The Use of Smartphone Diet Apps Among Sports Dietitians: A Survey in Five Countries


Department of Human Nutrition, University of Otago, Dunedin, New Zealand

There are thousands of diet applications (apps) now available on smartphones. Sports dietetics is a field that may benefit from the use of diet apps, by helping athletes track their macronutrient intake.

The aims of the study were to assess the prevalence and perception of smartphone diet app use by sports dietitians. A 27-item online survey was developed and sent to 1709 sports dietitians from Australia, Canada, New Zealand, the United Kingdom, and the United States, who were surveyed between 22 June and 11 November 2012. We surveyed registered sports dietitians who were members of Sports Dietetics-USA, Sports Dietitians Australia, Sports Dietitians United Kingdom, Dietitians of Canada, High Performance Sport New Zealand, or New Zealand Rugby Union. Follow up requests were sent three times to encourage response.

The questionnaire had a response rate of 10.3% (180/1709). Four respondents were excluded from analysis because they were dietetic students and were not yet working. Of the 176 eligible respondents to the questionnaire, 32.4% (n = 57/176) used diet apps with clients in sports dietetics. Twenty-eight different diet apps were used with 56.1% (32/57) of respondents using MyFitnessPal. Diet app users had a positive perception of diet apps, with the majority of respondents viewing diet apps as ‘better’ (25/53, 47.2%) or ‘equivalent’ (22/53, 41.5%) when compared with traditional dietary assessment methods, such as paper diet records.

As the adoption of smartphones increases and sophistication of the software improves, diet apps will grow in importance and become a valuable tool in the dietetic profession.

Using Simulation-Based Learning to Enhance Professional Skills Training and Assessment of Dietetic Students: The Massey University Experience


Nutrition and Dietetics, College of Health, Massey University, Auckland, New Zealand

Multiple studies have demonstrated the effectiveness of clinical simulation in replicating clinical environments and training health professionals. Simulation-based learning has been adopted into the Massey University MSc Nutrition and Dietetics curriculum to develop patient-centred communication and counselling skills.

The simulation centre at Waitemata District Health Board has provided a real-life clinical environment for inpatient and outpatient dietetic training. Initially students were immersed in life-like clinical situations and provided with reflective feedback on decisions and actions. Skills acquisition was based around a range of applied nutrition scenarios, e.g. type 2 diabetes, childhood obesity, coeliac disease, oral and enteral nutrition support. In following sessions, students undertook nutrition counselling of standardised clients in clinical inpatient and outpatient simulations. Actors were employed and the sessions recorded. Dietetic staff provided feedback from observations by way of video and one-way mirrors. The use of DVD recordings and reflective practice enabled students to critically evaluate their nutrition counselling skills.

Clinical simulation allowed students to improve their skills in a risk-free environment and helped bridge the gap between the lecture room and real life settings. This setting was also found to be suitable for reliable assessment of dietetic practice competence. Responses from student evaluations suggest that student learning and confidence in a clinical environment were enhanced. Simulation will continue to be used in dietetic student training at Massey University. Current teaching and training practices will be further refined to ensure optimal use of simulation-based learning and assessment.

Seniors Eating Well – Nutrition Education Course for Community-Living Older People


Older Persons Health Specialist Service, Canterbury District Health Board, Christchurch, New Zealand

Background: Good nutrition and eating well play an important role in maintaining the health and quality of life in community-living older people.

Aim: The purpose of this project was to determine where older adults can (1) improve their nutrition knowledge and (2) make positive changes to their diet after completing a seven week nutrition education course.

Methods: A convenience sample of 34 adults aged 65 and over voluntarily attended Seniors Eating Well, a seven week nutrition education course designed specifically for community-living older people. The majority (82%) of participants were women and over half (62%) lived alone. Two courses were held, one in Rangiora and one in Bishopdale. Each thirty minute weekly class consisted of interactive nutrition education followed by sharing morning tea together as a group. Topics covered included healthy eating, strong bones, healthy bowels, meal planning, snacking, food safety and nutrition myths. Each older person was asked to complete a pre and post-course evaluation form.

Results: All participants (100%) completed a pre-course evaluation and most participants (82%) completed a post-course evaluation. Participants rated their food and nutrition knowledge higher post-course than pre-course. Participants reported making changes to their diet post-course including consuming more vegetables, fruit, milk and milk products. More participants planned meals, used a list when shopping, and used wholemeal/wholegrain breads and cereals after the course than prior to the course.

Conclusion: Seniors Eating Well provides community-living older adults with an opportunity to improve their nutrition knowledge and make positive changes to their diet.

‘Kai-Culator’, Web-Based Dietary Assessment Programme: Current Status and Future Development


Department of Human Nutrition, University of Otago, Dunedin, New Zealand

The aim of ‘Kai-culator’, a new web-based dietary assessment programme developed at the University of Otago, is to provide dietitians, researchers, and teachers with a purpose-built method for determining the dietary intakes of New Zealanders using analytical data from New Zealand FOODfiles, and an additional 3,000 recipes developed during the Adult Nutrition Survey 2008/09 that reflect dishes consumed by New Zealanders.

Accredited users enter food intake data from diet records and 24-hour diet recalls on line, with different levels of access allowing users varying ability to change data or specifications for their project. For example, at the default level, foods and recipes can be entered for individuals. At higher levels of access, new recipes and nutrient data (e.g. flavonoids) can be added to a project database. Output Reports currently include: nutrients (total, mean, per occasion, contribution from standard or self-defined food groups); and foods (gram amounts, average portion size, frequency of consumption). The ability to self-define food groups and to add food components of interest (such as flavonoids, phytate, and haem iron), is particularly novel and has already enabled the University to conduct innovative research on both nutrient intake and dietary patterns in a range of populations.

While the method has been pilot-tested, and modified, to perform optimally in research and teaching settings, the next phase is to ensure that it performs equally well for dietitians in clinical settings. We plan to scope the potential needs of dietitians throughout New Zealand in 2014.

Do We Make a Difference? Reported Behaviour Change Post Nutrition Education in the Inpatient Setting


Nutrition and Food Services, Waitemata District Health Board, Auckland, New Zealand

Objective: To establish whether nutritional education delivered in the inpatient setting translated to reported behaviour change after discharge, and the preferred education setting.

Methods: Adult gastrointestinal disease patients and oral nutrition support inpatients, between May 2012 and August 2012, were eligible for inclusion. A clinical notes audit was conducted to describe the content of the nutrition education they received. Participants were surveyed by a telephone questionnaire 14 days to three months after discharge. Qualitative data were also collected to help explain reasons for practising/not practising nutrition education and the preferred education settings.

Results: 89 participants completed the questionnaire. 68% of participants reported practising the nutrition education (p < 0.05). Of those who did not practise the education (n = 28), 12 could not remember the dietitian and the content of the education provided, and this was associated with older age. 51% of participants said the inpatient setting was their preferred education setting. Other preferred choices included, a dietitian at the participants' general practice (27%), home visit by a community dietitian (20%), outpatient clinic (18%), other (10%), and Maori Hauora clinic (1%). Those who could remember the dietitian but could not recall the education (n = 8) stated the hospital environment had many distractions. 8 participants could remember the content of the education but were not practising it.

Conclusion: The inpatient environment is an important and effective place for nutrition education. An awareness of a patient's age and cognitive abilities is essential to improve recall. Reducing distractions in the clinical environment may also promote retention of the education.

Clinical Volunteering – Providing Positive Outcomes for District Health Boards


Allied Health – Corporate, Waitemata District Health Board, Auckland, New Zealand

Dietitians returning to practice, nutrition graduates exploring a career in dietetics and unemployed new graduate Dietitians are keen to gain work experiences in clinical settings. District Health Boards (DHBs) can offer this experience and at the same time address quality initiatives and training opportunities to optimise patient care.

In 2009 two nutrition graduates approached the DHB for dietetic observation experience. A process was developed to support these first volunteers including recruitment interviews, reference checking, standard screening forms. Individualised Job Descriptions and agreements were developed for volunteers, incorporating specific projects designed to meet the needs of the organisation and utilise skills the volunteer was happy to use or develop. Projects generally consisted of service related tasks that Dietitians would normally complete e.g. audits, resource development and education programmes.

Over four years the eligibility criteria for volunteers was extended, a large number volunteers have joined dietetic teams in the DHB and contributed to a wide range of projects including entering electronic research data, public health and paediatric projects, literature reviews and clinical audits.

Feedback surveys completed by volunteers show positive outcomes and justify the volunteer programme. Workforce benefits have included: experienced dietitians returning to the workforce within DHBs, and the private sector, nutrition graduates deciding to take up dietetic training and new graduate dietitians finding permanent positions in PHOs and other settings.

Clinical Volunteering is now an accepted part of the DHB dietetic culture, universities are recommending clinical volunteering opportunities, volunteer feedback indicates this provides clinical experience and supports job applications.

A Single Point of Request (SPOR) for Publicly Funded Dietitian Services in Christchurch


Canterbury Initiative, Canterbury District Health Board, Christchurch, New Zealand

Background: In Christchurch the process for general practice requesting dietitian services previously was confusing and complicated. General practice had to decide between 10 dietitian service providers (DSP) each with their own access criteria and request process. Criteria were incomplete and ambiguous.

Aim: To establish clear access criteria and a simplified process for general practice to request dietitian services.

Method: A single point of request (SPOR) was developed with HealthPathways, a web-based patient management system, and DSP. This included: 1) DSP jointly agreeing criteria and wait times; 2) establishing a simplified request process; and 3) a new pathway outlining criteria, exclusions, request process and wait times.

Results: The Dietitians SPOR has been launched on HealthPathways and is promoted to general practice. The new process includes the following significant changes: 1) a new pathway with the option to send requests via an electronic referred management system or fax to a single point; 2) requests triaged by a dietitian; accepted requests sent to the appropriate DSP and declined requests returned to general practice with reason and the next best option for the patient; 3) list of exclusions which are linked to relevant management pathways and written patient information; and 4) new email address for general practice to direct enquiries.

Conclusion: The Dietitians SPOR with clear criteria and a simplified request process has provided general practice with improved and more timely access to dietitian services. Benefits of the SPOR to DSP include improvements in request quality and reduced time managing and monitoring requests.

Cost Effective Weight Management Clinics in Primary Care


Department of Nutrition and Dietetics, Auckland District Health Board, Auckland, New Zealand

Background: Obesity is reaching epidemic proportions in NZ with over a quarter of the adult population obese, often coupled with other health conditions including Type 2 Diabetes and CVD, which left untreated or poorly managed, will lead to increased medical care, hospital admissions and a greater cost to the healthcare system.

Aim: To scope the training of Healthy Lifestyle Advisors (HLA) within primary healthcare in NZ utilizing Dietetic or GP assistants to deliver evidence based individual education to patients with a BMI 25–40 kg/m2 to provide better management at a primary healthcare level.

Methods: To apply a model of nutrition education developed within a London community dietetic service to train healthcare assistants/practice nurses as HLA's to deliver evidence-based individual nutrition education to patients with a BMI 25–40 kg/m2. They delivered 8 × 15 minute sessions per week following a custom-made 8-session workbook incorporating goal setting and dietary management. At 18 months, 91% (n = 914) of patients referred had accessed the HLA service, 74% had lost weight after their 8 sessions with an average of 2.9 kg loss.

Results: These results demonstrate that lesser qualified staff with adequate training and supervision can provide a cost-effective successful service that is more accessible to the patient and provides GPs with greater management options. This model could be applied within NZ primary healthcare utilizing funding packages such as DCIP or Care Plus and would support the Ministry of Health targets. Clear guidelines and professional dietetic support would need to be in place to for HLA's to remain in within their clinical competency, and ensure those requiring additional support continue to be referred to appropriate MDT services.

Group Education – A New Model of Care for Diabetes in Pregnancy Clinic in Counties Manukau Health


1Nutrition & Dietetics, Middlemore Hospital, Auckland, New Zealand

2Midwifery Services, Middlemore Hospital, Auckland, New Zealand

3Lets Beat Diabetes, Counties Manukau Health, Auckland, New Zealand

A three-fold increased in the number of pregnant women with diabetes seen in the Diabetes in Pregnancy clinic in Counties Manukau Health was observed between 1998 and 2008. An audit conducted in 2007 showed 70% of the women who attended the clinic did not have a follow-up consultation with a dietitian, well below the practice guidelines by the American Dietetic Association. This consequently determined the need for a group education trial.

The aims of the trial were to observe if 1) by consolidating patients' initial appointments into a group session, dietitian's time would become available for additional follow-up consultation and 2) if through dietary education it empowered patients to self-manage gestational diabetes.

A thirteen week trial of weekly group education sessions was conducted. These were facilitated by a midwife and a dietitian. At the end of each session, women were asked to complete an evaluation form. Women with type 1 diabetes or needing an interpreter were excluded.

A four-fold increase in follow-up consultation (2 before the trial vs. 8.3 during the trial) was achieved by doing group session. Written feedback from patients suggested an increased knowledge and confidence in self-managing gestational diabetes. This was supported by written feedback and observation from other multi-disciplinary team members. In conclusion, group education was an efficient and effective way of delivering nutrition education in a multi-disciplinary Diabetes in Pregnancy clinic. Since 2008, group session has been the adopted model of care for the Counties Manukau Health, Diabetes in Pregnancy clinic.

Cash Calories Putting Moderation into Practise in a Fijian Setting


Ministry of Health, Fiji

As Fiji moves steadily away from traditional food gathering and consumption patterns, towards more sedentary lifestyle habits and high-energy diets, obesity poses an increasing burden on the health system. Currently half of the adult population are classified as overweight (29%) or obese (18%)1. Both village and workplace settings are frequent venues for over-nutrition due to affordability, buffet style service and cultural traditions concerning food sharing.

Cash Calories is a new public health nutrition program designed to target these settings by putting the concept of moderation into practise. The program involves provision of a calorie allowance (in the form of printed notes-cash calories), which attendees use to ‘pay’ for food based on the calorie content (cost) per serving.

Though in its infancy the program has seen great successes with observable changes to consumption patterns. This includes reduced portion sizes, increased fruit and vegetable consumption and avoidance of sugary drinks and starchy carbohydrates. In a questionnaire based observational study of 19 community members, 86% reported they ate less overall at the function due to Cash Calories, 79% avoided high calorie foods while 100% felt motivated to change both their eating and exercise habits after learning about Cash Calories. Analysis of the weight/calorie content of food consumed throughout the day found that, on average, participants consumed approximately 717 fewer calories throughout the day, in comparison to a similar function where Cash Calories was not run.

Though further evaluation is required, Cash Calories is proving to be a promising form of health promotion in Fiji.


1. World Health Organisation. (2002). Fiji Non-Communicable Diseases (NCD) STEPs Survey. Ministry of Health, Fiji. Retrieved on 18th May 2013 from http://www.who.int/chp/steps/FijiSTEPSReport.pdf

The Effectiveness of Hypoglycaemia Packs Versus Conventional Treatment for Mild-To-Moderate Hypoglycaemia in a Medical Ward at Middlemore Hospital: A Pilot Study


1Nutrition & Dietetics, Middlemore Hospital, Auckland, New Zealand

2Whitiora Diabetes Service, Middlemore Hospital, Auckland, New Zealand

3Pharmacy Department, Middlemore Hospital, Auckland, New Zealand

Two audits conducted in Middlemore Hospital (MMH) suggested a knowledge gap and inconsistency with hypoglycaemia treatment practices.

The aim of this study was to compare 3 hypoglycaemic treatments: conventional treatment (3 La-Vita tabs [9 g carbohydrate (CHO)] and a CHO snack), hypo pack A (‘Twist’ drink [16 g CHO] and two cookies [16 g CHO]), and hypo pack B (Carrero gel [18 g CHO] and two cookies [16 g CHO]). The effectiveness of the 3 treatments was compared based on the number of treatments required to correct hypoglycaemia. Patients' and nurses' preferences were evaluated using questionnaires. Eligible patients were randomised to one of three treatments at the first hypoglycaemic event and received the same treatment for all subsequent events. Auckland ethical approval was obtained for this pilot.

One hundred and forty-eight patients consented to participate. Thirty-five of those consenting experienced hypoglycaemia. Data with complete capillary blood glucose (CBG) results were analysed from 11 of these 35 patients. Thirty-four of the participants experiencing hypoglycaemia completed a post-treatment questionnaire. Twenty-three nurses completed preference questionnaires. Hypo pack A had the highest mean CBG after hypoglycaemia treatment (7.8 mmol/L (SD: 1.0)) vs. hypo pack B (5.3 mmol/L (SD: 0.7)) vs. conventional treatment (4.6 mmol/L (SD: 0.4)). Results from the questionnaires showed patients and nurses preferred hypo pack A.

In conclusion, hypo pack A was the most effective treatment for mild-to-moderate hypoglycaemia and the preferred choice by nurses and patients in this study. Since the completion of the study, MMH mild-to-moderate hypoglycaemia treatment guidelines have been reviewed and new policy developed.

Meta-Analyses of the Effect of Dietary Sugars Intake on Blood Pressure and Blood Lipids


Department of Human Nutrition, University of Otago, Dunedin, New Zealand

Background: Sugar intake has been implicated in the aetiology of many cardiovascular and metabolic risk factors. The aim of these meta-analyses was to determine whether there is a relationship between consumption of dietary sugars and blood pressure or blood lipids.

Methods: Systematic reviews and meta-analyses of randomised controlled trials (RCTs) were conducted following the Cochrane Collaboration guidelines. Four article databases (Medline, EMBASE, CINAHL and Scopus) were searched for RCTs published before April 2012. We included RCTs from 1960 to the present, where dietary sugars intake was increased in one arm of the study in comparison with another. Mean pooled effects of higher versus lower sugars intakes on blood pressure and lipid outcome measures were estimated using inverse variance models of analysis with random effects.

Results: From 28,854 potential studies, 11 blood pressure studies and 35 blood lipid studies met the inclusion criteria. Systolic blood pressure was higher by an average of 3.81 mmHg in the parallel trials and diastolic by 1.42 mmHg in the overall analysis. Triglycerides, LDL cholesterol and total cholesterol were significantly raised with higher sugar intake. Meta-regression of differences in weight change had no significant effect on the effect of higher versus lower sugars for systolic blood pressure but did for diastolic blood pressure. Meta-regression of all trials suggested there was no effect of weight change on blood lipids.

Conclusions: These meta-analyses provide evidence that high dietary sugar intake is a determinant of increased blood pressure and raised lipid biomarkers of cardiovascular disease, indicating increased risk.

Lowering Postprandial Glycaemia with a Rice-Mix in Asian People with Type 2 Diabetes


1Department of Human Nutrition, University of Otago, Dunedin, New Zealand

2Auckland District Health Board Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand

Introduction: White rice is a staple food for many Asian people; however, its consumption may generate large glycaemic responses that are a risk factor for diabetic complications. Although Asian patients with diabetes are frequently advised to limit white rice intake, breaking this dietary habit may be difficult.

Objective: To review an alternative dietary approach to improve postprandial glycaemic control in type 2 diabetic patients experiencing difficulties in reducing white rice consumption by partially replacing white rice with wholegrains, pulses, nuts and seeds.

Design: This was a repeated randomised cross-over study of 12 Chinese patients with non-insulin dependent type 2 diabetes. Postprandial glycaemia (PPG), satiety and palatability were monitored over 3-hours following consumption of equal-volumes of white rice and the rice-mix. Incremental area under the curve was calculated comparing PPG, satiety and palatability.

Result: Postprandial glycaemia was 27% (95% CI: 17, 36) less after consuming the rice-mix than white rice (P < 0.001). The mean length of time that PPG exceeded 10 mmol/L was 30 min (95% CI: 13.8, 45.8) less (P = 0.001). No significant difference in satiety and palatability between two rice meals was found. Results of an exit questionnaire indicated that eight participants would consume the rice-mix meal on a frequent basis while two participants would be willing to completely replace white rice with the rice-mix.

Conclusion: Using rice-mix as an alternative to white rice is a feasible dietary approach to improve PPG in type 2 diabetic patients without compromising the satisfaction obtained from traditional white rice meals.

Estimating Body Fat Percentage: Testing Validity and Reliability of BIA and DXA Against Bodpod


1Institute of Food, Nutrition and Human Health, Massey University, Auckland, New Zealand

2Institute of Information & Mathematical Sciences, Massey University, Auckland, New Zealand

Body fat percentage (BF%) is most accurately predicted using air displacement plethysmography (BodPod) (gold standard method). Dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA) also predict BF%, but have not been validated against the BodPod in a large sample with a range of healthy adults.

The aim was to assess the validity and reliability of BIA and DXA against BodPod in estimating BF% in healthy adults. BF% of 164 adults (18–70 y) was measured twice within 5 days using BodPod, DXA and BIA. Agreement between measurements was analysed using t-tests, effect size, linear regression models and method of triads. Reliability was assessed by comparing and correlating repeat measurements (t-test; Pearson correlations).

BIA showed excellent relative agreement to the true value (ρ = 0.97 [0.96, 0.98]) and to Bodpod (R2 = 0.88), but absolute agreement was biased and the limits of agreement wide (−4.25 to 8.37%). BIA underestimated body fat with 2%, across all BF% values, not differing between men and women. DXA showed excellent relative agreement to the true value (ρ = 0.97 [0.96, 0.98]) and to Bodpod (R2 = 0.92), and good absolute agreement despite wide limits of agreement (−6.13 to 6.91%). DXA overestimated extreme low BF% (all men) and underestimated high BF% (all women). BodPod, BIA and DXA showed excellent reliability with repeat measurements differing by less than 0.2% with very small 95% CIs.

On average, BodPod BF% can be predicted from BIA measurements by adding 2%. DXA compares well to BodPod except at extreme BF% levels.

Evaluation of the Food and Nutrition Guidelines


Nutrition and Physical Activity Team, Clinical Leadership, Protection and Regulation (CLPR), Ministry of Health, Wellington, New Zealand

Background: The Ministry of Health produces a series of five population-specific background Guideline papers which provide evidence based recommendations for health practitioners.

Aim: To find out how the Guidelines are used by the sector and how they could be improved.

Method: In 2011 the Guidelines Series was evaluated by an independent group. International academic and grey-literature on the development of nutrition and physical activity guidelines was reviewed. Fifty-five stakeholders were interviewed including individuals who worked on the development of Guidelines and the end-users. An electronic survey targeting health practitioners was also circulated. Questions for both the interviews and e-survey covered use, accessibility, the impact of the Guidelines, and the processes used for developing the Guidelines. Demographic data were also collected. Interview and electronic survey responses were grouped thematically and described mainly qualitatively under key headings.

Results: There were 971 electronic survey respondents with most being pharmacists (26%), dietitians (14%), health promoters (13%), followed by community health workers, nurses, nutritionists and researchers (5–7%). The evaluation found that the Guidelines are highly valued by health practitioners and are seen by many as essential to safe practice for all health practitioners who provide advice or education in nutrition. Issues identified by the evaluation included the need to make the Guidelines more accessible to a wider range of health practitioners; to increase the speed of the review and update process; and to explore use of emerging technology to promote and distribute the Guidelines.

Conclusion: The current Guidelines are used and valued by health practitioners. Changes to the Guidelines process and final products could enhance their accessibility and value.

Determinants of Nutritional Status of Children Aged 1–3 Years in Rural Area of Pakistan


1Medical University, Graz, Austria

2King Edward Medical University, Lahore, Pakistan

3University of Veterinary & Animal Sciences, Lahore, Pakistan

Malnutrition is a pathological condition of varying degrees of severity and diverse clinical manifestations.

The aim of the current study was to find out the significant determinants of nutritional status of children aged 1–3 years in rural areas.

For this purpose we conducted a cross sectional survey. Multistage random sampling method was used. After fulfilling the exclusion/inclusion criteria, mothers of 400 children were interviewed. Data was collected using pretested questionnaire and was entered and analyzed using SPSS version 16. Data analyses included computation of descriptive statistics, and logistic regression analysis. To determine the malnutrition, the current weight of child was compared with WHO weight for age Z scores tables.

According to that 47% of children were normal weight and 53% were malnourished. Bivariate analysis revealed that few of the socio-demographic factors and feeding practices related factors were significantly associated however, all of the health status factors found to be statistically significant. Multivariate logistic regression backward model was used to control for possible confounding effect. It was observed that after controlling for all the factors studied the strongest association was exhibited by age (12–18 and 19–24 months) (OR 0.031 and 0.238), monthly income (less than Rs. 10,000/m) (OR 5.366), working mother (OR 4.146) and use of animal milk (OR 4.068). Other significant factors include low birth weight, delayed weaning, weaning food (regular family food), ARI attacks after first year (4–7 times) and immunization status (partially immunized) of the child.

The findings of current study suggest that complex socio-demographic factors, improper healthcare facilities and poor infant feeding practices are main contributors towards malnutrition among children aged 1–3 years in rural areas.

A Reduction in Fodmap Intake Correlates Strongly with a Reduction in IBS Symptoms – The Fibs Study


Nutrition Department, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand

Irritable Bowel Syndrome (IBS) affects 7–10% of the population. Patients have identified food as a trigger for symptoms. There is emerging evidence that a diet low in fermentable oligo-, di-, monosaccharides and polyols (FODMAP) is beneficial. This randomised control trial aimed to study the effect of a diet low in FODMAPs on IBS symptoms and quality of life (QoL).

Participants with IBS according to Rome III criteria enrolled in this trial were asked to complete the IBS SS (IBS symptom severity scoring system, 0–500 points increasing with severity), IBS QoL questionnaire (0–100 increasing with QoL) and a FODMAP specific food frequency questionnaire at baseline and at three months. They were randomised to either a low FODMAP diet under dietitian's guidance (FODMAP group n = 23) or a waiting list control (control group n = 27).

Participants in both groups had similar baseline values. There was a significant reduction in IBS SS in the FODMAP group (275.6 ± 63.6 to 128.8 ± 82.5) compared with the control group (246.8 ± 71.1 to 203.6 ± 70.1) (p < 0.0002). This correlated strongly with the reduction of FODMAPs consumed (p = 0.02). QoL improved significantly in the FODMAP (68.5 ± 18.0 to 83 ± 13.4) vs controls (72.9 ± 12.8 to 73.3 ± 14.4) (p < 0.0001). There was significant improvement in frequency of pain (episodes per 10 days) in the FODMAP group (5.6 ± 2.8 to 2.2 ± 2.6) compared with controls (3.8 ± 2.7 to 3.6 ± 2.6) (p < 0.0001). There was no improvement in severity of pain or bloating.

This study demonstrated that a reduction in dietary FODMAPs correlates with symptom improvement and an increased quality of life in participants with IBS.

Adult Cystic Fibrosis Vitamin D and Bone Mineral Density Audit


Canterbury Adult Cystic Fibrosis Service, Christchurch, New Zealand

Background: Up to 90% of individuals with Cystic Fibrosis (CF) are pancreatic insufficient. This can lead to fat malabsorption. Fat soluble vitamins are co-absorbed with fat and thus deficiencies may occur. Vitamin D deficiency is common in individuals with CF. Vitamin D deficiency has been related to decreased bone mineral density, osteopenia and poorer general and respiratory health in adults with CF. It is vital that there is continued monitoring of Vitamin D status in CF patients.

Aim: Audit the Vitamin D status and most recent bone mineral density (DXA) result of all patients (n = 54) cared for by the Canterbury Adult CF Service (CACFS) to consider if current supplementation processes are adequate.

Methods: Cross-sectional survey. Vitamin D status assessed via Plasma 25 Hydroxy Vitamin D (Vitamin D). Descriptive statistics calculated.

Results: 18% (n = 10) of patients had a Vitamin D result <50 nmol/L (suboptimal), 28% (n = 15) >50 but <75 nmol/L (adequate), and 54% (n = 29) >75 nmol/L (optimal). For patients with an available DXA scan (83%, n = 45), 71% (n = 32) had normal bone mass, 7% (n = 5) had low bone mass, 11% (n = 5) had osteopenia, and 7% (n = 3) osteoporosis. Of those patients with osteopenia (n = 5), one had a Vitamin D <50 nmol/L, two had a Vitamin D >50 nmol/L but <75 nmol/L, and two had a Vitamin D >75 nmol/L. All patients with osteoporosis (n = 3) had a Vitamin D >75 nmol/L.

Conclusion: The majority of patients cared for by the CACFS have a satisfactory Vitamin D status and bone mineral density; however 46% of patients potentially require more intense vitamin D intervention.

Vitamin D Prescribing: An Audit of Prescribing Practice at Auckland City Hospital


Nutrition Services, Auckland City Hospital, Auckland District Health Board, New Zealand

Vitamin D is a key determinant for bone health. Emerging evidence suggests a possible role in the prevention of cardiovascular disease, cancer and autoimmune diseases. The New Zealand National Nutrition Survey 2008/2009 found 5% of the population were deficient in serum 25-dihydroxyvitamin D3 and 25% had suboptimal levels. Hospitalised patients are often prescribed Vitamin D.

The aim of this study was to determine current prescribing patterns of Vitamin D in a tertiary hospital and compare to national prescribing practice.

An observational audit of 1151 adult patient's clinical notes and medication charts at Auckland City Hospital was conducted on 4 days (December 2012 to January 2013). National prescribing practice data for all health services in 2010 was obtained from Ministry of Health publications.

Twelve percent of patients (141) audited were charted Vitamin D, with 127 (90%) receiving cholecalciferol. Of those, 121 (95%) received the recommended dose (50,000IU monthly). Twenty percent of supplemented patients had osteoporosis and 18% a previous fracture. Aged care residents made up almost 25% of those receiving Vitamin D, compared to 5.4% nationally. No indication was identified for 38% prescribed Vitamin D. The review of national prescribing data showed Auckland District Health Board has the highest rate of vitamin D prescriptions nationally with 7.3% of the population receiving subsidised prescriptions, almost double the national average of 3.9%. Indications for Vitamin D prescriptions are available for only 62% of patients at Auckland City Hospital. The high profile of emerging Vitamin D research may contribute to prescribing practice not currently indicated.

Impact of Early Nutrition Supplementation in Patients with Fractured Neck of Femur


Nutrition Services, Auckland City Hospital, Auckland District Health Board, New Zealand

Introduction: Malnutrition is common among older people with fractured neck of femur (FNOF) and especially in those with dementia.1,2 Early nutritional support has shown to improve clinical outcomes and shorten length of stay.1 A new FNOF protocol at Auckland City Hospital (ACH) will make basic nutritional supplementation mandatory post admission.

Aim: To investigate if early nutritional intervention can improve the nutritional intake of older people FNOF patients and especially in those with dementia.

Method: An observational clinical trial using time series model of elderly (≥65 years) patients with FNOF's admitted to ACH was carried out between September 2012–March 2013. An observation period of four weeks was allocated to two successive groups for data collection. Group one (n = 32) received the standard hospital menu (SHM) only and was viewed baseline. In addition to the SHM, Group two received two ready-to-drink (RTD) supplements daily during admission.

Results: Between the baseline and supplemented group, no significant difference was found among the percentage of meal consumed at breakfast (P < 0.380), lunch (P < 0.16) and dinner (P < 0.80). The nutritional intake in cognitively well patients was slightly higher compared to dementia patients however this was not statistically significant. In the supplemented group, an overall 51% complied with basic supplementation while a greater compliance of 62% was found among dementia patients.

Conclusion: The implementation of early, basic nutritional supplementation within the new FNOF protocol increased the overall nutritional intake in older people FNOF patients and especially in those with dementia.


1. Avenell A, Handoll HG. Nutritional supplementation for hip fracture aftercare in older people (Review). The Cochrane Collaboration. 2009.

2. Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition (Review). The Cochrane Collaboration. 2009.

Fifteen Years of Parenteral Nutrition at Auckland City Hospital


1Nutrition Services, Auckland City Hospital, Auckland, New Zealand

2Nursing, Auckland City Hospital, Auckland, New Zealand

3Surgery, Auckland City Hospital, Auckland, New Zealand

Rationale: Parenteral Nutrition (PN) is an invasive, expensive, and essential therapy in contemporary acute health care. An important component of quality improvement in service provision is ongoing clinical audit. The Nutrition Support Team (NST) at Auckland City Hospital (ACH), an acute tertiary care 1000 bed hospital, conducted a 15 year audit with the aim of improving service delivery.

Methods: The NST at ACH assesses all patients referred for PN, and rigorously promotes the policy of enteral feeding when possible. All adult patients receiving PN between 1998 and 2012 inclusively were audited annually for central venous catheter (CVC) infections (paired matching central and peripheral blood cultures), indications for PN, and duration of PN.

Results: Over the fifteen years patients on PN increased from 103 to 294 episodes per annum. Ileus, small bowel obstruction/perforation and anastomotic leak were the major indications. Peripherally inserted catheters have overtaken subclavian CVCs as the preferred access. Sepsis rates have varied from 1.4 to 5.7 episodes per 1000 patient PN days.

Conclusion: The provision of acute PN has almost trebled over 15 years despite the advocacy of enteral feeding. Increasing complexity of surgical procedures' and higher acuity patients may be driving this trend. Service delivery by the NST together with the upcoming establishment of the NZ National Intestinal Failure Service in July 2013 needs to focus on prevention of CVC related sepsis, appropriate provision of PN with ongoing education for clinicians and updating and development of evidence based guidelines.

The Effect-Sah Pilot Study: Enteral Feeding and Fluid Effect as a Controlled Trial in Sub-Arachnoid Haemorrhage Patients


1Nutrition Services, Auckland City Hospital, Auckland New Zealand

2University of Auckland, Auckland, New Zealand

3Department of Neuro-surgery, Auckland City Hospital, Auckland New Zealand

Background: Critically ill patients require variable and large amounts of intravenous fluids (IVF) to replace perioperative losses and maintain mean arterial pressure (MAP). As a standard practice neurosurgery patients receive 3 L of 0.9% saline per day (triple-H therapy) to prevent cerebral vasospasm after a subarachnoid haemorrhage. This can result in sodium and fluid overload leading to poorer clinical outcomes.

Aim: To compare the key clinical outcomes from the effect of standard 3 L fluid therapy to individualised fluid therapy in acute subarachnoid patients post neurosurgery. Key clinical outcomes were cumulative fluid balance (CFB), high dependency unit (HDU) length of stay, mortality, vasospasm and modified ranking score (MRS).

Methods: All post-operative SAH patients meeting the inclusion criteria were assigned to either groups (15 in each arm) post neurosurgery by a non-randomised time series (three phase) model: Standard group received 3 L/day of 0.9% saline while the individualised group received fluids based on their body weight and individual requirements. Both groups receiving IVF were supplemented with enteral feeding when oral intake did not meet nutritional requirements. The study ceased on day 30 of HDU admission or discharge from the HDU.

Results: Differences were demonstrated between groups for CFB (P = 0.04). HDU length of stay was higher in the individualised group compared to standard group (P = 0.02). The individualised group had fewer vasospasm and mortality events. MRS was improved in the individualised arm. The trial indicated a trend that standard 3L fluid protocols provide no positive benefits, however the pilot informs a larger multi-centred randomised controlled trial to demonstrate significant differences in clinical outcomes.

Female Adolescent Ballet Dancers: Anthropometric Characteristics and Macronutrients Intakes – A Cross-Sectional Study


Institute of Food, Nutrition and Human Health, Massey University, Auckland, New Zealand

Background: Adolescent ballet dancers face challenges of consuming a diet containing adequate nutrient intake for growth and development, while maintaining a strong and lean physique.

Aim: To investigate the anthropometric characteristics and macronutrient intakes of adolescent female ballet dancers living in Auckland, New Zealand.

Method: Forty seven dancers (13–18 years) who danced at least one-hour per day five days per week participated in this cross-sectional study. Body mass index (BMI) was determined using weight and height measurements and percentage body fat using Dual-energy X-ray Absorptiometry (Hologic Discovery A). Participants completed a 4-day estimated food record.

Results: Mean BMI was 19.7 ± 0.3 kg/m2 and percentage body fat 23.5 ± 0.6%. Using the Centers for Disease Control and Prevention BMI-for-age growth charts, most dancers (89.4%) were a healthy weight (5th–85th percentile). Two (4.3%) dancers were underweight (<5th percentile) and three (6.4%) were overweight (85th–95th percentile). Food records completed by 42 participants showed a mean energy intake of 8097.3 ± 332.6 kJ/day (16.9% protein, 48.9% carbohydrate, 33.8% fat, 14.0% saturated fat). Mean carbohydrate and fat intakes were 238.9 ± 10.0 g/day (4.8 ± 0.2 g/kg body weight/day) and 75.0 ± 4.0 g/day respectively. Over half (54.8%) consumed less than 5 g carbohydrate/kg/day.

Conclusion: While mean body composition measurements and macronutrient intakes (carbohydrate, protein and fat) as a percentage of total energy intake fell within the recommended range for health, intakes of saturated fat were high, and several dancers were at risk of inadequate carbohydrate intake based on current sporting recommendations. Female adolescent ballet dancers may need to focus on increasing carbohydrate and decreasing saturated fat intake for training efficiency and future health.

Normalising Eating in the Treatment of Eating Disorders


1Regional Eating Disorders Service, Auckland DHB, New Zealand

2Institute of Food, Nutrition and Human Health, Massey University, New Zealand

Normalising eating is a primary goal for recovery from eating disorders. There is no working definition for what ‘normalised eating’ is.

Primary aims were to 1) describe normalised eating as a treatment goal for eating disorders using a sample of ‘expert opinions’ and 2) compare the description with the eating patterns of the general population and nutrition guidelines in New Zealand.

Mixed methods used an online survey and in-depth interviews conducted either face-to-face or by telephone. Participants were recruited through online and print advertising. Participants included a control group, individuals recovered from an eating disorder, and clinicians working in eating disorders (n = 67). Nutrient and food group analysis was completed on participant-provided normal day examples in order to compare data to the general population and nutrition guidelines.

Participant groups agreed overall, with a range of eating patterns described as normalised (e.g. 2–7 eating episodes in a day). Normalised eating as described contained more fibre than the general population and more baked products/sweets and sugar than nutrition guidelines. While normalised eating is likely to involve a specific set of actions most of the time (e.g. 3 meals and 2–3 snacks), reasons for eating seem to underpin normalised eating more than specific actions (e.g. ‘if hungry after dinner will have a piece of fruit’). Core characteristics of normalised eating were identified, which may be used as a working definition: eating mostly in response to physiological appetite, flexibility in food choices and eating behaviours, absence of fear or anxiety around eating, and nutritionally adequate.

Red Tray (A Tool to Reduce Malnutrition and Dysphagia Risk in Hospital) – is it Working?


Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand

Background: The Red Tray initiative was implemented across the Assessment, Treatment and Rehabilitation (AT&R) wards at Middlemore Hospital (MMH) in 2008. ‘Red Tray’ is a tool to help ward staff identify patients at risk of malnutrition and/or dysphagia who may require assistance and/or encouragement with oral intake.

Aim: To review the process and effectiveness of Red Tray four years following implementation.

Methods: The original audit tool developed by dietitians and speech-language therapists (SLTs) at MMH in 2008 was peer reviewed and updated in 2012.

An audit was then conducted on four AT&R wards in November 2012. There were 16 patients on Red Tray at time of auditing.

Results: Five (31%) had been identified on the nurses' handover sheet; nine (56%) had a ‘Red Tray Checklist’ in the medication folder which stated reason(s) for being on Red Tray and seven (44%) received the required assistance as identified on the checklist. Five patients had been identified by SLT as having swallowing difficulties but the ‘eating and drinking guidelines’ were only followed for two (40%) patients.

Conclusions: The results suggest significant gaps in the current system to ensure all patients on Red Tray receive the required assistance, encouragement and/or supervision to support good nutrition and safe feeding practice. Further training on Red Tray and good feeding practice are indicated. A review of Red Tray documentation may facilitate effective communication among the multidisciplinary team. Regular audits are also indicated to ensure the effective use of Red Tray.

Hospital Food Waste: A Qualitative Study of Food Production and Pre-Consumption Food Waste


Department of Human Nutrition, University of Otago, Dunedin, New Zealand

Hospital foodservices are large producers of food waste. The foodservice literature to date has predominantly focused on technical elements of the foodservice system at the expense of human interaction/influence on this system. By combining elements of systems and practice theory, a conceptual framework was developed to explore food waste generation and how it was influenced by practices of foodservice personnel.

An ethnographic research approach was adopted. Three New Zealand hospital foodservices were selected as research sites. Data collection techniques included document analyses, observations, focus groups and interviews. The combined model of systems and practice theory guided data collection and thematic analysis.

Most food waste occurred during service and as a result of overproduction. Reasons included inconsistencies during portion control and forecasting challenges. Attitudes and habits of foodservice personnel were identified as influential factors of waste generation. Implications of food waste were perceived differently by different levels of staff. While managers were concerned mainly with financial issues, kitchen staff also included social implications. Researchers identified organisational plans, policies, controls and use of pre-prepared ingredients to assist in waste minimisation.

Combining systems and practice theory reveals interesting links between elements of waste-related practices. This research supports the need to move beyond economic success, incorporating social and ecological values as measures of sustainability. Current results illustrate how waste-related practices are integrated and influenced by multiple factors within an organisation. Integrating systems and practice theory offers an innovative approach to foodservice management, providing a foundation to lead further research on sustainability within foodservices.

Knowledge of Café and Restaurant Managers to Provide a Safe Meal to Food Allergic Consumers


College of Health, Massey University, Auckland, New Zealand

Background: Many allergic reactions are attributed to food eaten outside the home.

Objective: To identify knowledge of managers (and owners) of cafes and restaurants to provide safe meals to food allergic consumers.

Methods: A structured self-administered knowledge questionnaire was completed by managers of 124 food establishments.

Results: Three quarters (76%) of managers agreed to participate. Overall 13% of managers provided correct responses for 11 true/false knowledge items. Most (93%) were very/confident to provide a safe meal to food allergic consumers and 64% very/confident to manage an allergen emergency. A quarter reported past training in food allergy management. Those with past training were more likely to have plans in place to provide a safe meal (p = 0.05), manage an emergency (p = 0.05) and have a training programme for staff (p = 0.001). Restaurant managers were more likely to have an emergency plan than café mangers (p = 0.01). Two thirds (65%) of managers kept written recipes with ingredient details. Recipes were more likely kept if member of an industry association versus non-member (p = 0.01). Seventy seven per cent were interested in future training. Interest was greater among industry association members (p = 0.02) and owners compared to managers (p = 0.02).

Conclusions: Knowledge levels of food establishment managers may compromise the safety of food allergic customers. Positive benefits of voluntary manager training are evident. For robust consumer protection it is suggested training be incorporated into the registration requirements for food establishments.