NHD June 2015 issue 105 by NH Publishing Ltd

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NHDmag.com

ISSN 1756-9567 (Online)

Issue 105 June 2015

Enteral feeding following stroke Marion Ireland and Shubha Moses p9 Do dietitians need to be sip feed prescribers? . . . p18

Dimple Thakrar Prescribing Support Dietitian Bolton CCG

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from the editor Welcome to issue 105 which offers a selection of articles for you to read whilst you are taking a break from Dietitians Week (8-12 June).

Chris Rudd NHD Editor Chris Rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCT Medicines Management Team, as a Dietetic Advisor.

@NHDmagazine

Jacqui Lowden takes us through the ‘W’ approach to Follow-on formula milks and leads us to a very interesting conclusion. New parents must get so confused and influenced about what to do with their infants! Ursula Arens almost ‘walks us down the milk isle in the supermarket’ to inform us of milk alternatives ‘The white stuff’. ‘Mock milks’ originate from many plant sources and Ursula’s article tells us more. Both these articles really do look at what milk is best! Appropriate prescribing of ONS has been the topic of interest for some while; however, there are many times when ONS are not used appropriately. Malnutrition and its consequences, nutritional screening, problem solving, care planning focusing on the food first approach, reviews and monitoring, along with staff training, audits, cost effectiveness, who should prescribe and when, are linked key themes. Dimple Thakrar tells us about the Sip feed project in Bolton and asks us, ‘Do dietitians need to be sip feed prescribers?’ Emma Coates takes on another aspect of ONS in Oral nutritional support: Worth every penny? Emma includes the contributing factors in malnutrition and covers the range and cost of ONS. The theme of malnutrition continues with members of the BAPEN Quality Group, Anne Holdoway, Ailsa BrothEditor Chris Rudd RD Features Editor Ursula Arens RD Design Heather Dewhurst Sales Richard Mair richard@networkhealthgroup.co.uk Publisher Geoff Weate Publishing Assistant Lisa Jackson

erton and Dr Mike Stroud telling us of the BAPEN Nutritional Care Tool. This is a new measurement tool to support the delivery of improvements in nutritional screening, nutritional care processes, outcomes and the patient experience. A date for your diary is the week commencing the 29 June 2015. Why? This will be the first scheduled national screening week using this new tool. I do hope that you will be willing, able and free to take part in this week. It is estimated that from six to 60 percent of patients show signs of malnutrition following a stroke. Marion Ireland and Shubha Moses’ article, Enteral feeding following stroke covers nutritional screening, assessment and requirements and types of nutritional support that can be offered, as well as the process leading to the discharge planning. Have you been trained HENRY style and work within the field of childhood obesity? If so, Rachael Brandreth’s article on The care pathway for weight management of children across Cornwall will be of interest and you will be informed of the LEAF programme. Rachael invites you to get involved, so read on to find the details. Diet swap sounds fascinating. It involves 20 rural Africans and 20 Americans. Ursula Arens reveals the details and concludes, ‘maize with amaze!’

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@ networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

NHDmag.com June 2015 - Issue 105

Contents

COVER STORY

Enteral feeding following stroke 6

News

38 Childhood obesity in Cornwall

14 Milk alternatives

41 Gut health: research

18 Sip feeds: dietetic prescribing

44 Web watch

23 Follow-on formulas

45 dieteticJOBS

27 BAPEN Nutritional Care Tool

46 Events and courses

33 Oral nutritional support

47 The final helping

Editorial Panel Chris Rudd Dietetic Advisor

Marion Ireland Specialist Dietitian, Stroke Rehabilitation

Neil Donnelly Fellow of the BDA

Shubha Moses Specialist Dietitian, Stroke Rehabilitation

Ursula Arens Writer, Nutrition & Dietetics

Dimple Thakrar Prescribing Support Dietitian, Bolton CCG

Dr Carrie Ruxton Freelance Dietitian

Anne Holdoway Consultant Dietitian, BDA and BAPEN

Dr Emma Derbyshire Nutritionist, Health Writer

Mike Stroud President of BAPEN

Emma Coates Senior Paediatric Dietitian

Ailsa Brotherton Chair of the Quality and Safety Committee, BAPEN

Jacqui Lowden Paediatric Dietitian

Rachael Brandreth Paediatric Dietitian

NHDmag.com June 2015 - Issue 105

Coming soon

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Important notice Cow & Gate Nutriprem Protein Supplement is a food for special medical purposes for the dietary management of extremely low birthweight infants who require additional protein. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. For enteral use only. Reference 1. Agostoni C et al. Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85-91.

news

More fruit and veg benefits

Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd

We are all aware that eating fruit and veg is good for us. Previous research has shown that eating fruit and veg offers a number of important health benefits, particularly in relation to coronary heart disease (CHD), although there have been some inconsistencies. The authors of this meta-analysis reviewed historic studies to establish whether increased fruit and veg consumption led to a reduction in CHD. This research identified and analysed 23 studies using a total of 937,665 people and 18,047 patients with CHD. Results showed that increasing fruit and veg intake can lead to significant reductions in CHD risk in Western populations but not in Asian populations. In Western populations the risk of CHD was reduced by 12 percent, providing around 477g a day fruit and veg were consumed, by 16 percent if 300g a day of fruit was consumed and by 18 percent if 400g veg a day was eaten. Further research is now necessary to equate this into relevant portion sizes and to further investigate the effect of fruit and veg consumption on coronary heart disease in Asian populations. For more information see: Gan Y et al (2015) International Journal of Cardiology Vol 183 (0) pg129-137.

Latest on vitamin D

Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

Falls in older people can lead to trauma, hospitalisation, loss of independence and institutionalisation. Existing research into vitamin D status and the likelihood of falls in older people has been inconclusive. In this study, the authors systematically reviewed previously published work and conducted a meta-analysis to find out whether vitamin D blood serum levels were linked to falls in older people. The review identified 18 good quality observational studies. Participant numbers ranging from 80 to 2,957 and age ranges between 63 and 84 years.

NHDmag.com June 2015 - Issue 105

More good news about eggs

Eggs are a simple and easy way of getting protein and essential micronutrients into the diet. Given this, along with their possible satiety and weight management benefits, it is thought that people with Type 2 diabetes (T2D) could benefit from eating these. New research has now looked into this. In this randomised controlled trial, researchers recruited overweight or obese people with either prediabetes or Type 2 diabetes (n=140). Each participant was then randomly allocated high-egg (two eggs daily for six days or the week) or low-egg diet (<two eggs per week) for six weeks. Markers of metabolic health were measured in both groups. Results showed that there were no statistically significant differences in total cholesterol, low-density lipoprotein, triglycerides, or glycaemic control between the groups. However, the high-egg group did report feeling less hungry and having felt fuller after eating breakfast when compared with the low-egg group. These are interesting findings which imply that high-egg diets could be included safely as part of T2D dietary management. These may also have the added benefit of helping to stave off hunger. For more information see: Fuller N et al (2015) The American Journal of Clinical Nutrition Vol 101 (4) pg705-13.

Results showed that blood serum 25(OH)D levels, a marker of vitamin D status was lower in fallers compared to nonfallers (i.e. tending to be <20ng mL-1). The risk of falls was also lower amongst those with higher serum 25(OH)D levels. The authors concluded that these findings might help to identify groups that would benefit from taking a vitamin D supplement. For more information see: Annweiler C and Beauchet O (2015) Journal of Internal Medicine Vol 277 (1) pg16-44.

news

Product / industry news

New research on nuts and health

Eating nuts is known to have beneficial effects on heart health and is thought to reduce the risk of cardiovascular disease. Two new studies have looked into further potential health benefits that might be associated with eating nuts. A new meta-analysis has looked at whether eating nuts could be associated with decreased mortality. The review identified 15 prospective studies and included a total of 354,933 participants. Results showed that eating just one serving of nuts per day was found to decrease the risk of all-cause mortality by four percent and CVD mortality by 27 percent. Nut consumption was also associated with a reduced risk of cancer deaths when data from the highest and lower intakes groups were compared. The authors concluded that nut consumption lowers the risk of death from CVD, although further research is needed to confirm these findings. A second paper has looked at nut consumption in relation to stroke risk in a German population, forming part of the European Prospective Investigation into the Cancer and Nutrition Potsdam Study. The study took place over 8.3 years (n=26,285), with details on nut consumption being collected at baseline using a semi-quantitative food frequency questionnaire. Results showed that the average nut intake was 0.82g per day. While an increased risk of stroke was noted in participants who never ate nuts, no other associations were found. Overall, findings looking into nut consumption and health are somewhat mixed. Lack of findings may be attributed to the epidemiologyical nature of these studies. More RCTs are needed in order to reach firmer conclusions. For more information see: Grosso G et al (2015) The American Journal of Clinical Nutrition Vol 101 (4) p783-793 and di Giuseppe R et al (2015) The European Journal of Clinical Nutrition Vol. 69 (4) pg431-435.

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Weaning methods and satiety

Weaning can be a difficult time with plenty of confusion over which method to use and what foods to provide. Now, new research has looked into how different approaches can affect satiety. A sample of 298 mums completed a questionnaire when their baby was aged six to 12 months and 18 to 24 months providing information about weaning style, timing of solid foods, child eating style and reported weight. If was found that infants fed using the babyled approach were significantly more responsive to satiety and less likely to be overweight when compared to those weaned using standard approaches. These are interesting findings, but additional studies are now needed in the form of randomised trials. For more information see: Brown A and Lee MD (2015) Pediatr Obes, 10(1), pg57-66. NHDmag.com June 2015 - Issue 105

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cover story

Enteral feeding following stroke Stroke is a major cause of morbidity and mortality in the UK and the third major cause of death accounting for 11% (1). Most people survive a first stroke, but are often left with significant morbidity and/or physical or cognitive deficits. Malnutrition following stroke Marion Ireland Specialist Dietitian, Stroke Rehabilitation, NHS Lothian & NHS Forth Valley

Shubha Moses Specialist Dietitian, Stroke Rehabilitation, NHS Lothian & NHS Forth Valley

Estimates vary from six to 60 percent of patients showing signs of malnutrition following stroke, variance depending on the criteria used to identify malnutrition (2). It is well recognised that malnutrition is an independent risk factor for increased morbidity, poorer outcomes and mortality after a stroke (3-6). The risk of malnutrition in stroke patients varies, but it is recognised that nutritional status can worsen during admission and that undernutrition following admission is associated with increased case fatality and poor functional status at six months (7). It is important to assess beyond swallowing problems and poor intake and look thoroughly at the mechanics of ‘plate to mouth’ and the entire meal process, to ensure that the impact of any residual deficits is minimised. Nutritional screening

Both Marion and Shubha have a longstanding interest in all aspects of Neurorehabilitation and have worked in the field for over10 years.

Screening of all patients should ideally be carried out within 48 hours of admission to hospital (8) and repeated regularly throughout the episode of care. It should also direct referral to a dietitian for assessment and management of nutritional risk. Malnutrition occurs in approximately 15 percent of all patients admitted to hospital, increasing to approximately 30 percent within the first week. It carries with it a strong association with poorer functional outcome and slower rate of recovery (9). In addition, SIGN 78 (10) recommends that a nutritional screening tool for use in stroke patients should focus on the effects of stroke on nutritional status, e.g. presence of dysphagia and ability to eat, rather than solely focusing on pre-existing nutritional status.

Nutritional assessment and requirements

It is unclear to what extent hypermetabolism and hypercatabolism occur post-stroke, with estimations for the increase in metabolic rate following stroke ranging from 10 percent up to 50 percent, (11) depending on the severity and clinical consequences of the stroke, and clinical judgement is required when estimating the increase in resting energy expenditure. Catabolic effects vary according to the individual, but usually persist for the first few weeks, then begin to resolve in the following weeks and months. Nutritional assessment and estimation of requirements commonly are based on predictive equations such as Henry (2005) (12). Management of Dysphagia following Stroke:

Dysphagia, is a common and clinically significant complication following stroke (6) which can result in aspiration. The presence of aspiration is associated with an increased risk of developing an aspiration pneumonia and other broncho-pulmonary infections (3). Both NICE 2004 and SIGN 78 recommend that, following acute stroke, all patients should be screened for dysphagia by an appropriately trained healthcare professional before being given food, drink or medication. NICE 2008 (14) recommends that, if the admission screen indicates a swallowing problem, then a specialist assessment should take place within 72 hours of admission. NHDmag.com June 2015 - Issue 105

Enteral feeding following stroke Effective management of dysphagia is of key importance following stroke, in order to prevent undernutrition and dehydration from occurring, as far as possible. This must involve multidisciplinary working and good communication between involved practitioners. Once a full assessment of dysphagia by a speech and language therapist has taken place, the appropriate route of feeding can be identified, making it more attainable to meet nutrition and hydration requirements. The route of feeding initially is often a combination of oral and enteral feeding, and the management of each transition through the different stages of this spectrum is a crucial part of effective dysphagia management. Enteral nutrition

Nutritional intervention following stroke can often involve enteral feeding in patients who are unable to meet their requirements safely or consistently via oral diet and fluids, and for some patients, oral intake is contraindicated completely. Contraindications to enteral nutrition are patient refusal, patients with a non-functioning GI tract and where it is inappropriate to feed for ethical reasons (16). Enteral feeding in stroke tends to focus on nasogastric and gastrostomy feeding, both of which are used in patients unable to meet their requirements, or who are at risk of diseaserelated malnutrition. Ethical considerations in enterally fed patients

The complexities of enteral feeding and insertion of enteral feeding tubes should lead us to concentrate more closely on the decision to feed in the first instance and the ethical considerations surrounding the initiation of feeding in stroke patients as an intervention. However, particularly in this patient group, this is a complex and multifactorial decision, as many of the functional measures that are initially impaired can improve, but at very different rates in each individual, thus making it hard to predict how each patient will progress Each patient’s capacity to contribute to this decision needs to be assessed and, if not deemed able to consent, then additional measures should be put in place regarding consent and capacity to do so. Enteral nutrition is regarded as an aspect of 10

NHDmag.com June 2015 - Issue 105

medical treatment and it is recommended that in cases where the benefits of nutrition support are uncertain, a ‘time-limited’ trial should be undertaken (14) Whilst it is important to avoid nutritional status deteriorating in the acute phase of stroke, the decision to feed severely disabled patients, with little prospect of neurological recovery is difficult, and all aspects of survival need to be taken into account. This needs to be a medical decision and any previously expressed wishes, e.g. living will or advanced directive, should be adhered to. Hydration

Fluid intake in stroke patients is of key importance and may need to be supplemented if unable to be met orally, most commonly by subcutaneous or intravenous fluids in the acute phase of treatment. Once an alternative feeding route is established, most likely nasogastric tube in the acute phase, this can serve a dual purpose of providing nutrition and hydration and should be the route of choice for meeting an individual’s requirements until oral intake of food and fluids improves. Many factors can make risk of dehydration in stroke patients more likely, such as decreased sense of thirst, fear of incontinence, inadequate intake of thickened fluids required to meet requirements, inability to self-feed and communication difficulties, e.g. difficulties in expressing thirst or need for a drink to carers. Again, with good observation of patients at ward level, coupled with robust assessment measures, these risks can be managed, thus decreasing the likelihood of dehydration occurring. Nasogastric (NG) feeding

Tube placement involves a fine-bore NG tube being inserted trans-nasally into the stomach. The tubes are usually between 8.0-10mm French Gauge, made from polyurethane, PVC or silicone. NG feeding is ideal in the acute setting, for patients who require short-term feeding, identified as less than four weeks (17). It can be used longer term if other options such as gastrostomy feeding are contraindicated or not appropriate (18). The position of the tube should be confirmed by aspiration of stomach contents and checking that the pH of aspirate is <5.5, indicating gastric contents, as per the National Patient Safety Agen-

Enteral feeding following stroke cy Guidelines from 2005 (19). The position of a NG tube should be confirmed before each use by aspiration of stomach contents, and radiological confirmation should only be used when there is ongoing difficulty in obtaining aspirate, or concern regarding the tube position that cannot be otherwise resolved. Consent should be obtained for placement of all feeding tubes, and this can prove difficult in stroke patients (and in other neurological conditions) as there may be cognitive impairment and significant communication difficulties, along with confusion and poor understanding, particularly immediately post stroke. Medical staff usually take responsibility for obtaining consent for procedures that are considered invasive, or identifying when patients do not have the capacity to consent, and putting alternative arrangements for procedures to take place, such as per the guidance for consent and capacity from the British Medical Association in England and Wales, or the Adults with Incapacity Act in Scotland. Results from the FOOD Trial indicated that early enteral feeding, clarified as within seven days, may reduce mortality and that dysphagic stroke patients should be offered enteral feeding via nasogastric tube within the first few days of admission. However, it also identified worse quality of life in patients who are allocated early tube feeding, concluding that early feeding may keep patients alive, but in a severely disabled state when they would otherwise have died (20). The RCP Stroke Guidelines go a step further, indicating that patients should be fed within the first 24 hours, based on the recommendations of the FOOD Trial and the observed reduction in mortality, with further consultation with patient representatives regarding the timing of initiation of feeding for maximum benefit. Nasal bridle (NB) tube retaining devices

Nasal bridles are enteral feeding tube retaining devices that are increasing in use in patients who repeatedly displace nasogastric tubes, e.g. in patients who are confused following stroke. The use of NB loop has been shown to have few complications and minimal discomfort for the patients, and in one prospective study, showed a reduction in 30-day gastrostomy mortality, in part due to better selection of patients for gas-

trostomy, and also that bridle loops allowed patients an average 10 days of nutrition prior to either recovery or gastrostomy placement. (21) The NICE Guideline for management of acute stroke (14) endorses the consideration of using nasal bridle tubes in stroke patients who are unable to tolerate a NG tube. Gastrostomy feeding

Gastrostomy feeding is generally used for patients who require longer-term nutritional support, usually identified as more than four weeks (14). Gastrostomy tubes are placed directly into the stomach, either endoscopically, surgically, or radiologically, and each patient should be fully assessed prior to placement to ensure that there are no contraindications to placement, e.g. previous abdominal surgery, and that placement is appropriate. Previously, a number of studies comparing nasogastric to gastrostomy feeding showed that there was better success in the administration of feed, less interruption to feeding regimen and lower risk of aspiration with gastrostomy feeding. As a result, patients were more consistently hydrated and fed and nutritional status improved and, with it, many of the functional measures associated with poor nutrition, such as increased frequency of infection, increased risk of pressure areas, depression, loss of muscle mass, etc. However, the FOOD Trial (20) found that there were no clinically significant benefits of gastrostomy feeding compared to nasogastric feeding and also found a reduction in poor outcomes with NG feeding. The recommendation from this was to use NG feeding initially for the first two to three weeks post stroke, unless there was a clear practical reason to use gastrostomy. An additional finding of interest was that the gastrostomy group had a higher rate of pressure sores, which raised the possibility that these patients may move less or be nursed differently. Poor outcome following gastrostomy insertion, as concluded by the FOOD Trial, must consider that patient selection is a factor, as those requiring gastrostomy are patients with poor nutritional intake and status and the poorest prognosis. This links in with the finding that, although early enteral feeding is recommended and does not cause any harm, this can keep patients alive but in a severely disabled state where they would NHDmag.com June 2015 - Issue 105

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Enteral feeding following stroke otherwise have died, i.e. survival itself does not equate to survival with good outcome. The commonly used terminology of Percutaneous Endoscopic Gastrostomy (PEG) and Radiologically Inserted Gastrostomy (RIG) refer to the methods of placement, not type of tube. Tubes are more commonly identified as BalloonRetained and Non-Balloon Retained, and the type of tube and method of placement vary depending on the individual, and which method is most suitable. Surgical gastrostomy can be placed in patients who have failed to tolerate both PEG and RIG procedures. There are various potential complications of gastrostomy tube insertion ranging from minor complications such as cellulitis and localised skin infection, to more major complications such as infectious peritonitis or buried bumper syndrome. Medication administration

Administration of medications is often necessary in stroke patients, due to dysphagia or Nil by Mouth status. Careful guidance should be sought regarding method and timing of administration,

along with any drug-nutrient interactions with feed products (22, 23). Administering each medication separately and flushing the feeding tube with 10mls water in between each medication is considered to be good practice. Guidance on monitoring

Monitoring of patients on enteral feeding should be multidisciplinary, depending on the healthcare professionals involved in that individual’s care. Anthropometric and biochemical markers are essential and useful, along with clinical judgement regarding the medical stability of the patient (24, 25) Discharge planning

It is essential that good practice is established in terms of coordination of discharge from hospital for patients on enteral feeding. Training and support for patients, carers and relatives on all aspects of feeding and ongoing tube care is critical, and it is essential that it is delivered in a timely fashion, with information provided in the most suitable medium for each patient and their carers.

References: 1 British Heart Foundation. Coronary Heart Disease Statistics. BHF 2004 2 Foley NC, Martin RE, Salter KL, Teasell RW. A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med 2009; 41: 707-713 3 Dennis M. Poor nutritional status on admission predicts poor outcomes after stroke. Stroke 2003; 34:1450-1456 4 Davis JP, Wong AA, Schluter PJ, Henderson RD, O’Sullivan JD and Read SJ. Impact of pre-morbid undernutrition on outcome in stroke patients. Stroke 2004; 35: 1930-1934 5 Martineau J, Bauer JD, Isenring EA, Cohen S. Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients. Clinical Nutrition 2005; 24(6):pp. 1073-1077 6 Yoo SH, Kim JS, Kwon SU, Yun SC, Koh JY and Kang DW. Undernutrition as a predictor of poor clinical outcomes in acute ischemic stroke patients. Archives of Neurology 2008; 65: 39-43 7 Dennis et al. FOOD Trial Collaboration: Routine oral nutritional supplementation for stroke patients in hospital: a multicentre randomised controlled trial. Lancet 2005. 365:p755-763 8 Nursing & Midwifery Practice Development Unit. Nutrition: Assessment and referral in the care of adults in hospital - best practice statement. NMPDU 2002 9 Royal College of Physicians. National Clinical Guidelines for Stroke. RCP 2004 10 Scottish Intercollegiate Guidelines Network. Clinical Guideline 78. Management of patients with stroke: Identification and management of dysphagia. SIGN 2004 11 Finestone et al. Measuring longitudinally the metabolic demands of stroke patients: resting energy expenditure is not elevated. Stroke 2003. 34: p2502-507 12 Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr 2005; 8(7A):1133-1152 13 Perry L, Love CP. Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 2001. 16(1), 7-18 14 National Institute for Health & Clinical Excellence. Stroke - Diagnosis and initial management of acute stroke and transient ischaemic attack. Clinical Guideline 68. 2008 15 National Institute for Health and Clinical Excellence. Nutrition Support in adults. Clinical Guideline 32. NICE 2006 16 Lennard-Jones JE. Ethical and legal aspects of Clinical Hydration and Nutritional Support. A report for the British Association for Parenteral and Enteral Nutrition. BAPEN 2000 17 Manual of Dietetic Practice (4th Edition) Blackwell Publishing Ltd 2007 18 McAtear CA (ed). Current perspectives on enteral nutrition in adults. BAPEN Working party report. BAPEN 1999 19 National Patient Safety Agency. Patient Safety Alert: Reducing the harm caused by misplaced nasogastric feeding tubes. 2005 20 Dennis et al. FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients: a multicentre randomised controlled trial. Lancet 2005. 365, 764-772 21 Johnston RD et al. Outcome of patients fed via a nasogastric tube retained with a bridle loop: Do bridle loops reduce the requirement for percutaneous endoscopic Gastrostomy insertion and 30-day mortality? Proc Nutr Soc 2008. 67 (OCE) E116 22 White R and Bradnam V (2011). Handbook of Drug Administration via Enteral Feeding Tubes. 2nd Edition. Pharmaceutical Press 23 Smyth J (2012). The NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. 2nd Edition 24 Todorovic and Mickelwright (2011). PENG - A pocket guide to Clinical Nutrition, 4th Edition 25 ASPEN Enteral Nutrition Practice Recommendations, JPEN (2009); originally published online

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Milk alternatives

The white stuff… Supermarket shelf space can sometimes tell you as much as more sophisticated research tools on what is selling (or rather on what we are buying). Christmas means towers of tubs of wrapped chocolates more than man-high.

Ursula Arens Writer; Nutrition & Dietetics

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

They are only given valuable shop floor space because they are bought in such huge quantities, of course. Valentine’s Day brings roses and presentation confectionary; July brings English strawberries with offers of ‘free’ cream and the end-of-October brings pumpkins which are needed to scare small children and are unlikely to be eaten, despite their nutritional excellence. An interesting feature of the last few years is the expansion of shelf space given to an increasing variety of other milks*. Not meaning infant formula. Not meaning other mammalian milks such as goat or buffalo, although the latter are also increasingly on offer. Not meaning modified cows’ milk (lactose-free) or ‘different’ cows’ milk, such as a2™ milk. Rather, milk-type plant-sourced liquids that can be used instead of cows’ milk to moisten breakfast cereals or counter the astringency of teas or coffees. The dairy-alternative market has grown strongly in the last few years in both volumes and varieties of products on offer, so confirmed the market research organisation Mintel in June 2014. In the two years to the end of 2013, the volume sales of cows’ milk alternatives (CMAs) rose by more than 150 percent in the UK: from 36 million litres, to 92 million litres. The lactose-free cows’ milk market, of which there is only one monopoly product (Lactofree made by the Danish dairy company Arla), reached volumes of 17 million litres in 2013, so less than one fifth of the volume of the plant-sourced milks. This is perhaps an indication that other factors are driving this trend beyond just the real or perceived diag-

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nosis of lactose intolerance. The Mintel survey reported that 18 percent of the 1,500 UK consumers asked, claimed to have drunk soya milk or other plantbased milk and five percent had drunk lactose-free cows’ milk in the previous week. Data from another market research organisation, Kantar Worldpanel (4), reported volume sales of soya milk in the year to January 2015 at 79 million litres, although they note a four percent decline in the year; also, to put the figure into context, this is less than two percent of the volume of cows’ milk sales in the same period. However, soya milk sales battle against the fact that they are a more expensive product at 95 pence per litre and rising, against the cost of cows’ milk of 59 pence per litre and falling. Also, the soya milk market is now a more mature part of the CMA sector and there has been an increase in the variety of other plant milks available in this period. Easily available choices now include products based on rice, almonds, oats, coconut and hazelnuts. Less-easily available choices such as seed milks (hemp or flax/linseed) or sweet chestnut or cashew drinks also exist. Not to mention all the other permutations that face the consumer in relation to white-liquid choices: products that are chilled or long life, original or unsweetened, organic or fortified, vanilla or chocolate flavoured, smooth or foamy. Also launched in the UK, but now withdrawn, was a statinfortified soya milk for those with concerns over high blood cholesterol. At the Food Matters Live conference held in London in November 2014,

milk alternatives Richard Hall, from the drink industry research agency Zenith International, reviewed consumer demand for dairy-free and lactose-free products. Lactose intolerance was the normal condition in adulthood globally; the Caucasian populations in and from Europe were the exception. But there had been a strong increase in awareness of lactose intolerance and, although, diagnosis was often unreliable, it introduced the motivation for people to seek alternative products. There was currently a greater variety of plant-based products available in the US and developments that he predicted for the UK market were range extensions to other dairy products such as creams and yoghurts, blends of plant sources such as different nuts, or products using sugar alternatives such as stevia. Plant milks can be made from: Soya Coconut Cereal - rice, oats, barley Nuts - almonds, hazelnuts, cashews Seeds - hemp, linseed Sweet chestnuts Why are UK consumers going for mock milks?

More than one quarter of the 1,500 consumers questioned by Mintel (2) agreed that plant-based milk was generally healthier than cows’ milk and eight percent reported more specifically that drinking cows’ milk caused them digestive problems and feeling bloated. There were also concerns over environmental and welfare aspects of cows’ milk consumption. A surprisingly large number of UK consumers were doubtful of the purity of cows’ milk: nearly 60 percent of the sample (and 70 percent of the under-25s) claimed distrust. There are many nutritional differences between cows’ milk and plant-sourced milks. Products that are marketed as organic may not be fortified, but many of the other plant milks have additions of vitamins B2 and B12 and calcium to match levels found naturally in cows’ milk. Many products also have additions of vitamin D at levels that are very much higher than the trace

levels and seasonably variable amounts naturally present in cows’ milk. Energy contents of cows’ milk and plant milks are similar, but macronutrient profiles differ: plant milks are always lower in saturated fats (with the exception of coconut), and are sometimes lower in proteins. They may, however, contain modest amounts of fibre. Other than nutrient differences, some plant milks also promote health benefits due to the presence of other compounds such as beta-glucan in oat milk or isoflavones in soya milk. For healthy adults, fortified plant milks offer a tasty and nutritious alternative to cows’ milk. But these drinks are unsuitable for infants and as a main drink in young children under three years of age**. There are some concerns that perceptions of the healthiness and naturalness of plant milks may lead to a too-early inclusion of these products into the diets of very young children. A study on the inappropriate premature and extended use of plant milks in infants in France (1) documented hypoalbuminemia, hypocalcaemia and impaired growth in infants fed plant milks. The researchers cautioned that the energy and protein content of these milks were not adequate for feeding infants and called for statutory measures to improve parental education on this issue. The US consumer is also increasingly considering non-dairy milks, which now command nearly 10 percent of the category sales and boast gains of nearly 95 percent in the five years period to 2014 (and retail sales at US $2,000 milNHDmag.com June 2015 - Issue 105

milk alternatives lion). In a Mintel survey (3), US consumers were asked what milks they had consumed in the last three-month period. Responses were that 71 percent had consumed cows’ milk, but plant milks were also a surprisingly frequent choice: almond milk (30 percent), soy milk (23 percent), rice milk (14 percent) and about 10 percent each for seed milks, oat milks and cashew milks. The primary reason given by US consumers for drinking non-dairy milk was the belief that it was generally more nutritious. Additionally, consumers enjoyed the taste of these products and believed them to be a good source of protein. Specific reasons given for choices of non-dairy milks were also lactose sensitivity or other intolerance to dairy products, and concerns about the use of growth hormones in dairy milk (rBST and/or rBGH - the use of bovine somatotropin to increase milk yield and bovine growth hormone to increase muscle is permitted and declared as safe in the US, but is not permitted in the UK or any other EU country). Another report on US consumer attitudes supports the strong growth of non-dairy milks (5). But there are winners and losers in the

year to 2014: in decline are soya and rice milk, whereas there is strong growth for coconut and especially almond milk. The dairy industry has not been shy in countering anti-cow claims by plant milk enthusiasts. Cows’ milk is generally higher in protein than some plant milks and possible muscle-building benefits from the higher leucine levels in whey protein are of great interest to the sports and body sculpture communities. Further, the naturalness of milk is emphasised: no fortification or ‘additives’ are needed to embellish this food. While the cow must plead guilty to being a very major contributor to greenhouse gas emissions, environmental finger-pointing has suddenly hit the halo held by almond milk: claims that one gallon of water is needed to produce one almond in the parched, über-dry West Coast of the US has caused discerning Californian consumers further confusion over which is the best milk. Consumers can ask the questions, journalists and tweeters can debate the issues and sciency-dietitians can, as ever, offer pragmatic answers to this and other questions of what-is-best food choice.

* The term ‘milk’ is protected, and defined by the EU milk marketing standards as, ‘produce of milking one or more farmed animals’. Companies producing plant-sourced mock-milks are careful not to use the term ‘milk’ on product labelling, and the use of the word in this article is just lazy-writeritis: it does not imply disregard for EU definitions or dairy interests. ** Alpro have launched a ‘soya +1’ drink that has been developed ‘especially for little ones’. In comparison to the Alpro original soya drink, the +1 product contains more energy and fat and carbohydrate (from maltodextrin), but slightly less sugars and fibre. The +1 product also contains iron and iodine and twice the levels of vitamin D. It is not suitable as a replacement for breast milk or infant formula under the age of one year. References 1 Le Louer B, Lemale J, Garvette K, Orzechowski C, Chalvon A, Girardet JP, Tounain P (2014) Severe nutritional deficiencies in young infants with inappropriate plant milk consumption. Arch Pediatr 21, 5, 483-8 2 Mintel report (June, 2014) UK: Dairy drinks, milk and cream 3 Mintel report (April 2015) US: Dairy and non-dairy milk: spotlight on non-dairy 4 www.dairyco.org.uk (13.2.15) quoting statistics from Kantar Worldpanel 5 Nutrition Business Journal (NBJ) 2015. Special Diet Report; infographic ‘nuts for non-dairy’

NH-eNews plus NHD eArticle with CPD The UK’s only weekly enewsletter for dietitians and nutritionists. To register please visit

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References: 1. Rapp et al. Clin Transl Allergy 2013; 3 (suppl 3):132. 2. Nowak-Wegrzyn et al. Evaluation of hypoallergenicity of a new, amino-acid based formula. Clinical Pediatr (Phila) 2015; 54(3): 264-72

Sip feeds: dietetic prescribing

Do dietitians need to be sip feed prescribers? Looking at the Sip Feed Project in Bolton

Dimple Thakrar Prescribing Support Dietitian, Bolton Clinical Commissioning Group (CCG)

Dimple works with Bolton GPs and ONS prescribers to advise and provide training on appropriate ONS prescribing and food first. She is also a member of the BDA Prescribing Support Dietitians, Neurosciences Specialist, Freelance Dietitians groups and a BDA media spokesperson.

Malnutrition can be defined as: ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome’ (1). The cost of disease-related malnutrition is in excess of £13 billion per year, of which ~93 percent live in the community (2). Tackling malnutrition can improve nutritional status, clinical outcomes and reduce healthcare use (2). The National Institute for Health and Clinical Excellence (NICE CG32) has shown that substantial cost savings can result from identifying and treating malnutrition, CG32 is ranked third in the top clinical guidelines shown to produce savings (3). Sip feeds are often used to treat malnutrition; however, they should only be considered when diet alone has proved to be, or clearly will be, insufficient to sustain or improve oral intake (4). Sip feeds are also referred to as oral nutritional supplements (ONS).It has been documented that ONS are often prescribed without involvement of a dietitian and with no attempt to improve oral intake by conventional dietary methods (4). The Project purpose

Over the last two years there has been a significant rise in spend on ONS in Bolton. In 2011/12 the amount spent was in the region of £1.4m and in 2012/13 it was £1.5m (sourced from 5). This represents an average growth of nine percent year on year to Bolton Clinical Commissioning Group (CCG). The purpose of this project was to establish the current prescribing practices of sip feeds within Bolton CCG to

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ensure the NHS commitment to providing best value for taxpayers money and the most effective, fair and sustainable use of finite resources (6). The prescribing of ONS has a significant impact on local prescribing budgets which are often prescribed inappropriately due to of lack of dietetic assessment (4). In order to identify if the CCG was spending inappropriately on ONS, a Medicine Optimisation Dietitian (MOD) was employed with the aims discussed below. Project aims

• Identify and evaluate current inappropriate ONS prescribing within the CCG for adults in Bolton Community, who are not under the care of a dietitian. • Audit the presence of nutritional screening by GPs or in care homes prior to prescribing ONS. • Stop and reduce inappropriate prescribing by investing in dietetic support. • Support GPs with screening, assessing and treating malnutrition appropriately. • Develop guidance on nutritional screening and prescribing of ONS for adults in Bolton community. • Educate prescribers of ONS on appropriate prescribing and the principles of ‘food first’ Food first, being defined as ‘using everyday foods to increase protein and/ or energy density of the diet, including drinks’, is often achieved through adding high fat/carbohydrate/protein foods/ drinks to the diet in food and/or drinks. It is not intended to achieve nutritional completeness for micronutrients.

Sip feeds: dietetic prescribing Figure 1: Summary of data collected and cost savings Subject

Total no patients

Total in %

103

Reduced sip

0.85

Changed sip

Stopped sip

Increased sip

0.85

Started on sip feeds

Referred to community dietetics

0.85

Take patient off community dietetic waiting list

1.7

No further dietetic intervention needed

Referred back to the GP for monitoring

Referred back to hospital consultant

Calculated rounded monthly cost savings

~£12,000

Calculated rounded annual savings

~£156,000

Pilot Project delivery

All patients who met the project criteria (see below) were assessed by the dietitian. Those who did not attend were assessed by telephone consultation. Appropriate nutritional care plans were agreed with all patients, including advice on ONS. Individual GP practice data was collated and then summarised for the seven practices detailed in Figure 1. Project inclusion criteria

• Over 18 years old • Currently being prescribed a ONS and not under the supervision of a dietitian • Not enterally tube fed • Not on palliative care register • Not diagnosed with an eating disorder The cost saving/avoidance has been calculated from the sum of the cost of the ONS discontinued and is only indicative of that moment in time and will be referred to as cost saving in this article. Results

Total number of patients seen: 117 (see Fig. 1). Conclusion

• 88 percent of the sip feeds being prescribed were inappropriate at the time of dietetic review. • The cost of the inappropriate prescribing calculated though cost avoidance was in the region off £156,000/annum.

~53% from total annual spend

• Over half of the spending on ONS prescribing could be saved with appropriate prescribing. • Though this was not collated, there was little evidence of nutritional screening, assessment, or monitoring of patients on ONS from the documentation. Anecdotal evidence suggests that the reasons for the inappropriate ONS prescribing were often due to: • unclear written or verbal communication as to clinical reasoning for starting and stopping ONS; • GPs lack of knowledge/confidence with food first and criteria for use of ONS; • lack of patient monitoring on ONS; • high volume of requests for ONS from care homes without establishing adequate food first techniques; • lack of dietetic involvement when ONS are commenced; • GPs welcomed the input from the dietitian and acknowledged the above. Recommendations

• To extend the project for the whole of the Bolton population. • The need for GP and staff Training GP on: 1. appropriate sip feed prescribing 2. food first • To collect data on nutritional screening and ONS initial prescribing source. NHDmag.com June 2015 - Issue 105

Sip feeds: dietetic prescribing Figure 2: Trend of cost savings in Bolton CCG compared to National and Greater Manchester

Source: NHS Business Services Authority December 2014, Advisor: Jole Hannan, Clinical Effectiveness Pharmacist, Bolton CCG

Main Project

Project design: The project was extended in the same format for 12 months, to cover the remaining 43 GPs. In addition, Prescribing Guidelines for the appropriate use of oral nutritional supplements (ONS) in the community (adults) (PGONS), July 2014, were developed to support GPs and provide food first handouts for patients. Following the patient assessment phase, an individual GP practice training programme was developed for all practice staff. This included: • a Practice Patient Data Summary Report, aiming to ensure that the training was relevant and pertinent to each practice; • a cost saving and incidence analysis of inappropriate ONS prescribing presentation; • a food first interactive game aiming to raise awareness of food first and increase knowledge of ONS nutritional contents and appropriate prescribing; • guidance on implementing the PGONS; • personalised practice recommendations aiming to provide future guidance; • a simple two-part project evaluation questionnaire. Results:

Forty GP practices were included in the project. Two had no patients that met the criteria and 20

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one practice refused to participate. 154 patients received dietetic review (average age 71 years old). The total cost savings were in the region of £152,000 per annum for the 40 practices; which equates to an average of approximately £1,000/ patient/annum. Only one out of 154 showed evidence of appropriate screening, i.e. MUST and % weight loss recorded in the GP patient notes. However, it is common practice for care homes to collect MUST scores and body mass index (BMI), but there was no documented evidence of this on request for ONS. There were no differences found in prescribing trends of ONS in care homes compared to patients in their homes. However, there was a greater incidence of under usage of ONS in patients in their own home, i.e. patients not taking their full prescribed dose of ONS. This suggests that patients when unmonitored by trained staff struggle to tolerate the directed dose of ONS as their food intake increases. This highlights the need for close monitoring, while a patient is on ONS to support the weaning off process and reduce wastage as per the PGONS. The majority of GPs were trained on food first and the PGONS with the exception of three who either declined or were unable to complete the training within the project time frame.

Sip feeds: dietetic prescribing The PGONS was made available to all GPs and hospital prescribers with the aim to reduce further inappropriate ONS prescribing and promote food first. Figure 2 demonstrates the impact of dietetic intervention (started January 2014) on cost savings compared to Greater Manchester and National trends. Qualitative data gathered following the practice training was very positive and in summary staff reported the following: • The training to be greatly needed and to be provided annually. • Very practical and easy to apply to practice. • The Food First Patient leaflets were well received. • Staff felt more confident to use food first as a first line approach over prescribing ONS. • Appreciated the importance of monitoring patients regularly. The limitations of this project are: • True cost savings over time were not collected due to the short project time, i.e.12 months. • Due to the limited dietetic funding, patients could not be reviewed and, while detailed instructions on monitoring and reviewing nutritional status was given to the GP and/or practice nurse, clinical outcomes could not be measured. Conclusions

Specialist dietetic intervention has been shown to reduce inappropriate spending on ONS in Bolton and achieved the aims of this project. It was evident from GP feedback that the training was a crucial part of the project, which will need to be continued to ensure sustainable and clinically safe cost savings. Further dietetic input is needed to continue to support clinically safe, cost savings in ONS prescribing, particularly in assisting prescribers to maintain safe and appropriate nutritional care, as well as enabling clinical outcomes to be measured and reported over a greater period than 12 months.

Nutritional recommendations for GPs and other ONS prescribers

• Assess nutritional status appropriately and set nutritional measurable goals. • Treat early signs of malnutrition with food first if appropriate. • Avoid ONS on repeat prescriptions. • Monitor, review and act upon nutritional changes. • Stop ONS when nutritional goals have been achieved. Recommendations for dietitians: • When communicating with GPs state clearly and concisely when and by whom review and monitoring of nutritional status should be completed. • Always consider food first as first line approach. • When first recommending ONS, ensure clear goals are agreed with the patient, carers, staff and prescriber, including how long the patient should expect to remain on ONS. • Be aware of the cost of ONS in Primary care. • Indicating clearly with dates, where possible, when ONS should be discontinued. • Promote dietetics by optimising on (ad hoc) training opportunities with GPs, i.e. in practice meetings or in passing when discussing patients. Future thoughts

It is clear from this project that those patients on ONS who aren’t under the supervision of a dietitian need close monitoring to ensure that their nutritional needs are being met appropriately and cost effectively, thus ensuring that the NHS runs efficiently. Is it time to pass ONS prescribing over to dietitians and use the cost saving demonstrated in this project to invest in dietitians? Let’s use every opportunity to fly the flag for dietetics. We are the nutrition experts!

References 1 www.guidelinesinpractice.co.uk/eguidelinesmains/index/page/5/www.gov.uk/www.dh.gov.uk/about_gip 2 Managing Adult Malnutrition in the Community. Including a pathway for the appropriate use of oral nutritional supplements (ONS). www. Malnutrtionpathway.co.uk 3 NICE CG32 4 Manual of Dietetic Practice (2007) 5 Health and social Care Information Centre (Dec 2014) 6 The NHS Constitution (2013)

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BREASTFEEDING IS BEST FOR BABIES

Science & nature

hand in hand

From the leading experts in organic infant nutrition, comes the UK’s lowest protein infant milk. Ours is the first infant milk in the UK to contain less than 2g/100kcal protein, making the protein level and quality closer to that found in breastmilk1. High protein intake in the first two years of life has been linked with an increased long term risk of being overweight or obese2. All the natural benefits of organic, coupled with 50 years of breastmilk research – and still costs less than the leading brand.3

Discover more at hipp4hcps.co.uk @hipp_for_hcps 1 Contains 1.89g/100kcal of protein, including _-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as at April 2015. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.

Infant formulas

FOLLOW-ON FORMULA MILKS The World Health Organisation (WHO) and the Department of Health (DH) both emphasise the benefits of exclusive breastfeeding (1, 2). In the UK, however, few mothers follow policy recommendations.

Jacqui Lowden Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH

For article references please email: info@ networkhealth group.co.uk

Presently team leader for Critical Care and Burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

The Infant Feeding Survey (IFS) 2010 (3) demonstrated that, although the initial breastfeeding rate increased from 76 percent in 2005 to 81 percent in 2010, and that mothers are continuing to breastfeed for longer, the proportion following current guidelines on exclusive breastfeeding for the first six months of a baby’s life have remained low since 2005, with only one in a 100 mothers following these guidelines. It is, therefore, essential that continuous improvements are made in infant formulas (IF) to ensure that the high nutrient requirements required by infants are met. The most recent definition describes is as a ‘food intended for use by infants when appropriate complementary feeding is introduced and which constitutes the principal liquid element in a progressively diversified diet of such infants’ (4). FOFM contains the same ingredients as standard IF, but with higher levels of protein, iron and micronutrients, such as vitamin D. The levels of nutrients are strictly controlled under the European Commission Directive on Infant Formulae and Follow-on Formulae. The Codex Alimentarius of the United Nations Food and Agriculture Organisation and the WHO also provide guidance on the composition of IF, which is used widely internationally (Codex Alimentarius Committee, 2006). The most recent UK legislation was 2007, with amendments made since. In 2014 the EFSA produced its opinion (5). This will form the basis of new legislation in due course, as there is presently a review of the Codex standard for FOFM, jointly with the WHO and the Food and Agriculture Organisation (FAO), due for completion in July 2016. Issues such as the age range of the

intended population, product definition, compositional requirements, the role of such products in the diet and the need for such a standard will be reviewed. WHO USES FOFM?

The IFS (6) has investigated the use of FOFM at different stages. At Stage 2 of the survey (four to 10 weeks old), use was low (nine percent). By Stage 3 (eight to 10 months old), mothers were more likely to be using FOFM (57 percent) as their baby’s main source of milk with IF at 35 percent. At Stage 3, 69 percent of all mothers had given their baby FOFM. Most mothers followed the recommendation of not giving their baby FOFM before the age of six months (16 percent had given FOFM when their baby was four months old, increasing to 50 percent at six months). Mothers from routine and manual occupations and mothers who had never worked were more likely than average to say that they had given their baby FOFM at an earlier age (18 percent and 27 percent respectively at four months). THE CHARACTERISTICS OF FOFM

Iron: The case for FOFM was its potential role in preventing iron deficiency anaemia. The health problems associated with iron deficiency anaemia have long been recognised, e.g. immune status alteration, adverse effects on morbidity, delayed behavioural and psychomotor development, below average school achievements and growth retardation (7-12). It was suggested that FOFM is given from six months, when an infant’s stores have become depleted (Domellof et al, 2001) and cannot be replaced by breast milk (being a poor source of iron). HowNHDmag.com June 2015 - Issue 105

Infant formulas ever, randomised controlled trials have not shown any consistent benefit from the additional iron in FOFM compared to IF, after the age of six months (13). There is also evidence that giving extra to those who are already replete in that nutrient could cause long-term damage and have an adverse effect on growth (14). Infants aged six to 12 months, who already had high iron levels, fed an iron fortified formula (mean 12.7mg/L) versus a low-iron formula (mean 2.3mg/L), scored lower on every 10-year development outcome (15). Excessive iron intakes may result in a reduced uptake of other trace metals, such as copper and oxidation of lipids, due to the pro-oxidant effects of excess iron (16). Morley et al 1999 (17) found that giving an iron supplemented FOFM to nearly 500 infants and toddlers between the ages of nine to 18 months, had no developmental or growth advantages. The recent EFSA opinion (18) proposes that the minimum content of nutrients in IF and FOFM should be the same apart from iron, suggesting that FOFM should have a higher minimum target iron content than first IF. If the same formula is to be suitable for the first year of life, then the EFSA recommend that the minimum iron content should be 0.6mg/100kcal. This is based on the assumption that about 70 percent of daily iron (equivalent to 5.7mg iron per day) could be provided by complementary foods, and a minimum content of iron in FOFM of 0.6mg/100kcal is proposed. First IF, however, currently meet this higher level and are therefore appropriate for the first year. The EFSA also noted that, although some data suggest that iron supplementation in iron-replete infants may lead to impaired growth and development and an increased risk of infections, the evidence is limited. Therefore, they have concluded that a maximum iron content in FOFM cannot be recommended. There is some argument, however, that FOFM should be considered for inclusion in anaemia prevention programmes, especially those aimed at some of the poorest families in the UK (19), although meat-rich weaning diets and use of commercially prepared baby foods which are iron supplemented, are also discussed as advantageous (8). Minerals: FOFM contains higher amounts of calcium and phosphorous because calcium requirement increases in the second six months of life. 24

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Infants should begin to consume solid foods at six months and, therefore, additional calcium and phosphorus requirements should be met without difficulty from first IF and food sources (20). Vitamin D: In the UK, all breastfed infants over six months of age, formula-fed babies receiving less than 500ml of formula and all children aged one to five years are recommended to take vitamin drops that contain vitamin D, as a public health policy. However, the uptake of children’s vitamin drops is very poor (3). At Stage 1, only seven percent of babies were receiving vitamin drops, increasing to 14 percent at Stage 3. The more deprived minority groups suffer most from the risk factors for vitamin D deficiency. These include darker skin, covering up, prolonged breastfeeding by vitamin D deficient mothers and a lack of usage of fortified formula milk (21). For these groups, there may be some benefit in the usage of fortified FOFM. If children are recommended to have vitamin drops and consume fortified milks, high intakes could be consumed, as vitamin D is a category A nutrient in terms of the risk of over-consumption (22). The ESPGHAN Committee on Nutrition, however, noted that reports on vitamin D intoxication are scarce and that there is no agreement on a vitamin D toxicity threshold (23). Recent intervention studies using doses of up to 25μg vitamin D per day (plus the amount ingested via fortified IF) for up to five months after birth, did not demonstrate that these intakes are associated with hypercalcaemia in infants. An upper level of 25μg vitamin D per day has been established by the European Food Safety Authority NDA Panel (18). Protein: Formula protein content is another major component that has been extensively studied, especially as current formulations of FOFM have led to higher protein intake. IF contains approximately eight to 12 percent energy from protein, whilst breast milk contains approximately five to six percent energy from protein (24). This higher content in formulas was intended to compensate for the lower protein quality. The potential for chronic disease risk attributed to rapid postpartum gain is increasingly being recognised and so the ideal degree of ‘catchup growth’ has become controversial. Healthy

Infant formulas term infants, when randomised to receive a higher protein formula, displayed higher weight gain velocity, Wt for age Z score, Wt for Length Z score and BMI-Z, but no differences in Length for age Z score by six months compared with controls (25, 26). These trends implied a larger fat mass accrual in the high-protein group, a finding that persisted until study termination at two years of age (27). Trabulsi et al (28) investigated the effect on infant growth of an IF with a protein content of 1.9g/100kcal compared with an infant formula with a protein content of 2.2g/100kcal. There were no statistically significant differences between the two groups with respect to weight gain, length gain and head circumference at the end of the study at four months of age. Previous recommendations by the Early Nutrition Academy is that formula high in milk protein should be avoided for infants. Recommendations for the protein content of FOFM used from six months to one year suggest that the protein content should not exceed 2.5g protein/100kcal or about 10 percent of the energy content (29). The EFSA recommends that a minimum protein intake of 1.8g/100kcal from FOFM based on intact milk protein is sufficient to ensure adequate growth and development. However, there is no scientific data which allows the establishment of precise cut-off values for the maximum protein content in FOFM. ROLE OF FOFM DURING WEANING

Protein needs are met by breast or formula milk protein, but at the time of weaning, the most suitable protein-to-energy ratio in a milk or formula will depend on the protein-to-energy ratio of the weaning foods available. This will obviously vary, on what is offered and what is available. The protein-to-energy ratio of weaning food in many developed countries is high, reaching 2.5g/100kcal after correction for protein quality (30). Thus, a very-high-protein milk is not needed to achieve satisfactory intakes. However, even modest displacement of breast milk or standard formula milk by low-protein complementary foods can result in inadequate total protein intake. In many developing countries, the only weaning food is maize or rice, which has a low protein-to-energy ratio. When the protein concentration of the weaning food drops below that of milk, i.e. when it is <1.0g/100kcal (such as for

cassava), it is impossible to meet total protein needs. The alternative approach to meeting protein needs in situations where complementary foods contain no or low amounts of protein, is to use a FOFM, containing more protein (31). CONCLUSION

The growth and development of infants fed FOFM need to be similar to those infants who continue to be breastfed while complementary food is introduced. IF consumed during the first year of life can continue to be used by young children. The recent EFSA panel has concluded that it is not necessary to propose specific compositional criteria for formula consumed after one year of age. Presently, there is no evidence to support the use of FOFM in infants receiving complementary foods containing adequate protein, carbohydrate, fat and iron (32). The Scientific Advisory Committee on Nutrition (33), stated that: ‘There is no published evidence that the use of any follow-on formula offers any nutritional or health advantage over the use of whey-based infant formula among infants artificially fed.’ In 2013, the WHO reiterated its position (34), that FOFM is not necessary and is unsuitable as a replacement for breast milk after six months. For this reason, FOFM is not included in the UK Healthy Start Scheme. There may be nutritional and health advantages to continuing formula milk intake into the second year for those infants considered at high risk of iron deficiency due to poor diet or other difficulties, such as fussy/faddy eating. It is advised, however, that first formula remains the milk of choice during the first year if babies are not breastfed (32). From a nutritional point of view, it maybe that FOFM is best considered in relation to the introduction of complementary food and the toddler diet, rather than breast/bottle feeding. The medical literature now contains mixed findings on their use when included in the introduction of solids for prevention of iron deficiency anaemia in babies over six months of age and in toddlers. With the ‘growth acceleration hypothesis’ suggesting that early and rapid growth during infancy programs the infant metabolic profile to be susceptible to obesity and the other components of metabolic syndrome, a review of the protein content of FOFM is quite timely and will lead manufacturers to review their formulations. NHDmag.com June 2015 - Issue 105

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Malnutrition

Introducing the BAPEN Nutritional Care Tool A new measurement tool to support the delivery of improvements in nutritional screening, nutritional care processes, outcomes and the patient experience.

Anne Holdoway Consultant Dietitian, Chair of Parenteral & Enteral Nutrition Group of the BDA and BAPEN Council Member

Mike Stroud President of BAPEN

Ailsa Brotherton Chair of the Quality and Safety Committee, BAPEN

Dr Ailsa Brotherton, Anne Holdoway, Dr Mike Stroud on behalf of the BAPEN Quality Group*.

In recent years, in collaboration with key stakeholders, including the British Dietetic Association and the Royal College of Nursing, the BAPEN Malnutrition Action Group have undertaken several national nutrition screening weeks (NSWs). Conducted over four years (one per season) in a variety of care settings, the NSWs have generated one of the largest malnutrition data sets in the world. Despite best efforts of many organisations and individuals to tackle malnutrition, the data illustrates the continuing high prevalence of malnutrition in the UK, with an estimated three million individuals being malnourished or at risk of malnutrition. Failure to treat malnutrition is a costly business. In 2007, the costs associated with malnutrition were estimated to be £13 billion; this has risen to approximately £20 billion in 2014. These costs arise from the increased cost of caring for someone with malnutrition and the greater utilisation of healthcare resources. The personal cost to individuals and their families is also significant, and are reflected in an increased mortality rate, increased admissions to hospital, increased pressure ulcers, falls and infections and an overall decrease in quality of life. Combating malnutrition in the UK continues to present a significant challenge. A shift in mind-set is now needed to work together to find innovative solutions and monitor their impact. In this article we introduce the latest data-gathering tool that will enable us to work together towards monitoring the provision of nutritional care,

evaluate practice and identify areas for improvement. Tackling malnutrition achievements to date

In 1992, the King’s Fund published the report: ‘A Positive Approach to Nutrition as Treatment’. This landmark document became available as a motivated group of nutrition champions established BAPEN. Founded by core groups representing nursing, dietetics, doctors, pharmacy and scientific professions, patients and members of industry, BAPEN set in motion a move to raise the profile of nutrition as an integral component of healthcare. In conjunction with the work of BAPEN, the last two decades have seen numerous national, regional and local nutrition initiatives such as ‘protected mealtimes’ and ‘Nutrition Now’ (Royal College of Nursing) and the publication of numerous standards, including the NICE guidance CG32, ‘Nutritional support in adults’ (2006) and the NICE quality standards QS24 (2012), which have helped to raise awareness of the prevalence and treatment of malnutrition. In addition, both governmental and non-governmental organisations have championed the need for nutritional care across care settings, facilitated by those in practice and those commissioning services. Whilst it is evident that ‘MUST’ has helped to detect malnutrition, malnutrition rates have changed little in 20 years. Combating malnutrition therefore remains a significant challenge. Part of the reason for the ongoing issue may be a lack of focus on measuring NHDmag.com June 2015 - Issue 105

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Malnutrition Table 1 Measurement for research

Measurement for learning and process improvement

Purpose

To discover new knowledge

To bring new knowledge into daily practice

Tests

One large “blind” test

Many sequential, observable tests

Biases

Control for as many biases as possible

Stabilise the biases from test to test

Data

Gather as much data as possible, ‘just in case’

Gather ‘just enough’ data to learn and complete another cycle

Duration

Can take long periods of time to obtain results

‘Small tests of significant changes’ accelerates the rate of improvement

Source: Institute for health care improvement: www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx

the impact of initiatives in delivering real improvements in nutritional care. Measurement to date has largely focused on catering, the quality of food served, rates of nutritional screening and targeted reductions in oral nutritional supplement usage. Measurements have however failed to capture in a meaningful way and at scale, the quality of nutritional care planned, delivered and the nutritional outcomes achieved. The rationale for developing a new measurement tool

Amongst senior professionals within BAPEN, it was noted that, whilst the NSWs have illustrated improvements in screening rates, smaller scale audits, submitted as abstracts to the Annual BAPEN conferences, suggest that there might be a problem with accuracy of completion of screening tools. In addition, little remained known, collectively, on the provision of nutritional care that followed on from screening. These concerns prompted the multidisciplinary quality group within BAPEN to focus on a shared interest, which was to develop a new measurement tool to answer key questions that were emerging. Questions included: • How accurate is the screening that is being undertaken? • What proportions of patients at risk have a nutritional care plan and are those care plans implemented and acted upon? • What are the nutritional outcomes following screening and care planning? • How good is the patient’s experience of nutritional care?

• How do we benchmark nutritional care and what variation exists across the system? • Which organisations or units are outliers, both positive and negative? To gather such information in a systematic way on a national basis, the Quality group felt that a measurement tool was essential. This drive reflected recent shifts in the NHS where new measures to track improvement, as opposed to measurement for performance (judgement) or measurement for research, have evolved. We were fortunate to welcome Kate Cheema from the Quality Observatory to the working group. Kate brought knowledge of measurement within the wider healthcare arena to the group and her involvement helped facilitate the groups’ understanding of measurement, highlighting that measurement to determine improvements could be differentiated from measurements for research. Put simply, appropriate measures are essential for a team to determine if the changes they are implementing are leading to improvements and for measuring the sustainability of improvements. Table 1 below outlines the difference between measurements for research purposes and measurement for process improvement (IHI). The purpose of the BAPEN Nutritional Care Tool

Over many months, through a process of iteration and testing amongst users, including more than 80 representatives from nursing and dietetics, the new measurement tool, suitably named the BAPEN Nutritional Care Tool, was develNHDmag.com June 2015 - Issue 105

Malnutrition oped to enable teams to deliver and measure improvements in nutritional care at a local level. Building on the national nutrition screening weeks’ data collection, the tool utilises quality improvement methodology (i.e. the data is intended for improvement purposes, not performance management or research). The final tool is of succinct design that incorporates: • process measures - prevalence of malnutrition and nutritional care processes; • outcome measures - weight loss (trackable over time for the duration of admission); • patient experience measures - of the nutritional care received. Designed by the multi-professional BAPEN Quality and Safety Committee, the tool underwent multiple rounds of testing and development within BAPEN’s core groups’ membership. The final rounds of testing involved dietitians and nurses beyond the BAPEN membership. Participants were invited from specialist groups of the BDA such as NAGE; oncology and nursing staff in acute and community care settings and care homes for older people. The patient experience questions were designed and approved by PINNT. Feedback from more than 80 users was obtained from several WebEx online forums resulting in further refinement of the measurement tool following testing in practice. The tool underwent a final round of testing in April and is to be launched at the second Digestive Diseases Federation (DDF 2015) meeting at Excel, London on 22nd to 25th June, where 4,500 delegates are expected to attend from many healthcare disciplines. Following launch at the DDF 2015, there will be pro-active rollout of the BAPEN Nutritional Care Tool and promotion to encourage adoption and implementation. Benefits of using the BAPEN Nutritional Care Tool in your organisation

Dr Mike Stroud President of BAPEN commented: “The evidence shows that good nutritional care is one of the most effective treatments available in the NHS, with meta-analyses demonstrating proven benefits from active nutritional support in malnourished patients. As around a third of patients in NHS care are in that group and their higher than average complication and mortality rates can be reduced by a third 30

NHDmag.com June 2015 - Issue 105

or more, the evidence is quite clear: the NHS can make enormous cost savings through improved nutritional care in the acute sector.” Many professionals across the length and breadth of the country are currently involved in leading improvements in the delivery of good nutritional care in our organisations. Trust Boards and/or management teams are undoubtedly asking those leading on the implementation of screening and nutritional care programmes, to provide assurance that the nutritional care subsequently delivered meets existing standards and compares favourably to the care provided in similar organisations. Equally, it is likely that many of us will be required to demonstrate ongoing improvements over time. In the absence of a standardised measurement tool, it will be a challenge to demonstrate goals achieved. We, therefore, anticipate the benefits of using the BAPEN Nutritional Care Tool to include: • assessment of the accuracy of the completion of ‘MUST’ screening across your organisation; using the tool will identify where variation exists for example identify wards who are completing ‘MUST’ accurately and wards who require additional support, e.g. education and training, to deliver improvements; • better identification of the prevalence of malnutrition on admission to an organisation and the variation that exists, e.g. between care of the elderly wards and medical/surgical wards; • assurance of compliance to nutritional care processes and/or identification of where improvements are needed; • a measure of nutritional outcome; a key indicator being the median patients’ weight loss during their admission under your care, taking into account their diagnosis (the tool has been designed to screen out patients for whom tracking weight would not be advisable, e.g. patients with ascites or irreversible severe cachexia); • a measure of the patient experience - this is a unique question in the new tool as other patient experience measures have tended to focus on food availability and quality. Many doctors, commissioners, nurses, managers still require convincing that good nutri-

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Malnutrition tional care makes a difference. Many dietitians work locally to prove that nutritional care does make a difference. As Dr Mike Stroud President of BAPEN concludes, “If this tool becomes widely adopted, it will also answer a lot of questions currently being asked about malnutrition. It will enable prevalence to be tracked on an ongoing basis, removing the need to undertake separate annual surveys, and the tool contains far more information about the nature of the patients. It can, therefore, generate data which will identify not only prevalence in specific patient groups but acceptable benchmarks for acceptable levels of weight loss for specific diseases, operations and the type of ward/unit providing care. We will then know what good looks like and, hence, where improvements are needed. The new tool is really the next logical step to using ‘MUST’ and it will help to deliver the changes that the NHS is looking for in care and the patient experience.” We appreciate that the complexities of delivering good nutritional care make measurement fraught with difficulty, especially around the implementation of care plans. As an example, evidence suggests that food record charts are often

poorly completed. Similar difficulties exist in selecting appropriate outcome measures given that nutritional status is often affected by many factors other than nutritional intervention, including the presence of underlying disease. However, we believe that beyond advancing the measurement of malnutrition, nutritional care is key to delivering further improvements. The new tool is available to all acute trusts, community hospitals and nursing/residential/care homes that wish to participate in future screening weeks. Summing up, Rachael Masters, Senior Special- ist Dietitian from the Focus on Undernutrition team County Durham commented, “The scale up of the Malnutrition Measurement Tool has the potential to radicalise nutritional care across the UK. This tool could make the vision ‘let’s be the generation that eliminates unnecessary malnutrition’ a reality!” The BAPEN Nutritional Care Tool is being launched at DDF2015. The first national screening week using the new tool is scheduled for September 2015. To register your organisation, please email bapen@bapen.org.uk

Acknowledgements: With thanks to members of the BAPEN Quality and Safety Group, the BAPEN core groups; NNNG and PINNT and members of the BDA who participated in the testing and refinement of the tool.

*Members of the BAPEN Quality and Safety Group – Dr Ailsa Brotherton, Dr Christine Baldwin, Kate Cheema, Liz Evans, Anne Holdoway, Rachael Masters, Lyn McIntyre, Dr Mike Stroud, Vera Todorovic, D r E l i z a b e t h We e k e s , C a ro l y n W h e a t l e y, We n d y L i n g - R e l p h , A n d re a C a r t w r i g h t , Katherine Wallis and Dr Nicola Turing

dieteticJOBS.co.uk The UK’s largest dietetic jobsite To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) 32

NHDmag.com June 2015 - Issue 105

ONS

Oral nutritional support: Worth every penny?

Emma Coates Company Metabolic Dietitian, Mevalia (Dr Schar UK)

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK – Mevalia Low Protein.

It is well known that malnutrition in the UK is as significant a problem as obesity and it presents huge financial implications for public health spending. It is estimated that disease-related malnutrition costs over £13 billion per year (1). The British Association for Parenteral and Enteral Nutrition (BAPEN) estimates that over three million people in the UK are malnourished, with 1.3 million of these people being over 65 years of age (2). As malnutrition screening is commonplace in most hospitals nowadays, the prescribing of oral nutritional support (ONS) supplements is part of routine pathways to treat the patients identified as ‘at risk’ or malnourished. With 25 to 34 percent of patients who are admitted to hospital being malnourished (2), ONS sip feed usage is frequent and costly. However, not all patients affected by malnutrition are found in hospitals. Statistics show that only two percent of malnourished patients are hospital based. Malnutrition in the community setting is a major task for healthcare professionals to tackle, with 93 percent of malnourished patients living in their own homes, five percent living in care homes and two to three percent living in sheltered accommodation (3). Malnutrition in care homes could affect up to one in three residents (4). As a consequence of all of these figures, ONS is a major part of the work we do on a daily basis as dietitians, whether we are working in the acute or community setting. Malnourished patients can benefit greatly from ONS supplements through the additional energy, protein and micronutrients they provide. There is some evidence to show that ONS may impact on health outcomes for malnourished patients; outcomes such as reduced hospital readmission (5). However, in 2013, the National Institute for Health and Clinical Excellence (NICE) stated that there was limited evidence for the efficacy of using ONS

supplements in some patient groups (6) and more research was needed in this area. NICE did acknowledge that the use of ONS supplements may help to improve energy intake and weight in older adults in the community. The use of such products may also be associated with a cost-effective improvement in quality of life, but there did not appear be to any improvement in mortality or hospital readmission rates when used post discharge. It is not just the elderly who require ONS, we see a huge range of patients across the lifespan who require our expertise to help them to achieve optimum nutritional intake when they unable to reach it through food alone. The contributing factors in malnutrition are variable and often a combination can be observed in the patients we treat, see Table 1 for examples of this. As a limited resource within the NHS, it is impossible for dietetics to manage malnutrition alone. As many of the guidelines published by NICE recommend, an MDT approach to the overall management of many of these patient groups is best practice. It supports a holistic treatment option where nutrition is given just as much emphasis as medication or other therapies. The ONS sip feed business is worth millions of pounds and companies are keen to expand and tailor their product ranges to meet the needs of our complex patient groups. From traditional 1.5kcal/ml sip feeds to the ever-growNHDmag.com June 2015 - Issue 105

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ons Table 1: Examples of the contributing factors in malnutrition Category

Disease related

Compromised mental health

Post surgical

Trauma Treatment related

Neurodisability

Other physical factors

Social factors

Example Cystic fibrosis Inflammatory bowel disease Chronic liver disease COPD/chronic lung disease Oncology related disease Chronic kidney disease Congenital heart disease Dementia Alzheimer’s disease Depression Schizophrenia Eating disorders Gastrectomy Bowel resection Head and neck surgery Transplant patients Burns Severe injury requiring ITU care Chemotherapy Radiotherapy Poly pharmacy Dialysis Cerebral palsy Progressive disorders, e.g. MND, muscular dystrophy Stroke Age related - over 65 years of age Dysphagia Pressure sores Loss of senses, e.g. reduced sight, smell, taste Reduced mobility/ability to feed self Poor dentition Isolation/living alone Poor housing/cooking facilities Homelessness Poverty/low income Poor knowledge and skills regarding food and cooking Drug or alcohol misuse/dependency

ing range of low volume ONS supplements (usually 2.4kcal/ml sip feeds), it seems that there is something to suit the needs and/or preferences of everyone. However, this comes at a price, with the average cost of a 1.5kcal/ml, 200-220ml milkshake style sip feed is approximately £1.87*; with the average cost of a low volume (2.4kcal/ml) 125ml ONS sip feed is £1.83 (**). Table 2 shows the cost of this intervention over a range of time scales per patient. Despite the cost of ONS sip feeds, along with the price of MDT intervention, it is recognised that screening for, identifying and treating malnutrition is key to reducing the ongoing financial burden malnourished patients create for the NHS. NICE have estimated that £17,800 could be saved for every 100,000 patients if malnutrition is managed effectively (7). When compared with non-malnourished patients, malnourished patients require twice as many healthcare resources (8); therefore, tackling malnutrition is a high priority for the NHS. Over recent years, prescribing pathways for drugs has become commonplace to not only ensure cost effective prescribing, but to improve patient safety and health outcomes. Such pathways have transferred well to the prescribing of borderline substances such as specialist infant formulas and ONS sip feeds. Prescribing pathways provide vital guidance for acute and primary healthcare professionals who will often meet a malnourished patient well before they meet a dietitian. Tying in guidance to support the implementation of nutritional screening is now fairly standard as part of an ONS prescribing pathway. This ensures that the correct patients

Table 2: Average cost of 2-3 x 200-220ml 1.5kcal/ml milkshake style sip feeds per day (***) and average cost of 2-3 x 125ml low volume (2.4kcal/ml) ONS sip feeds per day (****) per patient. 2 x 200-220ml

3 x 200-220ml

2 x 125ml

3 x 125ml

Per day

£3.74

£5.61

£3.66

£5.49

Per week

£26.18

£39.27

£25.62

£38.43

Per month (30 day supply)

£112.20

£168.30

£109.80

£164.70

Per year (365 days’ supply)

£1,365.10

£2,047.65

£1,335.90

£2,003.85

Prices taken from - www.evidence.nhs.uk/formulary/bnf/current/a2-borderline-substances/a22-nutritional-supplements-non-disease-specific/a222-nutritionalsupplements-5-g-or-more-protein100-ml/a2223-nutritional-supplements-more-than-15-kcalml-and-5-g-or-more-protein100-ml <Accessed 14/05/15> and MIMS december 2014 edition. (*) Based on Abbott Ensure Plus milkshake style - £2.02 per 220ml, Nutricia Fortisip - £2.06 per 200ml, Fresubin Energy - £1.48 per 200ml, Nestle Resource - £1.91 per 200ml. (**) Based on Abbott Ensure Compact - £2.02 per 125ml, Nutricia Fortisip Compact - £2.02 per 125ml, Nualtra Nutriplen - £1.45 per 125ml. (***) Based on the average calculated from using (*). (****) Based on the average calculated from using (**)

NHDmag.com June 2015 - Issue 105

ons are highlighted and the appropriate intervention is initiated. Creating a robust pathway that becomes a daily process for healthcare professionals to follow, in theory, also raises awareness of the particular issue in question. However, correct and continued use of this process, as well as further monitoring and appropriate onward referral to dietetics may not be as well managed as it could be, particularly in the community. Dietetic prescribing management posts have been born from the drive to achieve more streamlined and effective use of ONS. For many years, there has been a huge drive to improve nutritional screening in the acute setting. On admission to hospital, it is often mandatory for patients to undergo an assessment using the Malnutrition Universal Screening Tool (‘MUST’). Please visit the BAPEN website for full details of the MUST screening tool and it use: www.bapen.org.uk/screeningfor-malnutrition/must/introducing-must. The outcome of the assessment provides indication of the patient’s nutritional status and the intervention they require. Food first is often the first line intervention for lower risk patients. This includes a ‘little and often’ approach with high calorie/additional snacks, possibly food fortification, depending on the patient’s needs and preferences. For higher risk patients, ONS sip feeds are recommended, whether it be standard 1.5kcal/ml milkshake style/juice style sip feeds, powder sachet supplements or the increasingly popular, low volume (2.4kcal/ml) sip feeds. Prescribing of these products varies greatly between NHS trusts, some may be recommended as ‘first line’ products or others may be restricted due to their higher cost. Some pathways recommend the use of one presenta-

tion of ONS sip feed in the acute setting, e.g. a 1.5kcal/ml milkshake readymade style as the first line product, to then switch to another in the community setting once the patient is discharged, e.g. a powder sachet supplement. This may be due to the financial constraints that the dietetic department is facing. Initiating ONS in the community setting may be confusing and/or daunting for some primary healthcare professionals, particularly around the type of ONS sip feed to be prescribed and how frequently these patients should be monitored. The ‘Managing Adult Malnutrition in the Community Guide’ has been developed to support primary healthcare professionals to identify, treat and monitor malnutrition in the community. More details on this useful resource can be found at http://malnutritionpathway.co.uk/ <accessed 14/05/15>. The guide provides an ONS prescribing pathway as well as care plans for residential/nursing homes staff to follow when caring for a malnourished patient. There are also a number of useful downloadable tools on the website. Given that malnutrition affects many more patients over the age of 65, we are on course to see more of it as the ageing population is growing. Whilst there have been some major improvements in the identification of malnourished patients and we have the biggest range of ONS sip feeds available to us now, we are still struggling to significantly improve the nutritional status of many of the malnourished patients we see. There is still much work to be done in both the acute and community setting to upskill and educate the healthcare professionals and care staff who provide the day-to-day support for these vulnerable patients.

References: 1 Elia M and Stratton RJ (2009). Counting the cost of disease-related malnutrition in the UK in 2007 (public expenditure only) in: Combating Malnutrition: Recommendations for action. Report from the advisory group on malnutrition, led by BAPEN. 2 www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition <accessed 14/05/15> 3 Elia M and Russell CA (2009). Combating malnutrition: Recommendations for Action. Report from the advisory group on malnutrition, led by BAPEN 4 Russell C and Elia M (2012). Nutrition Screening Survey in the UK and Republic of Ireland in 2011. A report by BAPEN 5 Stratton RJ et al (2012). A systematic review and meta-analysis of the effects of the impact of oral nutritional supplements on hospital readmissions. Ageing Res Rev 2013, 12(4): 884-97 6 National Institute for Health and Clinical Excellence. Evidence update 46: Nutrition Support in Adults. A summary of selected new evidence relevant to NICE clinical guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ (2006). London: National Institute for Health and Clinical Excellence, 2013. Available at: www.evidence.nhs.uk/Search?q=Evidence+update+46%3A+Nutrition+Support+in+Adul ts. <accessed 14/05/15> 7 National Institute for Health and Clinical Excellence (NICE) (2006). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32 8 Guest JF et al (2011). Health economic impact of managing patients following a community-based diagnosis of malnutrition in the UK. Clin Nutr; 30(4): 422-249

NHDmag.com June 2015 - Issue 105

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Childhood obesity

The care pathway for weight management of children across Cornwall Being overweight or obese in childhood has become so common that it can be a surprise to parents and even to health professionals. Here, I aim to answers some basic questions about childhood obesity and then go on to describe the model that is used locally across Cornwall. Rachael Brandreth Paediatric Dietitian, Cornwall’s Paediatric Weight Management Service

Q. How do you define overweight and obesity in childhood?

A. Body Mass Index (BMI) is a measure of weight for height. It is the gold standard for assessing weight in children and it should be plotted on gender specific UK charts and the centile should be used for diagnosis and monitoring (1). Clinical cut-offs using these BMI charts: BMI >91st centile = overweight  BMI >98th centile = obese  Over this level there is no consensus in terminology. In our specialist clinics we use the SIGN definitions (2) as follows: BMI >99.6th centile = severe obesity  BMI >+3.5sd = very severe obesity  BMI >+4sd = extreme obesity   BMIs should not be used in isolation, but should be a key tool in your clinical assessment. Body shape is another consideration; however, waist circumference should not be used for diagnosis in children. Q. Is obesity really a problem in childhood?

As co-lead for children for DOM UK, Rachael campaigns for Junk Free Checkouts and sits on the APPG for a Fit and Healthy Childhood.

A. Yes! Cardiovascular and diabetes risk factors are not uncommon in obese children and young people. These include increased blood pressure deranged lipid profiles (e.g. cholesterol and triglycerides), enlarged left ventricular mass, hyperglycaemia and hyperinsulinaemia. Sleep apnoea and abnormal liver function tests (signs of non-alcoholic fatty liver disease) are other co-morbidities seen. There can also be significant psychological and social consequences. For information about screening for comorbidities see the OSCA statement (3). It is recommended that all

NHDmag.com June 2015 - Issue 105

children with a BMI >98th centile should be screened. In practice our GPs undertake much of this screen. Q. What does the evidence

say about treating childhood obesity?

A. NICE states that dietary guidance should not be given in isolation. Interventions should be lifestyle focused, including behaviour change, increased activity and decreased sedentary time (screen time), as well as reduced energy intake. At least one parent should be involved and whole family change should be promoted. Families should be encouraged to focus on SMART lifestyle goals (4). The aim of intervention should be to reduce BMI centile. In most overweight children, this will be achieved through weight maintenance or even decreased trajectory of weight gain initially. In more extreme cases, e.g. when a child will never grow into their weight, gradual weight loss may be necessary. This should be at a maximum rate of 0.5 to 1.0kg per month and post-puberty. Q. Is there anything else that should be considered?

A. Referral to the paediatrician should be considered if there is a suspected underlying cause, including if a child is obese and short for their age, if they are severely obese before the age of two years, or those with serious medical comorbidities. There are no medications licensed for use in children in the UK. However, Orlistat is sometimes used post puberty in extreme situations, although this is off licence and

Childhood obesity should only, therefore, be used under strict medical supervision. Surgery can be considered post puberty too in very severe obesity (BMI >3.5 SD) with severe comorbidities. It should only be carried out by very specialised multidisciplinary teams. Safeguarding is another consideration. Although there is not much guidance on this at the moment, good practice says that it should be considered as neglect if there is a repeated failure to engage. Emotional abuse can sometimes be part of the cause of the child’s obesity and so this should be considered. Viner (5) published a useful guidance paper and, more recently, a proposed framework has been set out by Garel (6). Our model in Cornwall

Cornwall has a disparate and rural population which had to be a strong consideration when designing service delivery. Although it is a popular holiday and second home destination and a wonderful place to live, there is significant socio-economic deprivation in the local population. The NCMP figures, available from National Obesity Observatory (7), show us that obesity in children is linked to deprivation with levels being twice as high from the lowest to the highest decile and our levels of obesity reflect this. We have two care pathways for overweight and obese children. The first is for babies and toddlers up to the age of two years and the second is for children and young people aged two to 16 years. The age split is based on the age for which BMI is more widely validated. The pathways aim to bring together the work of professionals in this area and are hosted on our website (8). This website aims to be the central point of information for both families and professionals. Although it is hosted by the Health Promotion Service, it aims to host information from all services working in weight management across the lifecycle and across Cornwall. As children’s dietitians, we work in a multidisciplinary (MDT), multi-agency team to provide weight management advice to families alongside training and clinical supervision to other professionals working in this area. We aim to provide care in a way that is most acceptable to families. When consulted, they said that they would prefer to gain the key messages through professionals whom they are already working with until there

is a greater level of concern. When there is that greater level of concern, we provide a specialist programme called LEAF (Lifestyles, Eating and Activity for Families), which is a level 3 service for the early years (children of six years of age and younger). In the team, we have a paediatrician, dietitian and Activity Advisor. We also work in partnership with the local children’s centres which provide the space for our group sessions as well as the crèche that is an important aspect of facilitating engagement. The LEAF programme was locally developed over three years ago as we were unable to find a model of intervention that was appropriate for our target age group. We are HENRY (Health, Exercise & Nutrition in the Really Young) (9) trained and, although it is not designed for level 3, we base many of our principles of intervention on the HENRY model. The format of LEAF is a one-to-one initial session, usually at the family home, where the focus is on motivation to change and their understanding of the referral as well as preparing them for the clinic. The next step is our MDT clinic at the hospital, where all three professionals see the family at the same time. This reduces the number of appointments and the time taken for families, which is an essential part of facilitating engagement in a county where they may be travelling for over an hour by car, or much longer if using public transport. Being together for the clinic is also beneficial for the professionals involved, as it allows us to ensure that we have all heard the same information and promotes consistent and manageable care plans. It is at this appointment that families are offered the GOOS (genetics of obesity study) (10). The next stage in the programme is six weeks (spread over two to three months) of small group-based sessions run in local children’s centres. Although it is our gold standard for intervention, it is not always possible for families to attend these sessions. If this is the case, we find other ways, such as working one-to-one, but also involving health visitors, school nurses or other professionals already working closely with the families, e.g. family support workers. Once this part of the programme is complete, we see them back in the MDT clinic before discharging to primary care for ongoing monitoring and support. NHDmag.com June 2015 - Issue 105

Childhood obesity In some instances, we will continue to work with families for a longer period where they have struggled to engage, but are now more ready. As you might expect in the group sessions, we cover a whole range of healthy lifestyle topics. As the groups are small, it allows us to really help families make the information relevant to them and each week we encourage SMART goals to be set. Although most of the sessions are parent focused delivery, one of the sessions is for the whole family in which we play fun games and do some ‘taste testing’ to see if we can eat a rainbow. If you would like to see other ideas to promote creative healthy snack times, you can follow my ‘Fun with food’ board on Pinterest (11). Our outcomes are based on pre- and post-intervention measures, which include BMI z-score, energy from drinks, amount of sleep and level of sedentary behaviours. We use the NOO SEF (the standard evaluation framework from the National Obesity Observatory, now part of Public Health England (7)). However, we found that there is a lack of validated tools for measuring outcomes in this age group and so started using our own drinks diaries and lifestyle questions. The drinks diaries seem to suffer less from the reporting bias of food diaries, but the lifestyle questions, including hours of sleep and number of hours of screen time, do. The former is subjective and based on clinical experience, but the latter is based on the relatively recent introduction of accelerometers for the older children in the programme (four years upwards). Something that we are looking to explore further is bio-impedance measures to show changes in body composition. We would like to hear from others working in this area to share experiences and improve our outcome measures. You can get in touch with our team via LEAF.programme@cornwall.nhs.uk Our other client group for one-to-one work is children with a genetic condition called Prader Willi Syndrome. The Prader WiIli Syndrome Association has lots more information on this condition (12). We work with children and young people up to transition to adult services and deliver dietetic intervention alongside the paediatric endocrinologist. What can you do?

Dietitians are very well placed to make a real difference in this relatively new and growing speciality. If you are in a specialist role, can I please 40

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Examples of ‘Fun with Food’ at a group session

encourage you to get involved with DOM UK (13) so that we can share our knowledge and experience to help progress this relatively new area of dietetics. Even if you are not in a specialist role, or even in a paediatric role, you can still make a difference by getting involved with promoting social change. For example, visit www.junkfreecheckouts.org to get involved with the joint DOM UK and Children’s Food Campaign movement to see checkouts free from the temptation of junk foods (14). Whether you have children of your own or not, you can promote change and attitudes in your local schools and communities. It is not just about treatment either. An excellent example of preventative work is the Food For Life Partnership (FFLP); you can find more details at www.foodforlife.org.uk (15). Many of our local schools are signed up (for free) to FFLP, which is a highly recommended platform to promote a whole food cycle approach to improving children’s nutrition. It incorporates growing, cooking and good nutrition through resources, lesson plans and ideas for schools, and aims to transform food culture. It has been shown to have a positive impact on both health and education, as well as its effects spreading into the wider community. Go on get involved - you CAN make a real difference! For article references please email: info@networkhealthgroup.co.uk

Gut Health: Research

Diet swap A study in swapping the diets of 20 rural Africans with the equivalent number of Americans for two weeks, led to some surprising results…

Ursula Arens Writer; Nutrition & Dietetics

A year ago, it was a great day for some 20 rural Africans living near the town of Empangeni in Kwa Zulu Natal South Africa. Some American researchers asked (paraphrased), “Would you like to eat an American diet (for free) for two weeks?” The answer could only be an enthusiastic yes, even when the priceto-be-paid, the butt-clenching procedure of colonoscopy, was revealed. At the opposite end of the globe, for some 20 African-Americans living in Pittsburgh Pennsylvania there was perhaps less appeal for the offer of the diet swap experiment; an all-you-can-eat typical African diet, but with perhaps the benefit of better health. The study of the diet swap between 20 rural Africans and 20 big-city Americans for the modest period of two weeks gained much interest in the media when published in April 2015, and mostly because there was astonishment about the speed of change to gut measures. Was a change of diet really such a fast-acting modifier on the colonic environment? It appears so. Lead researcher Professor O’Keefe, from the Department of Medicine and the University of Pittsburgh, concluded that the diet swap resulted in remarkable reciprocal changes in both groups in many of the colonic mucosal biomarkers of cancer risk (3). Colon cancer rates are more than 13fold higher in African Americans compared to rural South Africans, and differences in diet are likely to be the main factor. American diets are high in fat and animal protein and low in fibre and a typical African diet features the inverse. But are the risk factors associated with differences in disease rates, long-term

and cumulative effects from life-long dietary patterns? Or can modifications of diet result in near-instant measurable changes to gut environments? The typical African American diet would be familiar to many British dietitians; lots of prepared meat items such as hamburger, hotdogs, ribs or steak married to lots of refined and fatty starch, such as fries, white pasta or fried potato. Colour on a plate is more likely from ketchup or mustard than fruits or vegetables. The typical rural South African diet is small embellishments around the central base of phutu/mielie meal (also called pap or very confusingly and perhaps ironically, ‘African salad’) (2). This polenta-like staple may have very small additions of vegetables or fermented milk for flavour, but the only other usual additions to the diet are beans and cabbage/onion/spinach. Fruits may be seasonally available (bananas/ pineapple/guava), but these will only be occasional items, along with salad items such a tomatoes. Chicken, meat and sausages are much relished and appreciated, but are generally considered expensive foods for special days. After assessment for general good health and absence of exclusion criteria, 20 Americans and 20 Africans did a diet swap. The subjects were all middle aged (mean = 55 years) and most were overweight (mean BMIs = 28), although the Africans were shorter and lighter than the Americans. Diet were carefully prepared and measured and intakes observed: amounts consumed were ad libitum, but small additions of juice were added in situations where weight loss was observed in the two-week period. NHDmag.com June 2015 - Issue 105

Gut Health: Research Table 1 Energy kcals

Fat %E

CHO %E

Protein %E

Fibre g

US usual diet

2,393

African usual diet

2,353

US swap diet

2,205

African swap diet

2,526

The overall weight of all foods consumed by the Americans on the swap diet was bulky: it was nearly 2,300g compared to the denser 1,550g consumed by the Africans celebrating US-style cuisine. The Africans enjoyed foods such as sausages and pancakes, or bacon and cereal for breakfast, hamburger with fries or meatballs with spaghetti for lunch and steak with noodles or roast beef and potatoes for supper. The Pittsburghers had to get used to consuming a lot of maizemeal based items. Breakfast could be maize porridge or corn grits with scrambled egg. Lunch could be maize bread with kale salad or bean soup. Supper could be maize muffins with vegetables or lentils and rice. Because maize meal is bland-tasting, a challenge was for the Americans to consume enough of this food and spice flavourings or artificial sweeteners were permitted additions. Nutrient patterns in the swapped diets were very different. For the African-Americans, there was a reduction in energy intake due to significant reductions in fat. There were strong increases in energy from carbohydrate and fibre intakes increased nearly four-fold. For the African-Africans, the swapped diets were higher in energy diet to significant increases in intakes of fat and of protein; in fact protein intakes were considerably higher than usual American diets indicating perhaps a carpe diem attitude to the offers of luxury items such as steak and chicken. Fibre intakes in the swap diet for Africans was low; less than one fifth of their usual intakes. Intakes of a particular type of fibre, resistant starch, was calculated to be particularly high in the usual African diet and calculations from carbohydrate malabsorption of mielie meal have suggested that at least 10 percent of this food resists digestion. Data was then collected from colonoscopy undertaken before and after the diet swap. Ini42

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tial investigations found normal mucosal scores for four of the Americans (10 of the Africans). Adenomatous polyps were observed in nine of the Americans (none of the Africans). And diverticula could be observed in 14 of the Americans (but none of the Africans). Some of the markers of mucosal inflammations were higher in the Africans indicating, perhaps, higher levels of contact with parasites; two subjects were positive for schistosoma and one subject was host to a 6.0cm section of tapeworm. There were also profound differences in the baseline microbiota of the two sample groups; Americans were dominated by the genus Bacteroides and the Africans dominated by the genus Prevotella. Professor O’Keefe characterised the African microbiota as containing more ‘starch degraders, carb fermenters and butyrate producers’ than the resident populations of the American colon. Mucosal proliferative biomarkers of cancer were measured and were found to be significantly reduced in the US subjects following the swap diet and significantly increased in the African subjects. Further, protective faecal short chain fatty acids (acetate/ proprionate and butyrate) were increased in the US subjects and conversely reduced in the African subjects. Lastly, there was suppression of secondary bile acid synthesis in the US subjects and increased production in African subjects. Together, all of the markers in the American subjects after adoption of the rural African diet are considered as protective in relation to the risk of colon cancer (and the exact reverse in the Africans after the swap to a US diet). Conclusions

What conclusions can be drawn from this very small and very short-term study? Are beneficial effects more due to reductions in fat or in protein, or to massive increases in fibre? Professor O’Keefe considers that the clear and measure-

Gut Health: Research

Several large epidemiological studies have not been able to confirm associations between fibre intake and the occurrence of bowel cancer . . . able changes demonstrated in his study are remarkable, and that perhaps the next big food trend will be the ‘butyrogenic’ diet (which is, in fact, almost the inverse of the much discussed FODMAPS diet). Several large epidemiological studies have not been able to confirm associations between fibre intake and the occurrence of bowel cancer, but Professor O’Keefe suggests that there may be a threshold effect of about 50g per day (which is more than twice the current UK dietary target of 24g, and also very much higher that the proposed figure issued by the Scientific Advisory Committee on Nutrition [SACN] of 30g per day). Interestingly, the main contributors of fibre in the usual rural South African diets are not fruits and vegetable, and certainly not any wholegrain breads or cereals, rather the white stodge that is mielie-meal. And

the nutritional feature of this product seems to be the high content of starch tat is resistant to digestion - perhaps up to 18 percent claim Ahmed and colleagues (1). Eat-more-fibre has been a familiar dietary message for at least four decades and there are no obvious interests to challenge this concept. However, the conclusions from this study are that in relation to bowel health, we need a lot more and that white starchy maize can contribute significantly. This study has such a neat and tidy methodology and measured endpoints are so clear, that the small numbers and short duration do not limit the clarity of the conclusions. But the study does contribute muddle to the debates that are trying to define the components of fibre which may benefit colonic health. In seems that maize may amaze!

References 1 Ahmed R, Segel I, Hassan H (2000). Fermentation of dietary starch in humans. American Journal of Gastroenterology, 2000, 95,4,1017-1020 2 Engelbrecht S, de Beer T (2005). African Salad - a portrait of South Africans at home. Day One publications, Cape Town 3 O’Keefe S, Li JV, Lahti L et al (2015). Fat, fibre and cancer risk in African Americans and rural Africans. Nature Communications DOI:10.1038/ ncomms7342

the essential D AL IT IG O LY

N E

NHDmag.com

Issue 104 May 2015

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OPTIMAL DIET FOR BONE HEALTH Dr Carrie Ruxton p11

ISSN 1756-9567 (Online)

RETHINKING DAIRY . . . p29

Dr Justine Butler Senior Researcher and Writer Viva!Health

COELIAC DISEASE HOSPITAL FOOD DIABETES SPECIALIST INFANT FORMULAS

DIETETIC*/"3 s WEB WATCH s NEW RESEARCH

NHDmag.com June 2015 - Issue 105

web watch

web watch Online resources and useful updates.

End of lifE CarE NHS Improving Quality has published End of Life Care in Advanced Kidney Disease: A Framework for Implementation. The Framework is about enabling people to achieve high quality end of life care, rather than ‘telling them what to do’. To achieve this, it explores the ‘kidney specific’ issues of end of life care focusing on patients opting for conservative kidney management and those ‘deteriorating despite’ dialysis. The overarching aim is to help people with advanced kidney disease to make informed choices about their needs for supportive and end of life care. www. nhsiq.nhs.uk/resource-search/ end-of-life-care-in-advancedkidney-disease-a-framework-forimplementation.aspx

PatiEnt ExPEriEnCE Improving patient experience is going to be a big challenge for the incoming government, according to Picker Institute Europe. Picker has created an infographic which highlights some of the key patient experience related challenges that need to be addressed going forward, if a person centred approach is to be achieved. www.pickereurope.org/ wp-content/uploads/2015/05/GEinfographic-Final.pdf

Dementia friendly days out Care UK has published a new guide Good to Go: a guide to dementia friendly days out aimed at transforming the experiences of

those caring for loved ones living with dementia and providing information to overcome the challenges of getting out and about. This book explains how to plan trips and how to make the most out of every outing. www.careuk.com/ care-homes/news/dementia-guidehelps-carers-get-good-to-go

New anaemia leaflet A new patient information leaflet on anaemia has been produced by NHS Blood and Transplant. The eight-page booklet, What is anaemia? explains who is most at risk of developing the condition and explains that pregnant women are at a higher risk because the foetus takes essential iron from its mother for its own development. The booklet outlines the symptoms and explains the different types of anaemia, such as the underproduction of red cells, a problem in the bone marrow and excessive bleeding. The leaflet also explains what tests may be run to ascertain whether or not a person is anaemic and the treatments available. www.rcm.org.uk/tags/ leaflet Using apps in clinical practice The Royal College of Physicians has published Using apps in clinical practice. This guidance aims to provide clinicians and medical app developers with important information about the use of apps in clinical practice. www.rcplondon. ac.uk/sites/default/files/apps_ guidance_factsheet.pdf

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Hospital admissions for stroke in people aged 4054 years An analysis of hospital admission data by the Stroke Association has found that the number of people aged between 40 and 54 admitted to hospital following stroke has increased by 46 percent for men and 30 percent for women in the last 15 years. It is thought that the rise is due to increasing sedentary and unhealthy lifestyle, and changes in hospital admission practice. www.mynewsdesk.com/ uk/stroke-association/latest_ news/tag/life-after-stroke Alcohol consumption trends The Organisation for Economic Co-operation and Development (OECD) has published Tackling Harmful Alcohol Use Economics and Public Health Policy. The report highlights that harmful drinking is on the rise among young people and women in many OECD countries, partly due to alcohol becoming more available, more affordable and more effectively advertised. In the UK, the report highlights that the levels of alcohol consumption were above the OECD average and had increased during the last 30 years. In 2011, an average of 10.6 litres of pure alcohol per capita was consumed in the United Kingdom, compared with an estimate of 9.5 litres in the OECD. www.oecd.org/health/ tackleheavycostofharmfuldrinking. htm

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk

FULL-TIME HEALTHCARE DIETITIAN - ISS FACILITY SERVICES - HEALTHCARE Salary up to £35,000 pa (depending on experience). Due to continued business growth, we are expanding the operational dietetics team in our Northern division and as such are looking to appoint another Regional Healthcare Dietitian. This is an established and important position in the ISS Dietetics team. ISS Facility Services - Healthcare is a division in the UK of the global ISS Group, providing full facility services to the NHS and private hospitals. The role includes the provision of dietetic support to our Northern contracts, client liaison, training and the development of relevant resources for our NHS hospital trusts where we provide a patient catering service. You will liaise with our Client Dietitians in regards to menu planning and will be responsible for computer generated nutritional analysis and diet coding of menus. It is likely that you will also be involved in wider healthcare projects that the team is undertaking. You will be a HCPC registered dietitian with proven experience in contract catering and at least two years’ clinical experience. You will have an office base in the North but you must be willing to travel within the UK and hold a driving licence. For an informal discussion about the post, please contact: Lauren Bowen, Head of Patient Development, Nutrition & Dietetics, tel: 07787 532701. The closing date for applications is Friday 26th June 2015. Please send a covering letter with a copy of your CV to lauren.bowen@uk.issworld.com www.issworld.com Specialist Paediatric Dietitian Band 7 Specialist Paediatric Dietitian with experience of diabetes, carbohydrate counting and insulin pumps for an ongoing post from June. The role is hospital based in the South of England. Email your CV to registration@ pjlocums.co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

Band 6 Paediatric Dietitian - East Anglia We are currently looking for a Band 6 Dietitian with some paediatric experience. This is an acute post which will last for up to three months and ideally to start as soon as possible. Accommodation available. Excellent rates offered. Call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com for more information on this role. www.elitedietitians.com Paediatric Band 6 Dietitian - ASAP - Essex This is a part-time position required to cover clinics two days a week. The clinics are held on different days each week so this will suit someone who is not already in post and is flexible on which two days they can work from week to week. This department also requires a dietitian for adult clinics two days a week, so if you are available four days, this may work for you. Please contact Hayley on 0800 023 2275/01277 849 649, or email your CV and interest to hayley@eliterec.com www.elitedietitians.com Paediatric Band 7 Lead Diabetes Dietitian Full-time position. West London. (37.5 hours) covering clinics at school sites, patients homes and hospital clinics. Extensive experience of working with children with diabetes and insulin pumps. Starting as soon as possible until the end of August. Please Call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com. Please visit our website www.elitedietitians.com for up-to-date jobs. Band 6 Renal Dietitian London/Surrey borders. Starting end of June covering three acute wards - experience of chronic hemodialysis beneficial. 35 hours per week - one to two months. The applicant must have strong clinical NHS experience and be able to hit the ground running. Please call Hayley at Elite for further information on 0800 023 2275/01277 849 649. Email: hayley@eliterec.com or visit www.elitedietitians.com Band 5 Dietitian - Manchester Starting middle of June covering general medical and surgical wards. This is a full-time post and will run for one to two months. Excellent rates offered for the right dietitian. Please call 01277 849 649 or email hayley@eliterec.com for more information on this role. www.elitedietitians.com NHDmag.com June 2015 - Issue 105

career Band 6 - Kent - June start Covering adult community clinics, this is a full-time post running for two to three months. Car would be ideal but not essential as a hire vehicle can be arranged. To be considered for this role please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com. Please follow us on Twitter @elitedietitians or visit our website www.elitedietitians.com for up-to-date jobs. Band 6 Oncology - Staffordshire - start immediately Band 6 Acute Dietitian required to cover oncology wards and nutrition support. Starting as soon as possible and running for two months. Please call 0800 023 2275 or 01277 849 649. Email: hayley@eliterec.com. Please follow us on Twitter @elitedietitians or visit our website www.elitedietitians.com for up-to-date Jobs. Band 6 Acute Paediatric Dietitian - Norfolk Experienced Band 6 Dietitian with some paediatric experience required for two to three months. Starting as soon as possible. Accommodation available. Please call Hayley now for more information on the above position and other excellent roles we have available, 01277 849 649 or 0800 023 2275. Email: hayley@eliterec.com

events and courses University of Nottingham - School of Biosciences

Modules for Dietitians and other Healthcare Professionals

• Obesity Management Module - 30th September • Gastroenterology Module - 8th October For further details please email marie.e.coombes@ nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/ biosciences and click on short courses then ‘for practising dietitians’. 10th June - Priorities for improving outcomes in diabetes care: prevention, integration and personalisation This event is CPD certified Central London www.westminsterforumprojects.co.uk/ 12th June - Effective Clinical Supervision Master Class London Road Community Hospital, Derby www.ncore.org.uk 23rd to 25th June - IPC2015 International Scientific Conference on Probiotics and Prebiotics Budapest, Hungary www.probiotic-conference.net/

We urgently require dietitians for immediate vacancies To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk

• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health • Our aim is to find you the right person and the right job • We offer inpatient and community UK & NI coverage • Competitive rates

www.pjlocums.co.uk 46

NHDmag.com June 2015 - Issue 105

The final helping

Neil Donnelly

Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders

I love writing this short article every month. It keeps me in touch. It makes me look back. It helps me look forward. It’s personal. It’s now Bank Holiday Monday at 7.30am and I am putting this together following my return from Wembley Stadium at 2.30am this morning. Some years ago, 1967 to be precise, respected manager of some two and I read a book called Energy, Work a half years, Simon Grayson, was and Leisure by Dr JVGA Durnin. It quoted as saying, “When I came was the first of its kind. I still have there was no fitness coach, dietitian the original much thumbed-through or Chief Scout.” How fitting to see copy. It covered the energy expendi- our profession so widely recognised ture of adults engaged in a variety of at this level of professional sporting everyday activities, professions and activity. sporting activities, Our group was Energy expenditure, from gardening on the front row to bus conducting near the centre line. body fat content and to squash. I was The atmosphere hooked. Two years and nervous anticiappetite control became later, following my pation was tangipractical dietetic ble. Ninety minutes the fundamentals of my training in Glasplus added time of gow, I helped with individual energy career in Dietetics and one of his, (now expenditure based Professor John on a platform of the Durnin) research shaped the path I followed. team supporting studies at the Instithem was going to tute of Physiology I wouldn’t change a thing. define their season. at the University Suffice it to say that of Glasgow for six as I now look formonths. ward to the next Energy expenditure, body fat con- football season in the Championship tent and appetite control became the following a 4-0 victory, I still think fundamentals of my career in Dietet- back to how my own career started ics and shaped the path I followed. I and the joy and pleasure that comwouldn’t change a thing. bining energy, work and leisure gives So, back to Wembley. Well, Pres- throughout your life. ton North End (PNE) were in the I would, however, like to give League One Play-off Final. The win- my profuse apologies to the supners go into the Championship next porters of Swindon Town for the season, that’s one below the Premier bias in this article. Now back to the League. Before the match, our well- gardening… NHDmag.com June 2015 - Issue 105

Imagine if there were only 99s

Choice is good Offering a variety of oral nutritional supplements is likely to improve compliance and intake.1 That’s why Nutricia offers a wide range of flavours and formats, including Forticreme Complete (125 g pot), a high energy (200 kcal), high protein (11.9 g) dessert-style nutritional supplement. Forticreme Complete — the little pot packed with a lot of nutrition.

Visit www.nutriciaONS.co.uk/forticreme to request a sample or arrange a visit from your local Nutricia Representative. Reference 1. Nieuwenhuizen WF et al. Clin Nutr 2010;29:160–169. Date of preparation: 02/15

Right patient, right product, right outcomes