago and ‘crashlanded’ onto dialysis. This is going to be a challenge and in particu-lar reminds me that, ever increasingly, patients have so many medical and so-cial factors other than the one we have been asked to see them about. While on the unit, another nurse asks me to review a patient who they spotted eating an orange who has a potassium level of 6.2mmol/l. I report back following the consultation that the small orange (4mmol K+ and part of her fruit and vegetable allowance) probably didn’t have much to do with her potassium level; she had a latte (20mmol K+) as a one off and has been having a few more packets of potato crisps (10mmol K+) recently. We came up with a plan to find some suitable substitutes for her snacks and drinks which would still allow her to get the vitamins and minerals from a certain amount of fruit and vegetables.

A renAl dietitiAn

heather alford registered Dietitian, east and north hertfordshire nhs trust

i have worked in a combination of acute and community sectors within the nHS, including renal, where i have worked for the past two years. my areas of interest also include sports nutrition and gastro.

NHD extra - a Day in the life of . . .

My workload largely involves the main

haemodialysis unit based within the hospital.

I also see low clearance and post-transplant

patients in clinic and cover the renal ward

when needed

NHDmag.com October 2015 - Issue 108 59

NHD extra - a Day in the life of . . .

Once a week, after lunch, I meet with the consultant nephrologist, the renal pharmacist and one of the dialysis nurses for our qual-ity assurance (QA) meeting. We discuss a se-lection of the dialysis patients to determine whether they are well dialysed, meeting their biochemistry targets, whether they have any outstanding medical issues, whether they could be referred for an arteriovenous fistula or for transplant and their nutritional status. I make a list of those that would benefit from a review - one who is struggling with their phos-phate binder, one who wants to lose weight to be eligible for transplantation and one who’s intra-dialytic weight gains have increased and will put more strain on their heart and lungs. I spend some of the remainder of the afternoon preparing for the low clearance clinic, a manic multi-professional clinic with those who have progressive kidney disease and who are being worked up for haemodialysis, home-based thera-pies (peritoneal dialysis or home haemodialysis), conservative management or transplant. I have to spend a bit of time preparing this clinic because, although I really want to see everyone on the list, there isn’t enough time. So, I check everyone’s biochemistry and weight history and decide who might be more of a priority. There is generally a

nice range of renal dietetics for every clinic - a couple with small appetites and prescribed nu-tritional supplements, some with high potassium levels, some with high phosphate levels and some with diabetes and/or trying to lose weight. I will generally plan to see a couple of new patients as well, just to introduce myself and explain our role, since many of them won’t have seen a dietitian before. It is always good to explain what we are here for, so that we are more approachable. Here again, I plan to see a few more patients than I re-ally have time for, as there are always a few that don’t want to see the dreaded dietitian! Towards the end of the day, I try to write up my records, I am hot desking in the renal reception office this afternoon and since I am the only one in the office at the time, a couple of patients come up to ask where their appoint-ments are, or try to give me bottles of urine or blood that I really don’t want, for transplant tests and research projects. I smile and pray that the things they are about to hand over aren’t still warm. Even though fistulas and cir-culating haemodialysis machines don’t bother me anymore, this is one step too far for me! Undoubtedly, my write ups get carried over until later in the week, as I run out of time and head home having washed my hands thoroughly!