Nordic Nutrition Guidelines

Nordic Nutrition Guidelines

In June this year, the Nordic Nutrition Recommendations (NNR) were published, to inform public health nutrition messages and guidelines for individuals living in Nordic and Baltic nations. The result of five years of work of several hundred researchers and experts, the NNR2023 for the first time focused on food that is good for the environment, as well as nutritional quality of food. Additionally, the guideline makes significant strides in updating the daily reference values for many nutrients, as well as attributing reference values to other nutrients which previously had none. Key recommendations issued as part of the updated guidelines state that individuals should consume:

  • a predominantly plant-based diet high in vegetables, fruits, berries, pulses, potatoes and whole grains. Vegetables and fruit consumption should be between 500 and 800 grams daily.
  • ample intake of fish and nuts
  • moderate intake of low-fat dairy products
  • limited intake of red meat and poultry
  • minimal intake of processed meat, alcohol, and processed foods containing high amounts of fats, salt and sugar

Other important distinctions in this new guideline include:

  • The assignment of dietary reference values to eight nutrients for the first time, including biotin, Vitamin B5, choline, Vitamin K, magnesium, manganese, molybdenum and fluoride.
  • A 20% increase in dietary reference values for the B Vitamins B1, B6, folate, and B12, Vitamin C, Vitamin E, calcium, zinc and selenium.
  • The addition of a new section dedicated to antioxidants and phytochemicals. However, no specific recommendations are given here in terms of frequency or amount for these nutrients.

The World Health Organisation indicated in an official statement made by Director General Tedros Adhanom Ghebreyesus, that their new healthy diet recommendations, due to be released later this year, will follow the pattern laid out by the Nordic Nutrition Recommendations. The question remains as to whether the UK government will similarly make amendments to NHS recommendations and the EatWell plate to similarly reflect the stance taken by the NNR and WHO, particularly regarding dietary reference values, plant based sustainable diets and alcohol consumption.

Further reading:

Emulsifiers in Foods & IBD

The Guardian highlighted in a recent article the potential link between emulsifiers and IBD (inflammatory bowel disease) (Guardian, 2023). Emulsifiers are commonly used in the food industry, added to ultra processed foods (UPF) including bread, chocolate, cakes, ice-cream, margarine and processed meats, to extend shelf life, to bind ingredients together and even to improve appearance, as they stop separation of liquids (Eufic, 2022). Individuals who consume diets higher in ultra processed foods have been observed to have a higher risk of developing Crohn’s disease (Chen et al., 2023; Narula et a., 2021) , and recently EFSA (European Food Safety Authority) took the measure of including food emulsifiers as a key risk factor for IBD (EFSA, 2019) . This is most likely due to multi-faceted reasons, however the role of emulsifiers has been proposed as being a key consideration due to their impact on the gut. This includes increasing the vulnerability of the gut lining to inflammatory microorganism penetration. In a study on mice, emulsifiers were demonstrated to cause intestinal permeability, a key cause of malabsorption and increased inflammation (Sandall et al., 2020).

A small scale study including 12 patients with ulcerative colitis indicated that intake of emulsifiers  contributed to earlier relapse in patients with ulcerative colitis in remission. The study indicated that restriction of a specific dietary emulsifier, carrageenan, may benefit patients with ulcerative colitis (Bhattacharyya et al., 2017). However, due to the small participant size, this study requires repeating with a much greater number of participants to explore these findings further.

Due to the chronicity and severity of IBD, it is important to seek medical advice from a doctor and dietitian regarding long term management and treatment plan.

References

Bhattacharyya, S., Shumard, T., Xie, H., Dodda, A., Varady, K. A., Feferman, L., Halline, A. G., Goldstein, J. L., Hanauer, S. B., & Tobacman, J. K. (2017). A randomized trial of the effects of the no-carrageenan diet on ulcerative colitis disease activity. Nutrition and healthy aging, 4(2), 181–192. https://doi.org/10.3233/NHA-170023

Chen, J., Wellens, J., Kalla, R., Fu, T., Deng, M., Zhang, H., Yuan, S., Wang, X., Theodoratou, E., Li, X., & Satsangi, J. (2023). Intake of Ultra-processed Foods Is Associated with an Increased Risk of Crohn’s Disease: A Cross-sectional and Prospective Analysis of 187 154 Participants in the UK Biobank. Journal of Crohn’s & colitis, 17(4), 535–552. https://doi.org/10.1093/ecco-jcc/jjac167

EFSA (European Food Safety Authority), Afonso, A, Garcia Matas, R, Maggiore, A, Merten, C, Rortais, A and Robinson, T, 2019. Technical report on EFSA’s activities on emerging risks in 2017. EFSA supporting publication 2019: 16( 1):EN-1522. 59 pp. doi:10.2903/sp.efsa.2019.EN-1522

Eufic, 2022. What are emulsifiers and what are common examples used in food?

https://www.eufic.org/en/whats-in-food/article/what-are-emulsifiers-and-what-are-common-examples-used-in-food

Guardian, 2023. The truth about emulsifiers: are they destroying our gut health? Available at: https://www.theguardian.com/lifeandstyle/2023/jun/29/the-truth-about-emulsifiers-gut-health-microbiome

Narula, N., Wong, E. C. L., Dehghan, M., Mente, A., Rangarajan, S., Lanas, F., Lopez-Jaramillo, P., Rohatgi, P., Lakshmi, P. V. M., Varma, R. P., Orlandini, A., Avezum, A., Wielgosz, A., Poirier, P., Almadi, M. A., Altuntas, Y., Ng, K. K., Chifamba, J., Yeates, K., Puoane, T., … Yusuf, S. (2021). Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study. BMJ (Clinical research ed.), 374, n1554. https://doi.org/10.1136/bmj.n1554

Sandall, A.M.; Cox, S.R.; Lindsay, J.O.; Gewirtz, A.T.; Chassaing, B.; Rossi, M.; Whelan, K. Emulsifiers Impact Colonic Length in Mice and Emulsifier Restriction is Feasible in People with Crohn’s Disease. Nutrients 2020, 12, 2827. https://doi.org/10.3390/nu12092827

NHS Serve Processed Meat in Hospitals

The Guardian highlighted this year that 61 NHS trusts in England, including specialist cancer and children’s hospitals, are serving processed meat to patients. This is despite well established and growing evidence internationally which implicate processed meats in the development of cancer. The WHO (2015) classified processed meat as a Group 1 carcinogen (cancer-causing), meaning that there is sufficient evidence from epidemiological studies that eating processed meat causes bowel cancer. Further, it has been estimated that about 34,000 cancer deaths per year worldwide are attributable to diets high in processed meat (WHO, 2015).  Processed meats are carcinogenic because they contain nitrates and nitrites. Nitrates and nitrites salts are added to processed meat to extend shelf life and preserve colour and to prevent the growth of Clostridium botulinum, which is responsible for botulism. Nitrates and nitrites when ingested form a group of compounds called nitrosamines, some of which are carcinogenic (Eufic, 2022). There is no identified safe level of processed meat for consumption, and therefore The World Cancer Research Fund (WCRF) (2022) advises to avoid consumption completely. WCRF (2022) also advises that although popular and prevalent, ultra processed meat-free alternatives to processed meats, due to being high in salt and fat, are not beneficial alternatives and should be consumed minimally.

For more information regarding processed meat and cancer risk, please see this patient information leaflet from WCRF, which can be downloaded and shared in hospitals and GP surgeries.

References:

Eufic, 2022. https://www.eufic.org/en/whats-in-food/article/what-are-nitrates-and-nitrites-and-what-foods-are-high-in-them

Guardian, 2023. https://www.theguardian.com/society/2023/jul/11/nhs-hospitals-in-england-serve-meat-with-chemicals-feared-to-cause-cancer

WCRF, 2022. https://www.wcrf-uk.org/wp-content/uploads/2023/03/HI-Processed-Meat-Factsheet-2023-UPDATED-WEB.pdf

WHO, 2015. https://www.who.int/news-room/questions-and-answers/item/cancer-carcinogenicity-of-the-consumption-of-red-meat-and-processed-meat

South Asian Diets

We hear so much about the Mediterranean Diet and often other cultural diets are either dismissed as “unhealthy”, or not mentioned whatsoever, despite having many benefits. Although by no means a full or extensive list, here are some of the benefits of a South Asian Diet, and why we should celebrate it:

  • South Asian food is infused with flavour from herbs and spices. Many of these foods have been indicated by research to have beneficial properties, including antioxidant, anti inflammatory and gut health and brain health supporting attributes.
  • South Asian food contains many wonderful plant based dishes based on spinach, bitter gourd, cabbage and cauliflower, chickpeas and lentils, which are all a rich source of fibre and polyphenols
  • South Asia has a rich history of fermented foods, including fermented breads, dairy products, vegetables and fish. Fermented foods are great for supporting gut health.

South Asian diets have come under scrutiny in the nutrition world, as they can be high in trans fats, salt, sugar and refined carbohydrates (as is the Western diet, I may add!). However, these simple swaps below may help to address these areas, whilst enjoying all the incredible nutritious benefits a South Asian diet provides:

  • Try to have a wide range of colourful vegetables and fruit each day, adding them to curries, wholegrain rice and other dishes
  • Aim to consume high fibre varieties of rice and bread, for example wholemeal chapati or roti and wholegrain rice. These help to support gut health, are lower in sugar and will leave you feeling fuller for longer.
  • Reduce added salt when cooking and increase herbs and spices, if needed, to replace the flavour
  • Swap refined cooking oils for healthier alternatives, such as coconut oil and olive oil

As a final thought, as nutrition practitioners it can be incredibly culturally insensitive to suggest a Mediterranean diet to individuals, when they have their own cuisines which have so many things to celebrate. Supporting individuals where they are at to make positive changes that support their health, whilst honouring their heritage is essential. We really need to decolonise nutrition and ensure that we are representing and catering for the foods and requirements of all the wonderful ethnic groups that make up this great nation.

A South Asian version of the EatWell Guide has been produced, this can be a useful resource to share with your patients to support them to have a balanced and healthy diet.

Further reading:

Fareeha Jay’s South Asian EatWell Guide: https://www.instagram.com/p/CT1b4GwIrsy/

The Diverse Nutrition Association: https://www.diversenutritionassociation.com/

Saffron: A Novel Intervention for Depression in Nutritional Psychiatry

A recent mechanism review published in the Journal of Affective Disorders has suggested that the spice, Saffron (Crocus sativus) may help to support individuals living with depression, due to increasing levels of BDNF (brain-derived neurotrophic factor) in the hippocampus. Philpotts et al. (2023) reported in their mechanism review that levels of BDNF fall in response to long term chronic stress, increasing risk of depression. The study reviewed some human studies, which indicate that a 30mg capsule of saffron per day was significantly more effective than placebo and as effective as antidepressant medications for improving depression. Although saffron was observed to be generally well tolerated in the studies analysed, some minor adverse reactions were noted including drowsiness, sedation, anxiety, headache, sweating, nausea, changes in appetite, constipation, dry mouth, palpitation, and tremor. It should be noted, however, that the incidence of these effects was not significant compared to the placebo or antidepressant controls. Mechanisms of action whereby saffron may attenuate depression appear to be via increasing hippocampal expression of BDNF, as well as due to saffron’s antioxidant, anti-inflammatory, serotonergic, and HPA-axis modulating action. The findings are promising in terms of saffron’s applications to nutritional psychiatry, however limitations identified in the paper were lack of human studies (Philpotts et al., 2023). Therefore further research is needed among adults living with depression to extrapolate further. Moreover, further research to explore saffron within the context of other mental health conditions may also be meritied, as this is an under researched area.

References

Philpotts, R, Gillan, Dr N, Barrow, Dr M, Seidler, Dr K. (2023).Stress-induced alterations in hippocampal BDNF in the pathophysiology of major depressive disorder and the antidepressant effect of saffron. Journal of Affective Disorders Reports, 14. https://doi.org/10.1016/j.jadr.2023.100630

Personalised Nutrition Approaches to Coffee and Brain Health

In July, Nutritank were delighted to be invited to contribute to an article written by Dr David Cox in the Telegraph regarding coffee and health. If you haven’t read the article already, you can do so here. In this further article, nutrition scientist Alice Benskin and soon-to-be dietitian, Stacey Nash, from the University of Plymouth, team up to discuss coffee with relation to nutritional psychiatry and nutrigenomics.

Nutrigenomics and Coffee: Personalised Nutrition Considerations

When considering coffee, it is important to acknowledge the area of personalised nutrition and nutrigenomics. Ding, Xu and Lau (2023) found that ‘habitual coffee consumption’ altered DNA methylation sites located at 11 genes. Moreover, genetic variations have been indicated to impact an individual’s ability to metabolise the caffeine in coffee (Mullins et al., 2020).

Nutrigenomics and Coffee Metabolism

Caffeine is metabolised by the CYP1A2 enzyme, and genetic variations impact on the functioning of this enzyme. The cytochrome P450 1A2 (CYP1A2) gene is responsible for 95% metabolism of caffeine in the liver. For example, single nucleotide polymorphisms (SNP) of the CYP1A2 gene can lead to hypersensitivity to caffeine whereas carriers of the Heterozygous (Adenine/Cytosine) gene metabolise caffeine more slowly (Mullins et al., 2020). Individuals can therefore be either rapid or slow caffeine metabolisers, depending on the variation of the CYP1A2 gene that they possess (Cornelis et al., 2006).

Coffee and Brain Health

Coffee has been shown in recent research to be potentially beneficial in preventing risk of developing neurological disease and mental illnesses. In terms of nutrigenomic research in this area, Lee and Mhd Rodzi (2022) indicated that neuroprotective actions of caffeine include:

  • Antagonising the adenosine A2A receptor to regulate dopaminergic transmission.
  • Modulating VMAT-2 gene expression, preventing neurotoxicity and brain damage by regulating neurotransmitters like dopamine, serotonin and noradrenaline.
  • Upregulating cytochrome oxidase (Cox) expression for striatal neuron survival (learning and memory).

Alzheimer’s Disease

In Alzheimer’s disease, coffee has been suggested to decrease the accumulation of beta-amyloid, a key marker of Alzheimer’s, when > 2 cups per day were consumed (Kim et al., 2019). A study, which consisted of in vitro and in cell experiments, demonstrated that the whole coffee extract, caffeine, and genistein have biological properties in preventing aggregation, condensation, and seeding activity of the repeat region of tau, a key marker in Alzheimer’s disease. The study also identified a set of coffee compounds capable of binding to preformed tau fibrils. These findings are promising, but require further exploration in human subjects (Tira et al., 2023).  As a caveat, another recent study, on humans, indicated that consumption of 3–5 cups of espresso daily was significantly associated with increased serum total cholesterol (Svatun et al, 2022).

Parkinson’s Disease

Coffee has been indicated to modulate dopamine-mediated responses related to cognition and movement, which may have some preventative and ameliorative effects in Parkinson’s disease (Küpeli Akkol et al., 2021).  However, the effect of coffee in Parkinson’s disease has some sex-specific differences, to caffeine’s competition with oestrogen for the oestrogen-metabolizing enzyme, CYP1A2 (Kolahdouzan, & Hamadeh, 2017).

Depression

With regards to depression, a recent study in Spain demonstrated that participants who drank at least four cups of coffee per day showed a significantly lower risk of depression compared with those who drank less than one cup of coffee per day (HR: 0.37 (95% CI 0.15–0.95)). However, this study did not observe an inverse linear dose–response association between coffee consumption and the incidence of depression (p for trend = 0.22). Mechanisms through which coffee may reduce risk of depression may be due to coffee’s antioxidant content and anti-inflammatory action, as inflammation is a key mechanism in depression (Navarro et al., 2018).

Dosage

Harvard University (2020) recommends drinking two to five daily cups of coffee, as this may protect against heart disease, diabetes, and some cancers. However, there appears to be a lot of individual considerations, which may make recommendations of exact amounts difficult to quantify. Regarding caffeine, it is important to remember that UK guidelines are that no more than 200mg (around 2½ cups of coffee) in one sitting, or 400 mg overall day (which equates to 5 cups of coffee) are consumed daily.  Daily consumption of caffeine over 600 mg has been suggested to have a negative impact on heart and brain health, via increasing serum homocysteine and cholesterol levels (Gökcen, & Şanlier, 2019). Furthermore, higher intakes of caffeine have also been suggested to increase anxiety, restlessness and cause gastrointestinal disturbances (Sajadi-Ernazarova et al., 2022).

Timing

There has been some conflicting evidence regarding the best time of the day to consume coffee. It has been proposed that consuming coffee immediately after waking may decrease its energising effects, as the stress hormone cortisol is at its peak level soon after rising (Dowd et al., 2011). However, research by Lovallo et al. (2005) demonstrated that cortisol responses to caffeine are reduced, although not eliminated, in healthy young men and women who consume caffeine on a daily basis.  A study by Sherman et al. (2016) on students showed that consuming coffee in the morning had a positive impact on cognitive performance and enhancing memory in exams.  Additionally, consuming coffee in the afternoon should also be considered, due to proximity to bed time. The Sleep Foundation (2023) suggests that individuals should consume their last cup of coffee 8 hours before they plan to go to bed (i.e if you go to bed at 10pm, do not drink coffee after 2pm). This is supported by research, which demonstrates that if caffeine is consumed within a six hour window before bedtime, this can result in significant disruptions to the sleep cycle (Drake et al., 2013).

Contraindications

With regards to reproduction, current NHS guidelines suggest that no more than 200mg of caffeine should be consumed daily during pregnancy (NHS, 2023). Notably, the British Medical Journal has recently challenged this view based on findings from observational studies, which suggest that caffeine should be avoided completely whilst trying to conceive and during pregnancy, as it may increase incidences of miscarriage, stillbirth and adverse pregnancy outcomes (James, 2021).

References

Cornelis, M. C., El-Sohemy, A., Kabagambe, E. K., & Campos, H. (2006). Coffee, CYP1A2 genotype, and risk of myocardial infarction. JAMA, 295(10), 1135–1141. https://doi.org/10.1001/jama.295.10.1135

Ding, Q., Xu, Y.-M. and Lau, A.T.Y. (2023) ‘The Epigenetic Effects of Coffee’, Molecules, 28(4), p. 1770. Available at: https://doi.org/10.3390/molecules28041770.

Dowd, J. B., Ranjit, N., Do, D. P., Young, E. A., House, J. S., & Kaplan, G. A. (2011). Education and levels of salivary cortisol over the day in US adults. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 41(1), 13–20. https://doi.org/10.1007/s12160-010-9224-2

Drake, C., Roehrs, T., Shambroom, J., & Roth, T. (2013). Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 9(11), 1195–1200. https://doi.org/10.5664/jcsm.3170

Gökcen, B. B., & Şanlier, N. (2019). Coffee consumption and disease correlations. Critical reviews in food science and nutrition, 59(2), 336–348. https://doi.org/10.1080/10408398.2017.1369391

Harvard University, 2020. Moderate Amounts of Coffee are the Best. https://www.health.harvard.edu/staying-healthy/moderate-amounts-of-coffee-are-the-best

James J. E. (2021). Maternal caffeine consumption and pregnancy outcomes: a narrative review with implications for advice to mothers and mothers-to-be. BMJ evidence-based medicine, 26(3), 114–115. https://doi.org/10.1136/bmjebm-2020-111432

Kim, J. W., Byun, M. S., Yi, D., Lee, J. H., Jeon, S. Y., Jung, G., Lee, H. N., Sohn, B. K., Lee, J. Y., Kim, Y. K., Shin, S. A., Sohn, C. H., Lee, D. Y., & KBASE Research Group (2019). Coffee intake and decreased amyloid pathology in human brain. Translational psychiatry, 9(1), 270. https://doi.org/10.1038/s41398-019-0604-5

Kolahdouzan, M., & Hamadeh, M. J. (2017). The neuroprotective effects of caffeine in neurodegenerative diseases. CNS neuroscience & therapeutics, 23(4), 272–290. https://doi.org/10.1111/cns.12684

Küpeli Akkol, E., Tatlı Çankaya, I., Şeker Karatoprak, G., Carpar, E., Sobarzo-Sánchez, E., & Capasso, R. (2021). Natural Compounds as Medical Strategies in the Prevention and Treatment of Psychiatric Disorders Seen in Neurological Diseases. Frontiers in pharmacology, 12, 669638. https://doi.org/10.3389/fphar.2021.669638

Lee, L.K. and Mhd Rodzi, N.A.R. (2022) ‘Addressing the Neuroprotective Actions of Coffee in Parkinson’s Disease: An Emerging Nutrigenomic Analysis’, Antioxidants, 11(8), p. 1587. Available at: https://doi.org/10.3390/antiox11081587.

Lovallo, W. R., Whitsett, T. L., al’Absi, M., Sung, B. H., Vincent, A. S., & Wilson, M. F. (2005). Caffeine stimulation of cortisol secretion across the waking hours in relation to caffeine intake levels. Psychosomatic medicine, 67(5), 734–739. https://doi.org/10.1097/01.psy.0000181270.20036.06

Mullins, V.A. et al. (2020) ‘Genomics in Personalized Nutrition: Can You “Eat for Your Genes”?’, Nutrients, 12(10), p. 3118. Available at: https://doi.org/10.3390/nu12103118.

Navarro, A. M., Abasheva, D., Martínez-González, M. Á., Ruiz-Estigarribia, L., Martín-Calvo, N., Sánchez-Villegas, A., & Toledo, E. (2018). Coffee Consumption and the Risk of Depression in a Middle-Aged Cohort: The SUN Project. Nutrients, 10(9), 1333. https://doi.org/10.3390/nu10091333

NHS, 2023. Foods to Avoid. https://www.nhs.uk/pregnancy/keeping-well/foods-to-avoid/

Sajadi-Ernazarova KR, Anderson J, & Dhakal, A. (2022). Caffeine Withdrawal. https://www.ncbi.nlm.nih.gov/books/NBK430790/

Sherman, S. M., Buckley, T. P., Baena, E., & Ryan, L. (2016). Caffeine Enhances Memory Performance in Young Adults during Their Non-optimal Time of Day. Frontiers in psychology, 7, 1764. https://doi.org/10.3389/fpsyg.2016.01764

Svatun, Å. L., Løchen, M. L., Thelle, D. S., & Wilsgaard, T. (2022). Association between espresso coffee and serum total cholesterol: the Tromsø Study 2015-2016. Open heart, 9(1), e001946. https://doi.org/10.1136/openhrt-2021-001946

Tira, R., Viola, G., Barracchia, C. G., Parolini, F., Munari, F., Capaldi, S., Assfalg, M., & D’Onofrio, M. (2023). Espresso Coffee Mitigates the Aggregation and Condensation of Alzheimer’s Associated Tau Protein. Journal of agricultural and food chemistry, 10.1021/acs.jafc.3c01072. Advance online publication. https://doi.org/10.1021/acs.jafc.3c01072

The Sleep Foundation, 2023. https://www.sleepfoundation.org/nutrition/caffeine-and-sleep

Nutrition4Youngsters Abstract Published

At the recent NNEDPRO 9th International Summit on Nutrition and Health, medical students Diogo Izidoro, Yasmin Baker and Eleanor Smyth had the opportunity to present an abstract on the research that Nutrition4Youngsters, Nutritank’s school nutrition education initiative, has been conducting.

The study demonstrated exciting results, illustrating the effectiveness of the Nutrition4Youngsters programme in school. The positive impact of N4Y teaching sessions on the nutritional knowledge of primary school children was clearly demonstrated, but the research also highlighted the gaps and shortcomings of the current KS2 curriculum. Expanding N4Y teaching sessions on a national level, and including additional sessions aimed towards parents, were suggested by the authors to improve the social norm around nutritional education, whilst fostering a culture of prioritising nutrition and lifestyle medicine for future generations

There is a recording of the presentation delivered at the summit available here. The full abstract, which was authored by Diogo Izidoro, Yasmin Baker and Eleanor Smyth, of Imperial College London Nutritank Branch, and Nutritank co-founder Dr Ally Jaffee and Nutrition Education Lead Alice Benskin, is also available here.

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