Issue 58 June 2015

Issue x Winter 2015

This issue of Vital summarises highlights from the symposium Meals matter “Putting into meals” held The importance of meals as a unifying framework for elucidating and in Sydney on 28th April 2015. translating -disease relationships into nutrition education was a The topics elicited wide interest with strong theme of the symposium. over 600 people registering to attend either via webinar or at the venue. The symposium was hosted by the Nutrition Society of , sponsored by Meat & Livestock Australia, and supported by the Association of Australia (DAA), Australian Egg Corporation Limited, Dairy Australia, Horticulture Industry of Australia and Grains & Legumes Nutrition Council. The importance of diet quality focused around core foods daily, variety over the week and portion size was a dominant theme. At the same time, the importance of a flexible approach was raised. The webinar can be accessed from the Nutrition Society of Australia and Dietitians Association of Australia websites.

Program of presentations Nutrition education: a nutrition ecological perspective David Raubenheimer, Charles Perkins Centre, Nutrition education: a nutrition Exactly what is a balanced diet depends ecological perspective on many factors, including life stage and ecological circumstances. Putting the mmm into meals. Professor David Raubenheimer cautioned Using diet methodology to against considering the health benefits of Nutrition geometry, a method used by translate food patterns into meals nutrients or foods in isolation and explained Raubenheimer and colleagues, provides a Professor Clare Collins, why focusing on the optimal balance of framework to understand the impact of food University of Newcastle nutrients and foods was preferable. choices on dietary balance. Diabetes and diet: Comparing Palaeolithic diets with today’s a holistic approach To illustrate this point, he demonstrated how protein leverages the intake of fat modern diets illustrates this interaction Professor Samir Samman, where a sensory predilection for high fat, Otago University and carbohydrate. According to the Protein Leverage Hypothesis, protein carbohydrate foods evolved in response Mental health: a whole intake is strongly regulated to prevent to the scarcity of high fat, carbohydrate food approach hyperammonaemia whilst our appetite for foods and the energy limiting effect of Professor Felice Jacka, carbohydrate and fat is less well regulated. protein foods. Whilst this was important for Deakin University Hence, the balance of dietary protein, fat and survival during Palaeolithic times, in today’s Meals for active aging carbohydrate must be considered in order to modern world, there are no ecological Professor Caryl Nowson, determine energy intake. constraints to curb our appetite and prevent Deakin University overconsumption. Similarly, he illustrated how any one food Last night’s dinner on its own is not nutritionally balanced. For It was agreed that dietary fibre is an Veronique Droulez, instance, a steak alone would not constitute a important determinant of energy intake Meat & Livestock Australia balanced meal. Addition of vegetables and a along with protein and hence the quality of carbohydrate food such as rice is required to carbohydrate-rich foods is another important achieve nutritional balance. consideration. 1 1 When it comes to nutrition, context is bioavailability, he suggests having phytate-rich mortality and risk as well as weight loss3,4. everything. For this reason, Raubenheimer foods in separate meals to more bioavailable Diet quality is defined as eating a variety of recommends nutrition education, not zinc sources. foods from each of the core food groups in instruction, relating dietary advice to the meal recommended amounts. rather than to the total diet since this is the Putting the mmm into meals But at the end of the day, what matters most level at which food decisions are made. Translation of Australian Dietary Guidelines is how foods are combined into meals and is critical and Professor Clare Collins getting kids and dads involved in the day to Diabetes and diet: described a number of initiatives for engaging day routine of shopping and making meals a holistic approach the community in healthy eating. Since through community and after school cooking not one of the 7500 young women in the programs is an effective, practical way in which The importance of nutrient interactions Australian Longitudinal Study on Women’s to increase vegetable consumption. was echoed by Professor Samir Samman Health met all of the Australian Guide to who presented evidence on the impact of Healthy Eating targets for daily food group Veronique Droulez shared findings from bioavailable zinc on risk of type 2 diabetes. serves, there is an urgent need for community MLA-funded research on main meal choices Whilst the benefit of a diet high in dietary programs and accessible nutrition education and practices which suggests dinner is an fibre is well established, emerging evidence tools. ideal opportunity to promote healthy eating. suggests a positive association between zinc Popular meals are meat and 3+veg, spaghetti and reduced risk of type 2 diabetes. However, Professor Collins stressed the importance bolognaise, sandwiches, egg-based meals and phytate, found in foods rich in dietary fibre, of personalised dietary advice based on stir fry with some inviting more vegies to the such as nuts, seeds, grains and cereal foods, current dietary patterns and food choices. For plate than others. Almost everyone eats dinner inhibits zinc absorption. instance, in pregnant women, more emphasis and almost three-quarters prepare their meals on food hygiene is required to ensure that from scratch using foods recommended in the Ratio nutrient requirements are not met at the dietary guidelines. Those interested in cooking Bioavailability 2 Phytate:Zn expense of listeria exposure . are most likely to cook from scratch with little Immediate feedback is critical and difference by educational background or <4 High Professor Collins encouraged uptake of household income. mobile technology to satisfy demand for References 4-18 Medium instantaneous, personalised dietary advice. 1. Kuipers et al. Brit J Nutr 104:1666-1687 Smart phones can be used to determine food >18 Low intake from photos taken of the meal with 2. Blumfield ML et al. BMC Women’s Health voice message used for feedback. 2011, 11:37 3. Wirt A and Collins CE. Source: IZINCG 2007 Diet quality is a key focus of Professor Nutrition 2009:12(12);2473-92 Resolving this dilemma requires an holistic Collins’ healthy eating quiz since there is approach which Samman along with good evidence of improvements in health 4. O’Brien K, et al. Nutrition Journal 2014, Dr Garnett and colleagues explored in outcomes, including CVD and cancer 13:82. adolescents with type 2 diabetes. They compared bioavailable zinc intake in Online assessments provide another fast avenue for engaging the community. Newcastle overweight and obese children and teenagers University has developed a 5 minute validated Healthy Eating Quiz which provides feedback with pre-diabetes involved in a randomized in 15 minutes (www.healthyeatingquiz.com.au). The results suggest Australians need more controlled trial comparing a moderate help to eat better. carbohydrate, moderate protein diet with a high carbohydrate, low fat diet. Although Protein foods- Vegetables Fruit Meat/Fish/Chicken absolute zinc intake was similar between the two diets, the ratio of phytate to zinc and the Outstanding prevalence of inadequate absolute as well as Outstanding bioavailable zinc intake were higher on the Excellent

high carbohydrate diet. Needs Work Needs Work Excellent Needs Work ExcellentExcellent It is therefore important to consider the food Getting There source of dietary zinc. Indeed, the impact of zinc deficiency on growth was identified in Getting There Getting There Iranian adolescents low in zinc as a result of their high phytate diet. With this in mind, it is interesting to note a shift in dietary sources of zinc in Australian children from 1995 to 2007 Protein foods - from bioavailable zinc sources such as meat Vegetarian alternatives Grain Dairy and dairy foods to less bioavailable sources Whilst the implications of these dietary changes are unclear, it highlights the risk of Needs Work Excellent focusing on a single nutrient or food and the Needs Work Excellent Needs Work benefit of a meal-based approach to dietary Excellent advice. Samman acknowledges that the Getting There phytate:zinc ratio is difficult to use in practice. Getting There Since the inhibitory effect of phytate occurs Getting There at the level of the meal, to optimise zinc

2 Mental health: a role for dietitians With depression predicted to be the world’s second leading cause of disease burden by 2020, this new and emerging research provides new opportunities for dietitians. Associate Professor Felice Jacka is a mental health, psychiatric epidemiologist who has brought together the fields of mental health and nutrition.

As recently as 2010, the possibility that “dietary intervention at an individual or Red Meat intake and MDD/Dysthymia population level could reduce rates of psychiatric disorders” was first considered 5 in the American Journal of Psychiatry when Jacka reported an association between habitual diet quality and prevalence of mental disorders1. Since then, there is increasing evidence diet quality is related to risk of depression and that the impact of poor diet on long term 2 mental and physical health may start as early as pregnancy2. The association is not explained by socio- economic status and the protective effect of a healthy diet appears to be independent from that of an unhealthy diet with effects apparent within a week. Less Recommended More Systematic inflammation is a major cause of depression and there is increasing evidence that the gut is a key pathway to both physical 0.5 and mental wellbeing via the immune system. Odd ratios and 95% Confidence Intervals - adjusted for age and diet quality With approximately 100 times more bacteria in the gut than cells in the human body, Jacka et al. Psychother Psychosom 2012;81:196-198 producing a wide range of products essential for the normal function of key systems, supplements is generally weak. The strongest compliant with dietary advice because it is including the gastrointestinal, central nervous evidence35.0 is derived from adherence to something they can have control over. and immune systems, gut microbiota have healthy eating patterns with suggestions If successful, the findings have implications been called the ‘second brain’. that30.0 diet quality and balance are key for the role of dietitians as part of the overall underpinning principles. Diet, stress, age and medication have all been 25.0 management of mental health. shown to affect the composition and function Whether20.0 Spanish, Mediterranean or of the gut microbial communities, which in Japanese, Jacka supports a variety of If you are interested in this new turn can affect each of these systems. nutrient-rich,15.0 unprocessed foods from each and emerging field of research, of the five core food groups since depression Studies on single nutrients and foods on 10.0 appears to be more prevalent in vegetarians. visit www.isnpr.org, the home depression have produced inconsistent 5.0 of the International Society for results, although there is evidence that In addition, she believes balance is crucial Nutritional Psychiatry Research dietary fibre, zinc and iron may be important based0.0 on her analysis of red meat intake in for mental health. women whichMeat, chicken showedMilk &that products those consumingCereals & Cereal mixed(ISNPR). Vegetables MembershipFruit is freeBeverages and products dishes more or less than amounts recommend • Fermentation of dietary fibre is critical for open to all those with an interest (i.e. 65-100g serves, 3 to 4 times/week) producing short chain fatty acids which in nutritional psychiatry. had higher levels of depression, anxiety play an important role in driving immune of bipolar disorders than those eating the function. References recommended amounts3. • Several studies suggest low zinc intake 1. Jacka FN et al. Am J Psychiatry 2010; 167: 3 To confirm the role of diet, randomized is associated with increased risk of 2. Lai JS et al. Am J Clin Nutr 2013. controlled trials are required which Jacka depression. is currently running using a modified 3. Jacka et al. Psychother Psychosom • A review of the effect of poor iron status Mediterranean diet which includes the 2012;81:196-198 in premenopausal women found a strong NHMRC’s recommended amount of red association with depressive symptoms. meat. Nevertheless, Jacka recommends a whole There is some evidence that diet coaching food approach based on dietary guidelines, can help to reduce depressive symptoms since evidence supporting widespread use of since people with depression tend to be

3 Meals for active aging Healthy aging is about active aging with nutrition and exercise key strategies for improving quality of life.

An active lifestyle with little to no burden of Dietary strategies for disease or disability is as important as living PROT-AGE study group’s longer according to Professor Caryl Nowson. protein recommendations for optimising protein intake 1 in older people Defined as healthy life expectancy, current older people (>65 years) statistics suggest there is room for improvement Community Dwelling since a boy or girl born in 2001 will live 1.0-1.2g protein/kg/day to • Increase awareness of higher with a disease or disability for 7 and 9 years, maintain and regain lean body nutrient requirements, respectively. mass and function including protein and the One of the key indicators of quality of life and importance of exercise ability to carry out activities of daily living is 1.2g/protein/kg/day for those who the rate of loss of skeletal muscle mass, quality are exercising and otherwise active • Two to three meals/day should and strength associated with aging. contain 25 to 30g protein at Muscle health is a key indicator of frailty and least 2 to 3 meals/day 1.2-1.5g/kg/day for those with sacropenia is associated with increased risk of Frail elderly falls, fractures and chronic diseases. acute or chronic diseases • Optimise food quality and Optimising muscle health is therefore a core protein intake of at least 3 preventive strategy for older patients because The challenge for older people is to ensure its benefits extend to bone health as well as adequate nutrient intakes with less food since meals/day reduced risk of chronic diseases. their energy requirements decrease by about • Appropriate use of 2MJ (or 500kcal) by 75 years of age. A combination of good nutrition and exercise supplements, supplementary is required involving progressive resistance In addition to protein, requirements are drinks and fortification may be exercise and adequate amounts of dietary increased for vitamins B12, B6, D, calcium necessary protein is required to stimulate muscle and potentially zinc. This mismatch between synthesis. higher nutrient requirements and lower Residential Aged Care energy requirements means inadequate • A system-wide, multi-level Since more protein is needed to stimulate nutrient intakes are more likely to occur in protein synthesis in older than younger people, older people. approach is required protein requirements are higher after 65 years • Upskill staff on importance of of age than for any other age group. Professor Nowson recommends meeting higher nutrient requirements with a variety regular meals rich in protein The PROT-AGE study group suggests intakes of nutrient-rich protein foods. She showed • Encourage an individualized of up to 1.5g protein/kg/day are needed and how this was achieved in the Womens’ approach to ensure regular intakes of around 25 to 30g of protein at every Health and Muscle Health Study (WHAM) meal are recommended1. in which women over 65 years ate two 80g protein-rich meals are 2 These amounts are higher than current serves of red meat 6 days of the week . consumed recommendations of around 1.0g/kg/day She also suggests greater flexibility with which were based on nitrogen balance rather dietary recommendations around fat, sugar References than functional health outcomes. They are also and salt, particularly if it prevents them from 1. Bauer J et al. J Am Med Dir Assoc much higher than current intakes, particularly enjoying their food and compromising their 2013;8:542-59 in residential aged care where up to 25% of intake of nutrient-rich protein foods. intakes are below current recommendations. 2. Daly RM et al. Am J Clin Nutr 2014; There is poor awareness of the need for doi: 10.3945/ajcn.113.064154 regular meals based around protein amongst older people. Different strategies are required to optimise protein intake adapted to their living arrangements and activity levels.

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