NHD March 2015 issue 102

IG D AL IT LY N O E SU IS

NHDmag.com

Issue 102 March 2015

Diet and Kidney Transplantation Liz Rai p25

ISSN 1756-9567 (Online)

INTENSIVE CARE NUTRITION . . . p8

Emma Copeland Senior Dietitian

early years nutrition vitamin supplementation imd watch irritable bowel syndrome

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from the editor ‘Care is our business.’

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

Were you supporting, encouraging and celebrating the delivery the 6 Cs during the week of 23 to 27 February. Do you remember that in December 2012 the 6 Cs were launched? The Cs stand for Care, Compassion, Commitment, Competence, Communication and Courage.

If you feel that you can share what you did, especially during the live week, please let us know and we can communicate it via NHD. This month I am delighted that we have a patient, Kate who wants to share her story with us about her diagnosis of IBS and the start of her new journey of trying the FODMAPs diet. Kate has seen two dietitians in the last 30 years and both experiences seem to have been positive.

One of the standards set by the Intensive Care Society in 2013, stated that a dietitian should be part of the critical care team, involved in the assessment, implementation and management of the appropriate route of nutrition support.

Emma Copeland tells us more in her article on Intensive care nutrition.

For patients on renal replacement therapy, the dietitian plays a key role, and particularly in the pre- and postrenal transplant care pathway. Liz Rai shares the dietetic and patient challenges in Diet and kidney transplantation which includes a case study about Mr F. Editor 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

For the paediatric dietitians we can offer three articles. Oesophageal atresia is a congenital abnormality whereby the oesophagus ends blindly in a pouch, resulting in a non-continuous route from the mouth to the stomach. Learn more about the presentation, diagnosis, treatments and weaning challenges from Kathryn Lowes. The theme of early years’ nutrition is continued when Emma Haycraft and Gemma Witcomb tell us about The Child Feeding Guide: a helpful resource for families who are worried about children’s fussy eating. The advice can offer help to parents and caregivers to effectively manage a child’s difficult eating and hopefully support them in developing healthy eating habits that will last a lifetime.

Want to know about ‘super yucky’ to ‘super yummy’ scoring systems and food neophobia? If so, then turn to Taste preferences of young children with phenylketonuria, an article written by five members of the Dietetic Department at Birmingham Children’s Hospital.

Are vitamin supplements needed?

This may be a question that several of you are asking. Ursula Arens covers vitamin supplementation - but you may be the one with the answer!

I hope you enjoy reading this issue of NHD as much as I am looking forward to spring!

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NHDmag.com March 2015 - Issue 102

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Contents

25

COVER STORY

DIET & KIDNEY TRANSPLANTATION 6

News

34 Irritable bowel syndrome

8

Intensive care nutrition

36 Book review

14 Early years nutrition

38 Web watch

21 Vitamin supplementation

40 dieteticJOBS

28 IMD watch

41 Events and courses

31 Oesophageal atresia and

weaning

42 The final helping

Editorial Panel Chris Rudd Dietetic Advisor

Emma Copeland Senior Dietitian, Croydon University Hospital

Neil Donnelly Fellow of the BDA

Dr Emma Haycraft Senior Lecturer in Psychology, Loughborough University

Ursula Arens Writer, Nutrition & Dietetics

Dr Gemma Witcomb Research and Teaching Fellow, Loughborough University

Dr Carrie Ruxton Freelance Dietitian

Dr Claire Farrow Senior Lecturer, Aston University

Dr Emma Derbyshire Nutritionist, Health Writer

Liz Rai Renal Dietitian, Newcastle upon Tyne Hospitals

Dr Anita MacDonald Consultant Dietitian in IMD

Evans S, Daly A, Chahal S, MacDonald J, MacDonald A Dietetic Department Birmingham Children’s Hospital

Kate Harrod-Wild Specialist Paediatric Dietitian

Kathryn Lowes Paediatric Dietitian Great Ormond Street Hospital for Children

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NHDmag.com March 2015 - Issue 102

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DIET AND KIDNEY TRANSPLANTATION Liz Rai p25

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EARLY YEARS NUTRITION VITAMIN SUPPLEMENTATION IMD WATCH IRRITABLE BOWEL SYNDROME

INTENSIVE CARE NUTRITION . . . p8

Emma Copeland Senior Dietitian

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NEWS

Socio-economic gaps in diet quality

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

Variations in diet quality between socioeconomic (SE) groups can lead to unequal differences in health. An analysis of data from the 2008 to 2011 National Diet and Nutrition Survey has looked at this in more detail.

Data from 1,491 adults aged 19 years and over was used. SE status was determined using household income, occupational social class and highest educational qualification. Significant differences were found for three food groups. Higher SE groups ate up to: 1) 128 grams per day more vegetables, 2) 26 grams per day less red and processed meat and 3) less non-milk extrinsic sugars (2.6% points). Higher SE groups were also 2.4 to 4.0 times more likely to eat oily fish.

Overall, analysis of data from this survey shows the importance of aligning dietary patterns across SE groups.

Further public health guidance is needed, along with interventions targeting lower SE groups.

For more information, see: Maguire ER and Monsivais P et al (2015).

British Journal of Nutrition Vol 113 (1), pg181-189.

Measuring hydration status

Being adequately hydrated is important for cognitive (mental) and physical well-being. There is growing interest in the role that hydration has to play in health, yet data is often excluded from large population studies. Now, a new paper looks into the best ways to measure this.

Authors concluded that past methods have tended to be quick, inexpensive and lacking in technical expertise. For example, changes in body weight and urine colour while easy to measure, are not particularly accurate. Blood plasma osmolality (water content) is somewhat more reliable, but requires venepuncture which is not suitable for some study populations such as children.

Urine sampling and analysis was regarded at the best method as this is non-invasive and cost-effective. In particular, urine osmolality and urine specific gravity can be measured from urine samples. These are both good markers of hydration status and suitable for use in large studies.

For more information, see: Baron S et al (2015). British Journal of Nutrition Vol 113 (1), pg147-58.

Target childcare settings for obesity prevention?

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

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While some studies have found that childcare in general may be related to childhood obesity, few have looked at how childcare in infancy could affect this. As we see here, such research has now been carried out in Denmark.

A total of 27,821 infants born to mothers who took part in the Danish National Birth Cohort study and were registered on the Childcare Database (a record of childcare use) were recruited. The number of days spent in childcare from birth to 12 months was collected and body mass index (using z-scores for infants) measured at 12 months.

NHDmag.com March 2015 - Issue 102

It was found that 63.7 percent attended childcare during this period. A 30-day increment of childcare was associated with a significantly higher body mass index z-score and increased likelihood of being overweight at 12 months of age.

In summary, it seems that childcare in the first year of life may contribute to higher weight in infancy. Taking this on board it seems that childcare settings, e.g. nurseries and child minders, are important targets for obesity prevention.

For more information, see: Neelon SE et al (2015). International Journal of Obesity Vol 39, pg33-38.

NEWS

PRODUCT / INDUSTRY NEWS

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Reduced levels of iron in the brain have been linked to impaired cognition and certain neurodegenerative diseases. New research looks into this further.

The cohort study recruited 1,063 older participants (mean age 72.7 years) who were born in 1936.

Dietary intakes were assessed using a food-frequency questionnaire, blood samples taken and brain imaging carried out.

Findings showed that 72.8 percent of the study population had iron deposits in the brain, with 70.6 percent of the sample having deposits within the basal ganglia part of the brain. Mean iron intakes were 11.7mg but not associated with brain iron deposits, although calorie intake was significantly associated with ferritin levels (an iron storage protein).

Overall, study findings point towards iron (as ferritin) correlating with brain iron; but randomised trials are now needed.

A second study has looked inti the iron-binding effects of beta-glucan; a dietary fibre renowned for its cholesterol-lowering effects. Using a process known as the ‘Fenton reaction’, scientists found that at pH 4.7 iron formed complexes with both oat (most strongly) and barley beta-glucan. These results indicate that oat beta-glucans could reduce iron bioavailability, though human trials need to test this further.

For more information, see: Del C Valdes HM et al (2015). J Nutr Health Ageing Vol 19(1), pg64-91 and Faure AM et al (2015). Carbohydr Polym 115: 739-43.

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Selenium and pregnancy diabetes link

Past studies have shown that women who develop diabetes in pregnancy are more likely to have lower blood selenium levels. Now, a new meta-analysis paper has pooled results and looked further into this.

The new paper analysed data from six observational studies comprised of 147 women with pregnancy (gestational) diabetes and 360 women without the condition and with normal blood sugar levels.

Results showed that blood serum selenium levels were significantly lower in women with preg-

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nancy diabetes compared with women without it.

This was particularly the case in the second and third trimesters, though the association was not significant in the second trimester.

These are interesting and important findings highlighting that women with diabetes in pregnancy have lower selenium status. More work now needs to be carried out to determine why.

For more information, see: Askari G et al (2015).

J Trace Elem Med Biol Vol 29, pg195-201.

To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) NHDmag.com March 2015 - Issue 102

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INTENSIVE CARE

INTENSIVE CARE NUTRITION Dietary interventions in the ICU are supported by large trials, observational studies, systematic reviews and meta-analyses that have fed into comprehensive clinical guidelines from Europe, the United States and Canada. The consensus is that feeding early and feeding enterally is what dietitians should be promoting.

Emma Copeland Senior Dietitian, Croydon University Hospital

But this body of evidence has also given rise to controversies and questions: the what, when and how of nutrition support in the ICU is ever-evolving.

Dietitians are now recognised as vital members of the ICU team and are key to driving forward research and putting it into practice.

ROLE OF THE DIETITIAN

Emma Copeland is a Senior Dietitian covering critical care and gastroenterology at Croydon University Hospital. She has worked as an academic researcher and as a writer/editor (freelance and for Health Which?

Magazine).

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In 2013, The Intensive Care Society (ICC) set core standards for patient care (1). Importantly, dietitians were represented on the development group by Ella Segaran, Chair of the Dietitians in Critical Care (DCC) specialist group of the British Dietetic Association (BDA). The standards stipulate a dietitian should be part of the critical care team, involved in the assessment, implementation and management of the appropriate route of nutrition support.

The ICC and Faculty of Intensive Care Medicine Joint Standards Committee is due to publish Guidelines for the Provision of Intensive Care Services in 2015 (2). Dietitians Danni Bear and Ella Segaran wrote the chapter on dietetics, which sets out recommendations for the wide-ranging role of the ICU dietitian. Apart from nutritional assessment, implementation and monitoring of nutrition interventions, other vital roles include development of feeding protocols, contributing to ward rounds, meetings and clinical governance and the education and training of other members of the

NHDmag.com March 2015 - Issue 102

team. Some ICU dietitians may further develop their role to provide specialist support, such as inserting feeding tubes.

Audit and research are important elements of an ICU dietitian’s role, to drive quality improvement and expand knowledge. In the latest International Nutrition Survey of ICUs, University Hospital of Wales Cardiff ranked fourth and Beaumont Hospital Dublin ranked seventh in the top 10 ‘Best of the Best’ (3). Heyland et al (4) found an association between the presence of a dietitian in the ICU and the unit achieving a high ranking. Soguel et al (5) concluded that an ICU dietitian ‘can make a difference’, with increased daily energy delivery and reduced cumulative day seven energy deficit with dietetic input of 0.6 WTE. The CALORIES trial, published in the high profile New England Journal of Medicine (6), highlights the central role that dietitians are playing in critical care research. This was a hot topic at BAPEN 2014 and at the most recent DCC study day.

THE WHAT, WHEN, AND HOW OF ICU NUTRITION SUPPORT

Guidelines from Europe (7, 8), Canada (9) and the US (10) are used by ICU dietitians across the UK. Publication dates range from 2006 to 2013 and incorporate expert opinion, so it’s no surprise that, although there is consensus, there are also divergent rec-

intensive care

Early enteral feeding is suggested universally, where indicated. This means within 24 hours in Europe and within 24 to 48 hours in the US and Canada.

DIETITIANS IN CRITICAL CARE

The DCC runs excellent study days as well as an online forum where members can share ideas and ask questions. The group provides a regular research round-up and newsletter for members.

The Committee is currently working on producing outcome measures for nutritional care in the ICU. For more information visit www.bda.uk.com/regionsgroups/groups/criticalcare ommendations. Only the Canadian guidelines undergo regular update.

The PEN Knowledge Pathway for Critical Illness (11) is produced by Dietitians of Canada, with input from the DCC. This useful summary combines elements of each of the guidelines in a single accessible resource. The pathway benefits from evidence updates and BDA membership includes a subscription to PEN. What: how much energy and protein should ICU patients receive?

Indirect calorimetry (IC) is generally accepted as the gold standard for determining energy (kcal) requirement, but ICU dietitians do not always have access to this technology. The PEN Knowledge Pathway recommends use of IC, or predictive equations when this technology is not available. See Table 1 overleaf.

The consensus on the evidence base for estimating protein requirements is that more research is needed. Singer et al suggested provision of 1.5g protein/kg/day during the early phase of ICU admission to reduce catabolism, regardless of the energy provision (12). Practically, this can be achieved by use of protein modular supplements alongside enteral feeds.

Weight is used in all simple and predictive equations, but dietitians may not have access to actual weights, and use of actual weight is complicated by the oedema common in many

ICU patients. Ideal body weight (IBW) may be used, but different methods of calculation exist. Simple weight-based calculations do not account for age or gender, and clinical judgment is always needed.

Response to nutrition support in ICU patients may depend on nutritional status. Alberda et al (13) found higher intakes of energy and protein were associated with improved clinical outcomes (60-day mortality, ventilatorfree days) for patients with BMI<25 and ≥35.

Heyland et al (14) devised and validated the NUTRIC scoring system for ICU patients. A higher score was associated with poorer outcomes (28-day mortality, ventilator-free days) and patients with a higher score got most benefit from aggressive nutritional support.

When: how soon should patients receive nutritional support?

Villet et al (16) found that an energy deficit (goal vs provision) of just over 10,000 kcal built up over a week was associated with complications, especially infections. This can be seen as a marker of cumulative protein deficit, but the focus in earlier studies has often been on energy. Subsequent research has found that cumulative energy deficit is a risk factor for ventilator associated pneumonia (17).

Early enteral feeding is suggested universally, where indicated. This means within 24 hours in Europe and within 24 to 48 hours in NHDmag.com March 2015 - Issue 102

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intensive care Table 1: Summary of recommendations for estimating energy and protein requirements Guidelines

Patient group

Method for estimating energy requirement

Method for estimating protein requirement

European Society for Parenteral and Enteral Nutrition (EN) 2006

Not specified

20-25 kcal/kg/day (initial/ acute) 25-30 kcal/kg/day (recovery)

No recommendation

‘Severe under nutrition’

25-30 kcal/kg/day

Not specified

25 kcal/kg/day increasing to target over the next 2-3 days

1.3-1.5g/kg IBW/day

Not specified (assume BMI≤30)

Use simplistic formulas (25-30 kcal/kg/day) or published predictive equations

1.2-2.0g/kg actual BW/ day (and likely higher in burns or trauma)

BMI>30

60-70% target requirements 11-14 kcal/kg actual BW/ day 22-25 kcal/kg IBW/day

BMI 30-40: ≥2.0 g/kg IBW BMI≥40: ≥2.5 g/kg IBW

All patients with BMI<30

80% of target requirements initially 100% of target requirements as patient stabilises

No recommendation

All patients with BMI≥30

As per EN recommendations

No recommendation

Not specified

Insufficient data to make a recommendation on IC vs predictive equations

Insufficient data to make a recommendation

BMI<30

Penn State 2003b

BMI>30, younger patients

Ireton-Jones 1992 or Penn State 1998 or Faisy 2008

BMI>30, from age 60 years

Modified Penn State 2011

European Society for Parenteral and Enteral Nutrition (PN) 2009

Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (EN) 2009

Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition (PN) 2009

Canadian Critical Care Nutrition 2013

PEN Knowledge Pathway

Highlights the lack of high quality research examining protein requirements in critically ill adults, and cites a systematic review concluding that 2.0-2.5g protein/kg normal weight/ day could be optimal (15)

Bodyweight (BW), ideal body weight (IBW)

the US and Canada. The UK ICC Core Standards state that nutrition support should commence on ICU admission.

The European PN guidelines recommend starting feeding within 24 to 48 hours if EN is contra-indicated and/or where patients are not tolerating EN. The US guidelines say wait until day seven of ICU admission, highlighting this recommendation as their ‘most controversial’. The Canadian guidelines state that there 10

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is not enough evidence to say when PN should be started, but caution against using PN and high IV glucose in low risk patients with a predicted short ICU stay.

Where patients have not been meeting their EN target for two days, European guidelines recommend starting supplementary PN. The US guidelines recommend waiting to start PN for seven to 10 days if EN is not providing 100 percent of target energy. Again, citing insuffi-

intensive care

The REDOXS trial found poorer outcomes (mortality, infections) for patients in multiorgan failure (MOF) supplemented with high-dose glutamine . . .

cient evidence, the Canadian guidelines make no recommendation for when supplementary PN should be started - with the caveat that all strategies to maximise EN delivery should be attempted first. A systematic review of supplementary PN published in 2014 (18) concluded that ‘there are no clinically relevant benefits of early PN compared with late PN in terms of mortality and morbidity endpoints’.

How: what route of nutrition support should ICU patients receive?

To provide nutrition support for ICU patients without a functional or accessible gut, PN is required. But for other patients is one route superior? The CALORIES trial randomised patients where EN was not contra-indicated to receive EN or PN, with both types of feeding started within 24 hours. It found no significant difference in 30-day mortality between the groups.

Energy and protein intake and time of starting nutritional therapy, was similar in the two groups. As the authors point out, this was, therefore, a study looking at the route of feeding alone. But, as with many studies, energy and protein targets were not achieved in most patients. Interestingly, this trial highlights that, in practice, PN does not provide a means to meet energy and protein goals - problems often seen with EN due to feed intolerance and unplanned feed breaks.

Not all ICU patients require artificial nutrition support and the focus on nutrition may get lost after the switch to oral intake. Protocols for oral nutrition support are, therefore, just as important as for artificial feeding. A small study (19) found that on all days, for all patients, average intake of energy and protein

was not more than 50 percent of requirements for the seven days after extubation.

CONTROVERSIES - QUICK BITES

Sepsis The Surviving Sepsis Campaign Guidelines (20) recommend hypocaloric feeding in the first week of ICU admission. Recent analysis of international prospective pooled data found better outcomes (60-day mortality, duration of mechanical ventilation) associated with energy and protein provision closer to guideline targets in septic patients (21).

Glutamine The REDOXS trial found poorer outcomes (mortality, infections) for patients in multiorgan failure (MOF) supplemented with highdose glutamine - especially in those with impaired renal function (22). A meta-analysis (23) highlighted a dose-effect on mortality, with a poorer outcome when glutamine was given above 0.5g/kg/day.

The 2013 Canadian guidelines strongly recommend that high-dose glutamine supplementation should not be used in patients with shock and MOF. But glutamine can be considered in burns and/or trauma patients receiving EN (0.3-0.5g/kg/day) and patients receiving PN (0.35g/kg/day).

Gastric residual volumes High gastric residual volumes (GRVs) often lead to a reduction in EN provision and the usefulness of measuring GRVs is under debate.

An RCT (24) found no difference in rate of ventilator associated pneumonia, other infections, duration of mechanical ventilation, ICU length of stay or mortality between patients where NHDmag.com March 2015 - Issue 102

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intensive care GRVs were measured and those where no measurements were done. All patients received early EN and more patients were fed at their kcal target when GRV was not measured.

Summary

Nutrition support in the ICU is a well-researched area of dietetics, but it is vital to review the methodology used in trials and studies when assessing clinical outcomes. Measures of nutritional status may not be reported and some trials include or combine groups of patients that may not be relevant to a typical ICU. Targets for energy and protein may be set in a variety of ways

and these goals are often not achieved with EN or PN. The focus on energy over protein is starting to shift, but older studies sometimes fail to give equal prominence. Studies that aim to feed ‘early’ may not do so within 24 hours.

Which outcomes to measure are under review by the DCC. While mortality and infection rates are commonly reported, measures of functional status and quality of life are gaining weight.

The 2013 Canadian Critical Care Nutrition Guidelines offer the most up-to-date review of the evidence and, along with the PEN Knowledge Pathway for critical illness, currently offer the best resource for ICU dietitians.

References 1 The Intensive Care Society (2013). Core Standards for Intensive Care Units. Available from: www.ics.ac.uk/ics-homepage/guidelines-and-standards/ [accessed 10 January 2015] 2 the Joint Intensive Care Society and Faculty of Intensive Care Medicine Standards Committee consultation document (2014). Guidelines for Intensive Care Services. available from: www.ficm.ac.uk/news-events/guidelines-provision-intensive-care-services-gpics-consultation [accessed 10 January 2015] 3 The International Nutrition Survey Best of the Best (2013). http://criticalcarenutrition.com/index.php?option=com_content&view=article&id=295&Itemid=91 [accessed 10 January 2015] 4 Heyland DK, Heyland RD, Cahill NE, Dhaliwal R, Day AG, Jiang X, Morrison S and Davies AR (2010). Creating a culture of clinical excellence in critical care nutrition: the 2008 ‘Best of the Best’ award. Journal of Parenteral and Enteral Nutrition, 34(6), pp707-15 5 Soguel L, Revelly JP, Schaller MD, Longchamp C and Berger MM (2012). Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: The intensive care unit dietitian can make the difference. Critical Care Medicine, 40(2), pp412-419 6 Harvey SE, Parrott F, Harrison DA, Bear DE, Segaran E, Beale R, Bellingan G, Leonard R, Mythen MG, Rowan KM and CALORIES Trial Investigators (2014).

Trial of the route of early nutritional support in critically ill adults. New England Journal of Medicine, 371(18), pp1673-84 7 Kreymann KG, Berger MM, Deutzc NEP, Hiesmayrd M, Jolliete P, Kazandjievf G, Nitenbergg G, Van den Berghe G, Wernermani J, Ebner C, Hartl W, Heymann C and Spies C (2006). ESPEN Guidelines on Enteral Nutrition: Intensive care. Clinical Nutrition, 25, pp210-223 8 Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C (2009). ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clinical Nutrition, 28, pp387-400 9 The Canadian Clinical Practice Guidelines (2013). www.criticalcarenutrition.com/docs/cpgs2012/Summary%20CPGs%202013%20vs%202009_2July2013. pdf [accessed 10 January 2015] 10 McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; ASPEN. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine (2009). Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition, 33(3), pp277-316 11 Dietitians of Canada PEN Knowledge Pathway: critical illness. www.pennutrition.com/ [accessed 5 January 2015] 12 Singer P, Hiesmayr M, Biolo G, Felbinger TW, Berger MM, Goeters C, Kondrup J, Wunder C and Pichard C (2014). Pragmatic approach to nutrition in the ICU: expert opinion regarding which calorie protein target. Clinical Nutrition, 33(2), pp246-51 13 Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, Heyland DK (2009). The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Medicine, 35, pp1728-1737 14 Heyland DK, Dhaliwal K, Jiang X, Day AG (2011). Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Critical Care,15:R268 15 Hoffer LJ and Bistrian BR (2012). Appropriate protein provision in critical illness: a systematic and narrative review. American Journal of Clinical Nutrition, 96, pp591-600 16 Villet S, Chiolero RL, Bollmann MD, Revelly JP, Cayeux RNMC, Delarue J and Berger MM (2005). Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clinical Nutrition, 24(4), pp502-9 17 Faisy C, Llerena MC, Savalle M, Mainardi JL, Fagon JY (2011). Early ICU energy deficit is a risk factor for staphylococcus aureus ventilator-associated pneumonia. CHEST, 140(5), pp1254-1260 18 Bost RBC, Tjan DHT and Van Zanten ARH (2014). Timing of (supplemental) parenteral nutrition in critically ill patients: a systematic review. Annals of Intensive Care, 4(31) 19 Peterson SJ, Tsai AA, Scala CM, Sowa DC, Sheean PM, Braunschweig CL (2010). Adequacy of oral intake in critically ill patients 1 week after extubation.

Journal of the American Dietetic Association, 110(3), pp427-33 20 Surviving Sepsis Campaign Guidelines Committee (2013). Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Critical Care Medicine, 41 (2), pp580-637 21 Elke G, Wang M, Weiler N, Day AG, Heyland DK (2014). Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Critical Care, 18(1), ppR29 22 Heyland DK, Elke G, Cook D, Berger MM, Wischmeyer PE, Albert M, Muscedere J, Jones G, Day AG (2014). Glutamine and Antioxidants in the Critically Ill Patient: A Post Hoc Analysis of a Large-Scale Randomised Trial. Journal of Parenteral and Enteral Nutrition, May 5 [Epub ahead of print] 23 Chen QH, Yang Y, He HL, Xie JF, Cai SX, Liu AR, Wang HL, Qiu HB (2014). The effect of glutamine therapy on outcomes in critically ill patients: a metaanalysis of randomised controlled trials. Critical Care, 18(1), ppR8 24 Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F, Clavel M, Frat JP, Plantefeve G, Quenot JP, Lascarrou JB (2013). Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomised controlled trial. Journal of the American Medical Association, 309(3), pp249-56

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THE MOST COMPLETE PRETERM RANGE At Cow & Gate, we have given our all in the development of the most comprehensive range available for preterm babies.

By working closely with neonatal practitioners, Nutriprem is now the only preterm range that complies with the latest ESPGHAN guidance and includes a hydrolysed protein formula.1

For more information about preterm nutrition visit: www.in-practice.co.uk

Important notice Breastfeeding is best for babies. Cow & Gate Nutriprem 1 and Nutriprem 2 are foods for special medical purposes and should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. They are suitable for use as the sole source of nutrition for preterm and low birthweight infants. These products are for enteral use only. Infant formula is intended to replace breastmilk when mothers do not breastfeed. Infant formula should only be used on the advice of independent persons qualified in medicine, nutrition or pharmacy, or other professionals responsible for maternal and child care.

Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50: 85–91.

Early years nutrition

The Child Feeding Guide: a helpful resource for families who are worried about children’s fussy eating

Dr Emma Haycraft

Dr Gemma Witcomb

Dr Claire Farrow

Emma is a Senior Lecturer in Psychology at Loughborough University. Her research focuses on parent-child interactions around feeding/eating. She is a co-developer of The Child Feeding Guide.

Gemma is a Research and Teaching Fellow at Loughborough University. She is a co-developer of The Child Feeding Guide. Her focus is on translating research into tangible resources to aid breastfeeding, fussy eating, and clinical eating problems.

Claire is a Senior Lecturer at Aston University. Claire is interested in the factors that influence child eating behaviour and is a co-developer of The Child Feeding Guide.

14

Fussy eating is prevalent in young children with at least 40 to 50 percent of parents reporting that their child is fussy or eats a limited diet (1).

Although commonplace, particularly in children aged 19 to 24 months (2), fussy or difficult eating behaviours are significant as they often persist over time (3).

How this fussiness is managed can affect whether children outgrow it, or if it will continue as they get older, which is why parents and caregivers have such a vital role in helping children to develop healthy eating habits. Furthermore, a poor diet in childhood can predict a poor diet in adulthood and is associated with obesity and a range of preventable diseases, such as diabetes and cancer (4).

While the medical profession makes recommendations regarding the benefits of breastfeeding and the introduction of solid foods, a review of national and international feeding guidelines has suggested that many issues known to be important in establishing healthy feeding practices and diet in young children are not communicated to parents or caregivers at all, or only in very minimal detail. There is also an absence of any tangible practical advice about child feeding, particularly once weaning has occurred (5). Our own research has confirmed that many parents feel that the available resources about feeding young children and promoting a healthy diet are ‘too basic’, with parents often searching for information independently (6).

To address the reported lack of information and support available for parents surrounding fussy eating, we developed The Child Feeding Guide which is available as a website and free mobile app for iPhones/iPads and Android phones. Based on 25 years of collective research, The Child Feeding Guide

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provides evidence-based information and practical support for anyone who is concerned about children’s eating behaviours. Although it is directed at parents and caregivers (henceforth referred to as ‘parents’), it is also a useful resource for health professionals to use and disseminate to the families that they work with. The guide explains the science behind children’s eating behaviours, allowing parents to assess and monitor their own and their child’s responses around mealtimes and food. It also provides strategies to address fussiness in a positive way.

The Child Feeding Guide describes the five most common feeding pitfalls that families encounter. It explains what they are, why they occur and what parents can do to avoid them. Three of these pitfalls are summarised below. Details about the other two pitfalls (parental use of restriction and children’s unhealthy food preferences) can be found by visiting the website: www.childfeedingguide.co.uk.

1. Food refusal A common child eating behaviour which parents can find worrying, is food refusal. At around 18 to 24 months, many children go through a phase known as ‘food neophobia’, where they become wary of new foods or of foods that they previously liked (7). This phase often manifests as children being fussy and many parents are unsure how to respond to this. Research has indicated

early years nutrition

The Child Feeding Guide which is available as a website and free mobile app for iPhones/iPads and Android phones. Based on 25 years of collective research . . .

that children may require a food to be offered up to 15 times before they trust it and are willing to taste it (8). Once a food is deemed ‘safe’, it can take a further 15 offerings, or ‘exposures’, for the child to develop a liking for it (9). It is therefore important that parents continue to offer foods that their child dislikes, as only by increasing children’s familiarity with a food will it become likely to be eaten (10). These food exposures can be offered as part of a meal or snack, but they can also be in non-mealtime contexts, such as playing with the food (e.g. messy play with cooked spaghetti or mashed potato), reading stories about foods, or allowing the child to pick out and touch different foods when shopping.

Research suggests that parents tend not to offer pre-schoolers a disliked and refused food more than five times (2, 11). Given that it can take many more than five exposures before a food is trusted and liked by young children, The Child Feeding Guide includes an Exposure Monitor; an interactive tool which allows parents to keep track of how many times a food is offered to their child. After setting up a profile, parents can quickly and easily log each food that is being offered and whether it was eaten or rejected by their child. This information is stored and enables parents to objectively monitor and review their child’s exposure to different foods.

The Child Feeding Guide describes the five most common feeding pitfalls that families encounter.

It explains what they are, why they occur and what parents can do to avoid them.

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early years nutrition

The Child Feeding Guide includes an Exposure Monitor; an interactive tool which allows parents to keep track of how many times a food is offered to their child.

2. Pressure to eat Another common feeding pitfall that The Child Feeding Guide addresses is parental use of pressure to eat. Many parents find it concerning when they are faced with a child who won’t eat fruit or vegetables, but who will happily eat biscuits, pizza and other ‘junk’ foods. These parents may feel the need to pressurise or force their child to eat healthy foods, believing that this is in the child’s best interests. However, there is now a wealth of evidence which indicates that pressuring a child to eat a food, or to eat more than they wish, can have unintended negative consequences.

Research has shown that foods people are pressured or forced to eat become less desirable (12). This means that a child who is repeatedly forced to finish her vegetables is actually likely to eat even fewer of them. There is also evidence to show that if children are repeatedly asked to eat more than they want to at mealtimes, it can ‘teach’ them to ignore their internal signals about fullness and hunger, which, in the long-term, may lead to overeating and contribute to children becoming overweight or obese (13).

Rather than pressuring or forcing a child to eat, The Child Feeding Guide recommends alternative practical steps for parents to follow to help encourage children to have a healthy diet. These include: ‘examining the evidence’ (e.g. thinking about how long it is since the child last had a snack or filling drink, such as milk, which may be reducing their hunger); and ‘checking por16

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tion sizes’ to check that parents are not expecting children to eat too much (e.g. as a guide, a single portion is roughly what would fit in the palm of the child’s hand - providing too much food could be why children refuse to eat it). Following these simple steps can make parents more mindful of factors that might explain why their children are full and help parents to make changes, such as providing smaller portions, to promote healthier child eating behaviours.

3. Food as a reward Another common feeding pitfall is using food as a reward. Food can be very effective when used as a tool or a reward. For example, it can be tempting to offer children appealing foods, such as sweets, in exchange for good behaviour. Pudding is often used to reward children for eating vegetables. However, research shows that using food as a reward, or a bribe, can have adverse consequences (14). These include children having an increased liking for the reward food (pudding) and a decreased liking for the non-reward food (vegetables). This practice can also contribute to a child’s poor diet, as the foods that are most often used as rewards are often unhealthy, sugary treats and snacks, which can contribute to weight gain. The Child Feeding Guide explains all this and suggests alternative rewards, such as offering children real, tangible objects or experiences as rewards - a sticker or a trip to the park - rather than food. Evidence suggests that offering non-food rewards like stickers can be an effective way of getting children to taste disliked foods (15).

Here’s to choice Only Nutricia offers the widest range of compact nutrition, including Fibre and Protein

Fortisip Compact also has the widest range of flavours, from banana to forest fruit, which may aid patient compliance.1 Reference 1. Hubbard GP et al. Clin Nutr 2012:31;293–312.

Date of preparation: 02/15

Still #1 when it comes to choice and flavour range

early years nutrition

Initial evaluation of The Child Feeding Guide by parents and caregivers, health professionals and childcare workers has been incredibly positive.

As well as addressing common feeding pitfalls, The Child Feeding Guide provides tips for ways that parents can promote healthy eating. In the UK, consumption of five portions of fruit and vegetables per day is recommended. However, only around 20 percent of children achieve this (16). The guide has a section which outlines ways for parents to increase children’s fruit and vegetable intake. For example, this could be using real fruits and vegetables in messy play, ‘growing your own’ and getting children involved in food preparation and cooking. All of these activities help to increase children’s exposure to foods which serves to increase their familiarity with them. If a food is more familiar, it is much more likely to be eaten (10).

Initial evaluation of The Child Feeding Guide by parents and caregivers, health professionals and childcare workers has been incredibly positive. Users have reported that it is informative, contains novel information and has helped them to understand children’s eating behaviour better.

They also felt that it was empowering to have

this information available in this format. Health professionals commented favourably about the guide’s clarity, accessibility and ease of use, that it was engaging and interactive and that it offers impartial, credible advice to families. In addition, childcare workers reported that the guide contained information about unfavourable feeding practices that they were not aware of and that, having engaged with the guide, their strategies for feeding children in their care will change.

For dietitians working with families with a fussy eater, The Child Feeding Guide is a useful, freely-available and evidence-based resource which can help parents and caregivers to effectively manage their child’s difficult eating and hopefully support them in developing healthy eating habits that will last a lifetime.

For more information, visit our Child Feeding Guide website (www.childfeedingguide. co.uk) or download our free mobile app from the Google Play and Apple app stores. Follow us on Twitter @FeedingKidsUK or Facebook www. facebook.com/FeedingKidsUK

References 1 Reau NR, Senturia YD, Lebailly SA and Christoffel KK (1996). Infant and toddler feeding patterns and problems: normative data and a new direction. Pediatric Research Group. Journal of Developmental and Behavioural Pediatrics, 17, 149-153 2 Carruth BR, Ziegler PJ, Gordon A and Barr SI (2004). Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food. Journal of the American Dietetic Association, 104, 57-64 3 Farrow C and Blissett J (2012). Stability and continuity of parentally reported child eating behaviours and feeding practices from 2 to 5 years of age. Appetite, 58(1), 151-156 4 Nicklas TA and Hayes D (2008). Position of the American Dietetic Association: Nutrition guidance for healthy children ages 2 to 11 years. Journal of the American Dietetic Association, 108(6), 1038-1044 5 Schwartz C, Scholtens PAMJ, Lalanne A, Weenen H and Nicklaus S (2011). Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite, 57, 796-807 6 Mitchell G, Farrow C, Haycraft E and Meyer C (2013). Parental influences on children’s eating behaviour and characteristics of successful parent-focused interventions. Appetite, 60, 85-94 7 Birch LL and Fisher JO (1998). Development of eating behaviours among children and adolescents. Pediatrics, 101, 539-549 8 Wardle J, Carnell S and Cooke L (2005). Parental control over feeding and children’s fruit and vegetable intake: How are they related? Journal of the American Dietetic Association, 105, 227-232 9 Wardle J, Cooke LJ, Gibson EL, Sapochnik M, Sheiham A and Lawson M (2003). Increasing children’s acceptance of vegetables: a randomised trial of parent-led exposure. Appetite, 40, 155-162 10 Aldridge VK, Dovey TM and Halford JCG (2009). The role of familiarity in dietary development. Developmental Review, 29(1), 32-44 11 Carruth BR and Skinner JD (2000). Revisiting the picky eater phenomenon: Neophobic behaviours of young children. Journal of the American College of Nutrition, 19(6), 771-780.

12 Galloway AT, Fiorito LM, Francis LA and Birch LL (2006). ‘Finish your soup’. Counterproductive effects of pressuring children to eat on intake and affect.

Appetite, 46, 318-323 13 Carper JL, Fisher JO and Birch LL (2000). Young girls’ emerging dietary restraint and disinhibition are related to parental control in child feeding. Appetite, 35(2), 121-129 14 Puhl RM, Schwartz MB (2003). If you are good you can have a cookie: How memories of childhood food rules link to adult eating behaviours. Eating Behaviours, 4(3), 283-93 15 Holley CE, Haycraft E and Farrow C (in press, 2015). ‘Why don’t you try it again?’ A comparison of parent-led home based interventions aimed at increasing children’s consumption of a disliked vegetable. Appetite. http://dx.doi.org/doi: 10.1016/j.appet.2014.12.216 16 Health and Social Care Information Centre (2014). Statistics on Obesity, Physical Activity and Diet: England 2014. www.hscic.gov.uk/catalogue/PUB13648/ Obes-phys-acti-diet-eng-2014-rep.pdf

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Here’s to compliance 30% more people are likely to finish NEW thinner Fortisip Compact1*

to the very last...

Nutricia are delighted to announce the launch of NEW Fortisip Compact now with lower viscosity.2 In a blind comparative test of 100 participants a significantly greater number of people preferred NEW Fortisip Compact compared with Ensure® Compact (p = 0.024).1*

Speak to your local Nutricia Representative to arrange a taste test or to request a sample. *Strawberry flavour. New Fortisip Compact vs Ensure® Compact.

References 1. Data on file, November 2014. Leatherhead Food Research Compact Evaluation Report. A blind comparative test of compact ONS (New Fortisip Compact, Old Fortisip Compact and Ensure® Compact) in 3 flavours (vanilla, strawberry and banana).

2. Data on File, 2014 (excluding chocolate flavour).

Date of preparation: 02/15

Still #1 when it comes to choice and flavour range

NHDmag.com . . .

Your essential resource

Discover new features and resources with an easy-to-navigate layout

Vitamin supplementation

Supplementary questions The use of dietary supplements in the US has increased strongly over the past two decades. The latest industry data (5) states that 68 percent of all US adults reported taking dietary supplements. Figures show, as they have done consistently in the past that usage rates are slightly higher in women, in older adults, in the better off and the better qualified.

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.

Nearly twice as many supplement takers trust doctors (56 percent) rather than nutritionists as a reliable source of information, and supplement takers all score higher for other healthy habits (better diets/less smoking/ more exercise). One very interesting observation is that supplement taking is especially high amongst health professionals. So it seems that most American doctors and nurses are not confident that they either 1) have wellbalanced healthy diets and/or 2) that such diets contain adequate amounts of particular nutrients. In any case, the data on the use of micronutrient supplements demonstrates that most American health professionals view their use as an essential tool to support their own good health (whatever they tell their patients).

Analysis by Hyun Ja Kim and colleagues (3), from the prolific gift-thatkeeps-on-giving, the long-term prospective Harvard cohort studies of Health Professionals, documents the use of dietary supplements over the 20 year period 1986 to 2006. The headline statement is that more than 88 percent of the women and 80 percent of the men reported some use of dietary supplements. But, within the massive swell of increased usage, there are some astonishing sub-plots. A specific contrast figure for the prevalence of use of at least one supplement in the general US population (National Health Interview Survey 2000 and NHANES 2003-2006), is 50 to 65 percent.

The average age of the subjects in the 75,000 strong female-only Nurses’ Health Study was 53 years; for the 50,000 strong male-only Health Professionals Follow-Up Study, it was slightly higher, at 55 years. In the 20-year period from 1986, the use of micronutrient supplements, i.e. excluding herbs or botanicals, blossomed by 17 percent in women and by an even greater amount of 25 percent in men. The hardy minority of health experts not taking any supplements crashed by more than 40 percent to the year 2006, to only 20 percent of the health professionals and 12 percent of the nurses.

When comparing the trend data, there are clear winners and losers.

Out-of-favour in 2006 is the antioxidant triad of beta-carotene, vitamins C and E and also down are vitamin A and iron. Considerable disappointment in some of the intervention trials looking at the use of antioxidant nutrients to reduce the risk of heart disease and some cancers is a clear explanation for these shifts. It is probable that health professionals would be the first to know of trial outcomes, and would be more sensitive to the fine-tuning of information of the effects of individual micronutrients compared to the general population.

In contrast, there are strong gains in the use of other vitamins. Folic acid supplement use is up more than 13fold in women and more than 12-fold in men. Darling of the moment, vitamin D, is up more than14-fold in womNHDmag.com March 2015 - Issue 102

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Vitamin supplementation

en and six-fold in men. Fish oil supplements are up 11-fold in women and nearly seven-fold in men. Figures for general all-in-one multivitamins show less spectacular growth, but the high base rates in 1986 of about 43 percent usage, makes current figures of about 72 percent astonishing.

Further general observations by Kim and colleagues were that supplement taking was higher in non-smokers (compared to smokers) and increased with age. Secular trend analysis showed that the increased use of many of the supplements was a result of real changes in practice and could not be explained by the ageing of the cohort population.

Several previous studies have reported on the intakes of micronutrient supplements in health professionals, although the data all relates to the US (1). Published data on use by dietitians is rarefied. A survey of 900 dietitians carried out in 1981 reports that 37 percent claimed to use supplements regularly. A later survey in 2001 amongst 676 student dietitians reports that 43 percent took supplements frequently/daily; of the 68 supervisory dietitians questioned, the figure was higher, at 53 percent. A survey of 300 dietitians published in 2012 (2), reports that 74 percent were regular users of dietary supplements.

There is not much information of the use of vitamin supplements by UK health professionals, but there are endless facts and figures on UK consumer practices (which of course, includes health professionals within this data).

The most recent four-year NDNS survey issued in May 2014 reported that 17 percent of 22

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adult men and 27 percent of women had taken a nutrient supplement in the four-day survey period. These figures were significantly higher in those over the age of 65 years (35 percent/47 percent). The trade association Propriety Association of Great Britain (PAGB) reports stagnant retail sales in the year to December 2013, with an annual value of over £350 million (so annual per person spend of about £6). But strong growth areas in vitamin supplements are for products distributed via internet orders, where data is less available.

Industry experts planning UK supplement distribution will all have purchased the latest 130-page review of the sector by the market intelligence company Mintel (4). Published in September 2014, it is available for £1,750 + tax! The vitamin supplements report describes trends and predicts future developments: essential information to have before the investment of £££s in the production and marketing of these products. What does Mintel predict for the vitamin supplements market in the UK? There are three strong themes that are likely to steer activity. Consumers want more personalisation of supplements, with the change in focus of communications. Instead of, for example, messages that vitamin x is good for tall red-haired women, the messages will target tall red-haired women with information on requirements for vitamin x. Market opportunities are particularly identified in the youngest and the oldest consumers. Secondly, in relation to the robust published opinions on health claims from the European Food Safety Authority (EFSA), there will be more muscular clamp-down on

Vitamin supplementation incorrect or misleading labelling claims by the Advertising Standards Association. For example another negative verdict from ASA on a vitamin supplement product marketed at women planning pregnancy (Viabiotics product Pregnacare - conception), was issued in February 2015. This will put a tighter leash on some of the more excitable marketing promotions that can be made to develop the sales of supplements.

Thirdly, motivations to take supplements seem to have developed particularly in relation to appearance benefits, in women and in the young adults. It is a disappointment that being healthy is less the issue for this supplement-taking group, however having smooth skin, strong nails and glossy hair is vital. Other general themes identified as focus areas by the Mintel report are for women = weight gain/fatigue and healthy bones, and for men = healthy heart. The young (under 30s?) are in desperate want of ‘energy’, although the meaning of this is the consumer interpretation of vibrancy and vigour and not the dietitian’s meaning of calories from foods. The two meanings for the same word are an endless joy for marketers, especially those promoting particular drinks.

The use of dietary supplements can have very potent effects on nutrient intakes, and their use is so widespread and common that they must increasingly be the default assumption in assessments and discussions about nutrient intakes in populations. Clearly, dietitians are the experts in nutrition knowledge, but supplements sometimes seem to be part of the section: ‘non-diet, other’ in health assessments and many alternative health nutrition therapists claim this territory as their own. If patients need advice on supplements, then dietitians should be their first go-to, (and perhaps ask, “Which ones do you take?”).

Information sources 1 Arens U (2001) News and Views: Expert practice. British Nutrition Foundation Nutrition Bulletin 26, 311-312 2 Dickinson A, Bonci L, Boyon N, Franco JC (2012). Dietitians use and recommend dietary supplements: report of a survey. Nutrition Journal 14, 11, 11-14 3 Kim HJ, Giovannucci E, Rosner B, Willett WC, Cho E (2014). Longitudinal and Secular Trends in Dietary Supplement Use: Nurses’ Health Study and Health Professionals Follow-Up Study, 1986-2006. Journal of the Academy of Nutrition and Dietetics, 114, 3, 436-443 4 Mintel (www.mintel.com) Vitamins and supplements UK report. September 2014 5 CRN consumer survey 2014 at www.crnusa.org

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Only 0.5g of carbohydrate per sachet (suitable for the Ketogenic diet) For further product information or samples, please contact either your local Vitaflo representative, or call the Nutritional Services Helpline on: +44 (0) 151 702 4937 or e-mail vitaflo@vitaflo.co.uk

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REFERENCE: 1 Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. HMSO, London.

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new nHD App AL IT IG D O LY N E SU IS

NHDmag.com

Issue 102 March 2015

DIET AND KIDNEY TRANSPLANTATION Liz Rai p25

ISSN 1756-9567 (Print)

INTENSIVE CARE NUTRITION . . . p8

Emma Copeland Senior Dietitian

EARLY YEARS NUTRITION VITAMIN SUPPLEMENTATION IMD WATCH IRRITABLE BOWEL SYNDROME

DIETETIC*/"3 s WEB WATCH s NEW RESEARCH

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cover story

Diet and Kidney Transplantation: Dietetic input pre- and post-kidney transplant A kidney transplant is considered the renal replacement method of choice for patients with end stage renal disease (ESRD) (1). This article explores the dietetic challenges presented both pre- and post-transplant.

Liz Rai, Renal Dietitian, Newcastle upon Tyne Hospitals NHS Foundation Trust

Liz has worked as a Renal Dietitian at the Freeman Hospital since 2001. She works with patients with CKD and those receiving dialysis and also supports patients following a kidney transplant.

PRE-KIDNEY TRANSPLANT

The patient awaiting a kidney transplant is usually receiving renal replacement therapy in the form of haemodialysis or peritoneal dialysis. A small number of patients may receive a pre-emptive renal transplant prior to requiring dialysis. The challenges in all groups are the same.

Obesity Current guidelines state that patients with a BMI>30kg/m2 are at higher risk of perioperative complications and this risk increases in patients with a BMI >40kg/m2 (1). For this reason, a weight reducing diet may be required to enable a patient to lose the necessary weight to be listed for transplant. Dietetic advice can be similar to that given to a non-renal patient but within the context of a renal diet.

There is some evidence to suggest that bariatric surgery may be beneficial in reducing body weight prior to transplantation (2). There is also work that suggests the risks of performing bariatric surgery in patients with CKD outweighs the benefits and that this area requires further research (3).

Orlistat may also have a role to play when combined with a low fat, low energy diet and exercise (4, 5).

Various studies have assessed the outcome of transplanting obese patients compared with non-obese. Outcomes considered included delayed graft function, acute rejection and graft and patient survival. A recent systematic review of 21 such studies published from 1990-2013 suggests that although delayed graft function may be more likely to occur in obese patients, there was no evidence of an association with long-

term graft and patient survival (6). This suggests that a high BMI alone may not be an accurate indicator of a successful outcome post kidney transplant and patients should be assessed in the context of other comorbidities.

Malnutrition Poor nutritional status may prevent a renal transplant taking place. In addition to delayed wound healing and increased risk of infection, there is evidence to suggest that very low BMI is associated with significantly worse graft and patient survival (17).

Promotion of adequate nutrition to sustain a healthy BMI is, therefore, appropriate pre transplant and the use of oral nutritional supplements may be appropriate.

Cardiovascular and bone health Effective control of serum phosphate, calcium and parathyroid hormone (PTH) levels in patients with ESRD is well documented in reducing the risk of long-term health problems, including cardiovascular disease (8) and vascular calcification (9). Although a successful kidney transplant normalises serum phosphate, effects of previous damage remain. Poor phosphate control prior to a kidney transplant has been shown to delay graft function and increase risk of graft failure (10). Pre transplant dietary support should therefore put high priority on promoting a low phosphate diet and adherence with phosphate binders.

POST KIDNEY TRANSPLANT

Adequate nutritional intake is essential for wound healing and recovery posttransplant. If necessary, nutritional suppleNHDmag.com March 2015 - Issue 102

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renal disease ments and NG feeding should be initiated but in most cases these are not required.

Promotion of a healthy lifestyle is recommended for long-term good health and graft survival (11).

Promoting maintenance of a healthy weight, avoiding hyperlipidaemia and advising on a healthy diet is part of this. Prior to their transplant, most patients have had their dietary choices limited by a low potassium, low phosphate, reduced salt and fluid restricted diet. On receiving a successful transplant, these restrictions are relaxed. Combined with improved appetite and steroids taken for immunosuppression, weight gain is likely. This increases the risk of cardiovascular complications. Dietetic advice should focus on promoting a balanced diet low in saturated fat and rich in fruit and vegetables centred on the Eat Well plate (12). A reduced salt diet is still applicable to aid blood pressure control (13), essential for prolonging transplant function (14) and reducing the risk of cardiovascular complications.

Additional dietetic challenges may also present post-transplant and these will now be discussed in more detail.

Diabetes Diabetes or impaired glucose tolerance post-transplant is common and has been reported to affect 15 to 30 percent of patients in the first year (15). It is widely documented that steroids and the immunosuppressive agent Tacrolimus have a significant role to play in this (16). Relaxed dietary restrictions and weight gain may also play a part, as well as age and genetic background. Advice should be given to limit sugar and sugary foods, encourage regular meals containing carbohydrate and to follow a healthy diet as discussed above. For patients on steroids, blood sugar levels may return to normal as steroid dose is reduced.

Hypophosphataemia The effect of a new kidney is to increase urinary excretion of phosphate. Hypophosphataemia is, therefore, common in the early postoperative period. A high dietary phosphate intake should be encouraged until levels improve to normal. Phosphate supplements may also be required. Care should be taken to inform patients that this a shortterm dietary intervention and that eating large quantities of high phosphate foods, such as cheese and milk, will also lead to a high fat intake.

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Hyperkalaemia Despite a well-functioning kidney transplant, hyperkalaemia may still occur. This is usually caused by the immunosuppressive agents Tacrolimus and Cyclosporin. A low potassium diet is, therefore, necessary to keep levels within normal range and prevent hyperkalaemia. In some patients, this can be relaxed as immunosuppression is adjusted, but others may require a restriction long term.

Other considerations Grapefruit and grapefruit juice affect the absorption of the immunosuppressive drugs Cyclosporin, Tacrolimus and Sirolimus. Patients should, therefore, be advised to avoid these. Adequate calcium intake should be encouraged for patients on longterm steroids to reduce the risk of steroid induced osteoporosis.

Food hygiene advice The use of immunosuppressive drugs may increase the risk of food born infections, although there is limited evidence to support this in renal transplant patients. One case-control study (17) found an incidence of listeria in only 0.12% of solid organ transplant recipients (of theses 26 percent were kidney transplant patients). However, of those who did contract the infection, a 30-day mortality rate of 26.7% was reported. In many units food hygiene advice is given which includes the avoidance of undercooked eggs and meat and avoidance of unpasteurized cheeses. Good hygiene practises in food preparation and storage are also essential.

CONCLUSION

Good nutrition has an important role to play in the health of renal patients’ pre- and post-renal transplant. There is good evidence to suggest that outcome can be affected if this is not achieved. Dietitians are best placed to provide nutritional advice and support to these groups of patients.

CASE STUDY Mr F, aged 57, was first seen by the dietitian in predialysis clinic in October 2010. He weighed 138kg, BMI=49kg/m2, but did not have diabetes or evidence of cardiovascular disease. Advice on a low potassium, low phosphate and weight-reducing diet was provided.

renal disease Table 1. Nutritional Challenges of Kidney Transplant Patients Pre-transplant

Post-transplant Short term

Long term

Achieve and maintain a healthy BMI

Promote adequate nutrition for wound healing

Maintain a healthy BMI

Maintain phosphate, calcium and parathyroid hormone levels within target (18)

Promote a high dietary phosphate intake

Encourage an adequate phosphate and calcium intake for healthy bones

Advise on a low potassium diet if potassium levels >5.5mmol/L

Continue a low potassium diet if levels remain raised

Advise on a low sugar diabetic diet if raised blood sugars

Maintain a diabetic diet if ongoing impaired glucose tolerance or diabetes Encourage a healthy, no added salt diet for long-term cardiovascular health

On starting dialysis in September 2011, his dry weight had reduced to 118kg (BMI=42kg/m2), phosphate control ranged from 1.9-2.3mmmol/L. He was assessed for a live donor kidney transplant in 2013 and a target weight of 98kg (BMI=35kg/m2) was stipulated prior to transplantation. Further dietetic input was provided to help with this.

Mr F completed a four-day diet diary, which revealed a high fat, high sugar diet. Advice on reducing his intake of these was given, along with reducing overall calorie intake. Mr F was keen to lose weight and also started swimming three times a week. By August 2014 his dry weight had reduced further to 108.5kg (BMI=39kg/m2). As a result of

the changes to his diet, phosphate control had also improved to 0.93-1.53mmol/L (within target (18)).

The transplant team were happy to proceed with the transplant, which was successfully performed in November 2014.

Following renal transplant, Mr F recovered quickly and had immediate graft function. Phosphate levels dropped to 0.46mmol/L, but returned to normal within four days. Potassium levels were within normal range. Healthy eating advice was provided on discharge. Two months post-transplant his weight had risen to 117kg (BMI 42). He, therefore, requires ongoing dietetic support to encourage weight loss and prevent cardiovascular complications.

References 1 Dudley C, Harden P (2011). Assessment of the potential kidney transplant recipient. Clinical practice guideline. The Renal Association 2 Modanlou KA, Muthylal U et al (2009). Bariatric surgery among kidney transplant recipients: Analysis of the United States Renal Data System and literature review.

Transplantation 87 (8) 1167-1173 3 MacLaughlin H, Macdougall IC et al (2013). Safety and efficacy of bariatric surgery in obese patients with CKD: the London Renal Obesity Network (LonRON) experience. Abstract: meeting of Journal of American Society of Nephrology TH-OR111 4 Cook SA, MacLaughlin H, Macdougall IC (2007). A structured weight management programme can achieve improved functional ability and significant weight loss in obese patients with chronic kidney disease. Nephrology Dialysis Transplantation 23: 293-268 5 MacLaughlin HL, Cook SA et al (2010). Non randomised trial of weight loss with Orlistat, nutrition education, diet and exercise in obese patients with CKD: two-year follow-up. American Journal of Kidney Diseases, 55/1(69-76) 6 Nicoletto BB, Fonseca NK et al (2014). Effects of obesity on kidney transplantation outcomes: A systematic review and meta-analysis. Transplantation 98 (2) 167-175 7 Meier-Kriesche HU, Andorfer JA, Kaplan B (2002). The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 73 (1) 70-74 8 Covic A, Kothawala P et al (2008). Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of all-cause mortality, cardiovascular mortality and cardiovascular events in chronic kidney disease. 24:1506-1523 9 London GM, Guerin AP et al (2003). Arterial media calcification in end-stage renal disease: impact on all cause and cardiovascular mortality. Nephrology Dialysis Transplantation 18 (9) 11737-1740 10 Sapir-Pichhadze R, Parmar K, Kim SJ (2012). Pre transplant serum phosphate levels and outcomes after kidney transplantation. Journal of Nephrology 25 (06) 1091-1097 11 Baker R, Jardine A, Andrew P (2011). Post-operative care of the renal transplant patient. Clinical practice guideline. The Renal Association 12 The Eat Well Plate. Crown copyright (2011). Department of Health in association with the Welsh Assembly Government, the Scottish Government and the Food Standards Agency in Northern Ireland 13 Sacks FM, Svetkey LP et al (2001). Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. New England Journal of Medicine 344 (1) 3-10 14 Opelz G, Dohler B (2005). Improved long-term outcomes after renal transplantation associated with blood pressure control. American Journal of Transplantation 5:2725-31 15 Chakkera HA, Weil EJ et al (2013). Can new-onset diabetes after kidney transplant be prevented? Diabetes Care 36:1406-1412 16 Rodrigo E, Fernandez-Fresnedo G et al (2006). New onset diabetes after kidney transplantation: risk factors. Journal of American Society of Nephrology 17:S291-295 17 Fernandez-Sabe N, Cervara C et al (2009). Risk factors, clinical features, and outcomes of listeriosis in solid-organ transplant recipients: a matched case control study.

Clinical Infectious Diseases 49:1153-1159 18 Steddon S, Sharples E (2010). CKD Mineral and bone disease. Clinical practice guideline. the renal association

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Taste preferences of young children with phenylketonuria (PKU) Evans S, Daly A, Chahal S, MacDonald J, MacDonald A Dietetic Department Birmingham Children’s Hospital, Steelhouse Lane, Birmingham

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The primary treatment of phenylketonuria (PKU) is a restrictive lowphenylalanine diet with a limited range of natural foods allowed. Within the confines of the dietary restriction, it is important to encourage a wide range of flavour preferences to maximize food choice. Basic taste perceptions of bitterness and sweetness are largely innate and evident at birth (1).

The early introduction of bitter-tast- the confines of their dietary restricing phenylalanine (phe)-free L-amino tion (7). However, it is unknown if acid supplements from diagnosis (<14 ‘flavour imprinting’ occurs due to the days of age), may be an important in- early introduction of L-amino acids fluence on food preferences in PKU. and, if so, how long this effect may There is a sensitive learning pe- last. The aim of this controlled proriod in the first few months of life, spective study was to determine the during which unpalatable flavours flavour preferences of children with can be rendered palatable (2). Hydro- PKU and to compare these with a lysed formulas designed for cows’ group of healthy age matched control milk protein intolchildren. erance contain free There is a sensitive learning METHODS amino acids, diperiod in the first few Thirty-five children and tripeptides and with PKU aged have similar bitter flavour notes (e.g. months of life, during which four to 13 years of age following a low sulphur volatiles) to vegetables like unpalatable flavours can be phenylalanine diet providing ≤10g/ broccoli (3). There rendered palatable. day of natural prois considerable evitein, were comdence to demonpared with 35 age/ strate that children gender-matched given these formulas during infancy are more likely to controls on a normal diet. Children prefer broccoli and other bitter and tasted 10 blinded puree foods (apsour-tasting foods than children who ple, banana, strawberry, low protein received sweeter milk-based formula custard, broccoli, cauliflower, carand the effects of this on flavour pref- rot, sweet potato, lemon, coffee) in erences can continue for several years random order and rated them using after the initial exposure (4-6). So it a seven-point pictorial hedonic scale might be expected that introduction (8) (super yummy to super yucky) of L-amino acid supplements in PKU and then ranked them in preferential order. Caregivers completed a neomay have a similar impact.

Parental likes and dislikes and phobia questionnaire to measure their food neophobia may also affect chil- child’s variety-seeking tendency with dren’s food choices. There is evidence respect to food (9). Caregivers also that young children with PKU eat a completed a food frequency questionlimited range of foods even within naire indicating the number of times/

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Children with PKU were consistently reported by caregivers to be more food neophobic than control children, being more particular about what foods they eat . . .

week children consumed each of 60 commonly eaten food items and how often children consumed each of the 10 test foods.

RESULTS

Rating of Foods (1 = super yucky and 7 = super yummy) Both groups of children preferred sweet foods to savoury, sour and bitter. The three most liked foods by PKU children, irrespective of age, were custard, banana and apple, and for control children the same, but in reverse order. On average, PKU children rated most foods higher than controls, particularly custard (5.8 vs 4.8; p=0.001), sweet potato (4.6 vs 3.4; p=0.009) and carrot (4.6 vs 3.5; p=0.009).

Food Ranking (1 = most liked, 10 = least liked) The three most highly ranked foods by PKU children were custard, banana and strawberry and for controls, banana, apple and custard.

PKU children liked sweet potato significantly more than control children (PKU 5.3 vs 6.5; p=0.03), whilst control children preferred apple (PKU 5.0 vs 3.5; p=0.02). When considered in food groups, control children ranked fruits higher than PKU children (PKU 4.6 vs 3.7; p=0.03) whilst PKU children ranked vegetables higher than controls (PKU 5.6 vs 6.3; p=0.05).

In the PKU group caregivers significantly underestimated their children’s liking for custard (child 3.4 vs parent 6.0; p<0.0001) and coffee (7.6 vs 8.2; p=0.02) and overestimated their liking for strawberry (4.8 vs 2.6; p=0.0005).

Control group caregivers also overestimated liking for strawberry (4.4 vs 2.1; p<0.0001) and carrot (6.3 vs 5.2; p=0.03), but underestimated

liking for cauliflower (6.5 vs 7.5; p=0.05) and coffee (7.7 vs 9.4; p=0.0002).

Food Frequency Questionnaire Per week, children with PKU consumed 50 to 100 percent more than control children of high energy, sugar containing drinks (9.4/week vs 2.9/week; p<0.0001), sweets (6.3 vs 2.8; p=0.001), chips/fries (3.2 vs 1.5; p=0.002), sweet biscuits (6.0 vs 3.4; p=0.01), crisps (4.1 vs 2.6; p=0.01) and pasta/low protein pasta (5.2 vs 2.5; p=0.006).

Intake of fruit and vegetables and most other foods was similar across PKU and control groups, with daily servings of about three fruit, three vegetables, one to two milk/milk replacements, two bread/low protein bread and two to three water; and weekly servings of three to four sugar-free drinks and five to six natural fruit juices.

The four most frequently eaten study foods per week for both groups were: strawberry (PKU 4.2 vs 2.8; p=0.01), banana (PKU 3.6 vs 3.4), apple (PKU 3.4 vs 3.5) and carrot (PKU 3.3 vs 3.3). Sweet potato was eaten more frequently by children with PKU (1.5 vs 0.5; p=0.004).

Neophobia Scale (1 = always, 7 = never) Children with PKU were consistently reported by caregivers to be more food neophobic than control children, being more particular about what foods they eat (mean: PKU 2.7 vs 4.2; p=0.001), less trusting (mean: PKU 3.4 vs 4.5; p=0.002) and more fearful of new foods (mean: PKU 3.4 vs 4.6; p=0.003). However, whilst children with PKU were more uncomfortable in new and different situations, their NHDmag.com March 2015 - Issue 102

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neophobia did not make them less social, as both groups were equally comfortable talking with, or sitting next to a stranger.

DISCUSSION Despite anecdotal evidence and studies in children taking protein hydrolysate formula, children with PKU aged ≥ four years did not prefer bittertasting foods associated with the taste of L-amino acids, nor did they prefer savoury foods in preference to sweet foods. In fact, children with PKU demonstrated a significant preference for sweet foods. This suggests that the taste imprinting seen in previous studies (4, 10, 11) may be limited to infancy and pre-school age, decreasing with continuing exposure to a wider range of foods.

Food neophobia is a protective trait designed to prevent humans from ingesting potentially harmful foods (12), so it is not surprising that children with PKU are particularly food neophobic as they are educated from an early age that high

protein foods are potentially harmful. Whilst children with PKU may generally be more reluctant to try new foods, in this study they appeared to be less fussy, consistently rating most foods higher than control children. Therefore, whilst neophobia may inhibit children with PKU from trying a wider variety of foods, it is not necessarily because they are averse to the flavour.

This study suggests that any taste imprinting that may exist in PKU does not extend beyond the pre-school years. Consistent and frequent intake of sweetened phe-free L-amino acid supplements from the age of three years may well mask the bitter flavours of some L-amino acids. The increase in the proportion of energy from food and the reduction in energy from L-amino acid supplements with increasing age may also act to normalise taste preferences. However, children with PKU are significantly more fearful of new and unfamiliar foods and attention to caregiver influences and food neophobia requires further study.

References 1 Anliker JA, Bartoshuk L, Ferris AM et al. Children’s food preferences and genetic sensitivity to the bitter taste of 6-n-propylthioruracil (PROP). Am J Clin Nutr 1991; 54: 316-320 2 Beauchamp GK, Mennella JA. Flavour perception in human infants: development and functional significance. Digestion 2011; 83 (suppl 1): 1-6 3 Menella JA, Kennedy JM, Beauchamp GK. Vegetable acceptance by infants: effects of formula flavours. Early Hum Dev 2006; 82(7): 463-68 4 Mennella JA, Beauchamp GK. Flavour experiences during formula feeding are related to preferences during childhood. Early Hum Dev 2002; 68(2): 71-82 5 Beauchamp GK, Mennella JA. Early flavour learning and its impact on later feeding behaviour. J Pediatr Gastroenterol Nutr 2009; 48 (Suppl 1): S25-30 6 Beauchamp GK, Mennella JA. Flavour perception in human infants: development and functional significance. Digestion 2011; 83 (Suppl 1): 1-6 7 MacDonald A, Rylance G, Asplin D et al. Abnormal feeding behaviours in phenylketonuria. J Hum Nut Diet 1997; 10: 163-70 8 Chen AW, Resurreccion AVA, Paguio LP. Age appropriate hedonic scales to measure food preferences of young children. J Sensory Stud 1996; 11: 141-63 9 Pliner P, Hobden K. Development of a scale to measure the trait of food neophobia in humans. Appetite 1992: 19: 105-20 10 Owada M, Aoki K, Kitagawa T. Taste preferences and feeding behaviour in children with phenylketonuria on a semisynthetic diet. Eur J Pediatr 2000; 159(11): 846-50 11 Sullivan SA, Birch LL. Pass the sugar, pass the salt: experience dictates preference. Developmental Psychology 1990; 26: 546-51 12 Knaapila A, Tuorila H, Silventoinen K et al. Food neophobia shows heritable variation in humans. Physiol Behav 2007; 91: 573-78

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infant weaning

Oesophageal atresia and weaning Oesophageal atresia (OA) occurs in one in 2,500 to 4,500 births. It is a congenital abnormality whereby the oesophagus ends blindly in a pouch, resulting in a non-continuous route from the mouth to the stomach. It occurs in isolation in only seven percent of infants; however, in 86 percent of cases it is diagnosed with a distal trachea-oesophageal fistula (TOF) also present (1).

Kathryn Lowes Paediatric Dietitian Great Ormond Street Hospital for Children

In 50 percent of cases, OA +/- TOF will present with anomalies such as VACTERL association (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies and limb abnormalities), CHARGE syndrome (Coloboma of the eye, heart defects, atresia of the choanae, retardation of growth and/or development, genital and/or urinary abnormalities and ear abnormalities and deafness), Trisomy 13, DiGeorge syndrome, along with others.

Presentation and diagnosis

OA can be suspected on an antenatal scan, but a confirmed diagnosis will be made after birth. An infant with OA +/- TOF will classically present with respiratory distress, choking, feeding difficulties and frothing at the mouth in the first few hours after birth.

Pre-surgery management and surgery

Kathy has been working at Great Ormond Street for the last three years. She has spent the last 18 months working in general surgery and intestinal failure, which has involved working with children with complex feeding difficulties.

Essentially the management of an OA/TOF involves surgical correction of the anomaly. Until surgery, management is to provide nutritional support and hydration and to prevent aspiration. A multidisciplinary team approach is required throughout the infant’s journey; from pre-repair to the teenage years, as many children will go on to have further complications and interventions. This should involve, surgeons, nursing staff, physiotherapists, dietitians and speech therapists (2, 3).

Surgery to repair the anomaly will take place as soon as possible, but the distance between the proximal and distal ends of oesophagus needs to be short enough to form a primary anastomosis.

The surgeons will often pass a transanastomotic tube (TAT), allowing a continuous route for milk through to the stomach and for gastric decompression.

In some infants, the distance between the two ends is too great; this is called ‘long gap oesophageal atresia’. The way this is managed differs between hospitals; in some cases a temporary cervical oesophagostomy is formed to allow the infant to swallow saliva and a gastrostomy is placed for feeding. Children can wait up to six months for a repair. Often ‘sham feeding’ is recommended to prevent oral aversion while the infant waits for the surgical repair. Sham feeding involves a ‘Replogle Tube’ connected to suction to drain the milk from the upper oesophageal pouch, thus preventing aspiration. Sham feeding is used to promote the establishment of oral feeding either by breast or bottle, prior to repair of the OA (1).

If oral feeding is delayed for more than even just a few weeks, oral sensitivity and vomiting can become a problem and this can take a long time to resolve.

So where there is a delay in repairing the OA and if an oesophagostomy has been placed, it is good practice to start sham feeding to prevent oral aversion.

Infants usually grow well on breast milk or standard infant formula if they are able to receive sufficient volumes.

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infant weaning

Infants and toddlers will not chew their food to begin with, so it is best to avoid foods that could get stuck until chewing and oral development have improved.

Post-surgery and weaning onto foods

Once the oesophagus has been repaired, there are ongoing problems that will occur in most children, though some children will not have any problems. Below are some of the complications that can occur post-surgery.

• Stricturing - narrowing at the anastomosis, often requiring a dilatation procedure.

• Oesophageal dysmotility - can continue into adult life.

• Oesophageal obstruction - food is not propelled down to the stomach, due to an incoordination of the oesophageal muscle or due to a stricture and a mechanical obstruction.

If the blockage does not clear with sips of water, this will require admission to the local hospital to have the piece of food removed.

This is likely to become less common as the child gets older.

• Gastro-oesophageal reflux (GOR) - if a child is refusing food regularly, further investigations into this will be necessary, even if they are not vomiting (2, 4).

Evidence suggests that oesophageal foreign body obstruction does occur in a number of patients who have had OA/TOF and parents should be cautious of lumpy, sticky foods up until five years of age and especially when different food textures are being introduced (this will depend on the individual as some patients may be on a puree/soft diet and/or even an enteral feed for longer) (5).

Weaning is an essential milestone in any child’s life and, where possible, this should not be delayed. It is important for dietitians and often speech therapists to work closely with the child and to liaise with the surgical team about what foods the child can have safely. The introduction of solid foods may be particularly useful if the child has GOR, as food is heavier/denser 32

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than liquid and less likely to cause reflux.

Advice for children post-OA/TOF repair will depend very much on the individual. Where possible, the infant should start weaning at the usual age of around six months on stage 1 foods. Emphasis should be put on taking it slowly and going at the baby’s pace, as moving on to a greater variety of textures will be a longer, slower, process in children who have had OA +/-TOF (2).

The role of the dietitian is to ensure that the diet is nutritionally complete and the child is growing on the limited textures that he/she is managing. Advice about what textures are allowed and not allowed should be given. It is important to remember every child is different and some may progress faster than others.

Infants and toddlers will not chew their food to begin with, so it is best to avoid foods that could get stuck until chewing and oral development have improved. Difficult to chew lumps, such as meats or raw vegetables and sticky/doughy foods should be avoided until three to five years of life - this will depend on the surgical team’s advice and the child’s progression post-surgery.

Foods to avoid and feeding advice

There is limited research on weaning these children and so advice is largely based on the experience of parents and healthcare professionals, who have worked closely with this patient group (2, 4).

On initial introduction, adding liquid to foods and keeping a smooth consistency is advisable (a blender may be needed and a sieve used to remove the lumps). It is best to start with a thin puree and assess how the infant manages before thickening.

A thicker consistency should be gradually given, offering a couple of spoonful’s at a time to assess how the child copes. The child should be in an upright position, not force fed and moving on at the child’s own pace (2, 4).

infant weaning

As children get older, support is still required and children/teenagers often benefit from eating small, more regular meals and taking their time with each meal.

When ready to try finger foods, ‘bite and dissolve’ foods are a good option for introducing the child to solid foods and help develop chewing. The speech therapist should be consulted on what they would deem appropriate. This will often involve foods such as puffy crisps, Organix crisps, Wotsits, Quavers, meringues or sponge fingers.

Problematic foods to avoid until three to five years of age

• Doughy/sticky foods - breads, doughnuts, croissants, pizza • Lumps of meat - these are fine to give if pureed (will often be needed as a source of protein) • Raw apple • Raw vegetables • Orange slices Foods to treat with caution

• Slippery foods - hard to control foods, such as peaches, banana slices, grapes • Rusks - they may soften easily in the mouth, but still contain lumps when swallowed • Fibrous foods - cooked vegetables, some whole wheat/bran cereals As the child gets older (more than > three years of age) and the introduction of more lumpy foods is appropriate, again advice would be to take it slowly. Most children will continue to do well with foods accompanied with sauces/gravies to provide more moisture to help with their swallow.

As they move on to meats, softer types such as chicken or sausage should be given rather than

beef and pork (these are more fibrous). When introducing meats, to begin with they must be minced or chopped very finely and mixed with a sauce (3).

Drinking

Some children will find it hard to co-ordinate their swallow and especially those who had long gap OA. They will not necessarily have developed a good suck reflex; they may find it easier to use a beaker or straw for fluids (3). If a child is having difficulty with drinking, he/she may need a swallow assessment from a speech and language therapist.

As children get older, support is still required and children/teenagers often benefit from eating small, more regular meals and taking their time with each meal. Growth should be carefully monitored and the diet supplemented where needed.

Summary

Every infant/child should be treated as an individual when it comes to the management of post-OA/TOF repair. A supportive multidisciplinary team is important in the management of nutrition and further oral development.

There are also charities, such as TOFs (see website below), to support these families and allow them to talk to each other. Each step should be taken slowly, with an awareness of risks and their management, while working to support the family in helping the child lead as normal a life as possible.

References 1 Shaw V 4th Edition Clinical Paediatric Dietetics (2014). Chapter 8 Surgery in the Gastrointestinal Tract, pages 143-150 2 Puntis JWL, Ritson DG, Holden CE and Buick RG. Growth and feeding problems after repair of oesophageal atresia, Archives Disease in Childhood year: 190 (65): 84-88 3 Cimador M, Carata M 3rd author et al. Primary repair in oesophageal atresia. The results of a long-term follow-up. Journal etc 4 TOFs - www.tofs.org.uk - UK registered charity to support children with TOF/OA 5 Zigman A and Yazbeck S. Esophageal foreign body obstruction after esophageal atresia repair. Journal of P

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ibs

Irritable bowel syndrome: my story ‘Kate’ is a patient suffering from IBS. Here she tells us about her symptoms and diagnosis and how, with the help of a dietitian, she has taken on the FODMAP diet.

My name is Kate, aged 52 and I am a teacher working full time at an Infant school. My husband Dave is also a teacher and our two grown up ‘children’ are now at university. I was diagnosed with irritable bowel syndrome (IBS) a couple of years ago and, at the time, tested to see if I had lactose intolerance and thankfully that was not the case.

I have only seen a dietitian on two separate occasions in my life. My first experience was just after I had completed my training. My mum, who was a nurse, suddenly died and both my dad and I found that a very difficult time. As an only child, I wanted to be with Dad but he insisted that I took my exams and ‘make Mum proud’ and qualify as a teacher. My mum had always insisted that we ate a healthy diet and she was a great follower of highfibre foods. I well remember taking natural bran once or twice a day when I was in my early teenage years! However, after mum died and, whilst revising for my exams, I drank lots of strong coffee, smoked more cigarettes and only ate one meal per day. My weight dropped off me and my shocked dad made me go to see our doctor and immediately who told me that I must go and see a dietitian. She was a ‘Miss Jean Brodie’ in a white coat and I was encouraged and supported by her to revert back to the sensible eating principles. I gained weight and felt the benefit of that.

My second experience with a dietitian occurred after I had been seen by a new doctor at the surgery. I have never been fond of going to the doctor’s and it has only been since the diagnosis of IBS and trying different approaches that I wondered if the FODMAP diet was worth trying. I considered that ‘you are what you eat’ and maybe I was not eating the right foods for me. I had read about the fermentable oligosaccharides, disaccharides, monosaccharides and polyols which make up FODMAP and I had searched the in34

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ternet, but felt that I needed some support and monitoring to actually give it a go. I am delighted that my second dietitian did not disappoint me and my first appointment was well worth the wait.

My symptoms seemed to have worsened over the years and I felt very bloated and uncomfortable on a daily basis. Sometimes I felt nauseous. My abdomen, to me, seemed to expand as the day progressed and it felt as if there was a process of fermentation going on in my gut. I was always gurgling and bubbling inside! I know it is normal for gas to be produced and we all pass flatus, but for me, it seemed to be getting more frequent, louder and smellier. It became increasingly embarrassing and a slow release was often replaced with a noisy explosion which made me cringe if it happened at school.

Some years ago after watching the film Blazing Saddles, I had excluded beans and onions from my diet as I had noticed that such foods did not suit me. When I was diagnosed with IBS, I was told to avoid eating bread and not to drink fizzy drinks even though I ate little bread and only tended to drink fizzy water. I have always been a lover of fruit, vegetables and wholegrain cereals and tended to eat three meals per day, although often with long gaps between meals. I usually drink at least two litres of fluid per day. I enjoy cooking and entertaining. My weight is steady.

My journey has now started on the FODMAP route. The dietitian increased

ibs Table 1: Examples of the foods Kate used to eat and what her new plan looks like Meal

My diet before FODMAP

My new plan

Pre breakfast

Tea – no milk no sugar

Tea – no milk no sugar

Breakfast

Watermelon and/or prunes Large bowl of mixed cereals such as Special K, Weetabix and fruit and fibre with lots of milk Banana

Cantaloupe melon Large bowl of porridge made with half milk half water Banana

Lunch

2 small slices of artisan type bread with cheese, fish or meat Tomatoes, beetroot Small packet of crisps or savoury biscuits Apple or pear and/or cake, or scone Water Coffee

Cheese, fish or roast meat with mixed salad of lettuce, cucumber, carrot, tomato, celery Rice cakes or oatcakes and spread or a jacket potato, OR Butternut soup homemade with homemade wheat-free bread Homemade wheat-free scone or orange Water Decaf coffee

Dinner

Salmon or chicken or lean meat, or homemade bolognaise/lasagne/meat pie Pasta or boiled potato Cabbage, asparagus, carrots, courgette and green beans (lots of) Fresh fruit with yoghurt or apple crumble or stewed plums and custard Grapefruit juice and fizzy water Decaf coffee Wine at weekends

Salmon or chicken or lean meat Rice or potato Smaller portion of veg such as spinach, carrots, courgette, parsnip, butternut squash ‘Allowed’ fruit with yoghurt or wheat-free pudding Grapefruit juice Water Decaf coffee

Mid morning, mid afternoon and evening

Coffee (mid-morning), tea (mid-afternoon) and decaf coffee (evening) and water at bedtime

Decaf coffee and allowed fruit (mid-morning) Tea and small homemade oat biscuit (midafternoon) and water through the evening

my confidence, as she had told me that when she had attended courses informing her of FODMAP, she had been encouraged to try that approach for several weeks. At first it all seemed overwhelming and after that ‘heart-sink’ moment, when I had the list of ‘foods to avoid’ explained and realised how many I actually ate and often ate lots of, that I knew it was not going to be easy. I felt, though, that it was important to me and I felt reasonably confident that with support I could give it a go.

It was to be an initial eight-week exclusion phase before even reintroduction of a food could be considered. I was pleased to see a ‘suitable foods’ list.

I must confess to being a cabbage lover. I have eaten two each week for years now and, of course, that was on the ‘avoid’ list, as well as asparagus, mushrooms, beetroot and mangetout, all of which I also ate very regularly. All wheat containing foods are out, but I do like oats and porridge and I often bake gluten-free items for my

friend who has coeliac disease. My favourite fruit is black cherry and there is nothing better than a very hard pear - both on the avoid list!

I left my dietetic appointment with a detailed plan which I had put together with guidance from the dietitian, along with an information booklet, a date for a follow-up appointment and an email address and phone number for me to use if I had any queries about my diet. I agreed to keep a symptom dairy. I don’t expect immediate relief, but realistically, I hope to identify culprit foods over time. I also needed time, in fact several weeks, to make sure that I had all the suitable foods at home and a batch baking session undertaken so that it reduced the likelihood that I would end up eating ‘forbidden foods’.

I promised to write this, my story, so it could be shared within the dietetic profession. It is still early days and several weeks before my followup appointment, but my fingers are crossed for a good outcome.

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book review

The Shape We’re In: how junk food and diets are shortening our lives

by Sarah Boseley Guardian Faber Publishing (26 Jun. 2014) ISBN-13: 978-1783350384 Amazon: Paperback; £10.55; Kindle £4.79 Review by 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.

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‘Being fat is your own fault. You eat too much.

You’re clogging our NHS waiting lists. You should go on a diet, get some exercise, learn self-control.’

This is the push-against position that gin women hits 38 percent (compared is the starting point for the book by to African men at 17 percent), whereas Sarah Boseley; health editor of The Chinese-origin adults only show obeGuardian newspaper. There are truths sity in seven percent. What are African to all of the above statements (if you women doing wrong? What are Chiare fat), but the author’s concerns are nese adults doing right?

There is much disthat the demonisation cussion about the posof overweight people . . . when it comes to sible particular contri(by media, and polibution of free sugars ticians [and dietitians?]) is unrelenting prevention and treatment in relation to the risk of overweight. Sugand seems to do little of obesity, there is much ary and fruity drinks to prevent or treat the are now consumed in condition. Who is to finger pointing, but no greater amounts and blame and what can with greater frequency be done (in the view fights for ‘ownership’. than previously, and of Sarah Boseley)?

There are no easy the author comments answers and Sarah that this may be one observes that when it consequence of previcomes to prevention and treatment of ous, and still current, public health adobesity, there is much finger pointing, vice to limit intakes of fats in the diet. but no fights for ‘ownership’. Increas- The multi-national soft drink manufacingly, media portraits of über-obese turers have all extended their ranges to individuals show voyeuristic non- include fruit juices and smoothies and sympathy and may in fact give com- the nearly cheapest natural sweetener fort to many of the viewing popula- now available to the food industry is tion who are themselves overweight, apple-juice concentrate produced in but not to the point of the fat-handicap bulk in China. The consumer is like a portrayed in the TV exposés. There are ping-pong ball of confusion between lots of statistics to confirm population concepts of natural versus artificial fattening, but of particular interest are and juice-good versus juice-bad. Pragthe peaks and dips of these figures: in matic dietetic advice on public health UK residents, obesity in African-ori- nutrition is needed more than ever,

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book review

Sarah Boseley has written a fact-filled but readable book about many of the food and health issues being discussed in the UK . . . despite or because-of, the explosion of nutrition information sources (my view; not stated directly by Sarah Boseley).

Obesity is increasingly a ‘radicalising’ issue and there is an urgent need to better translate the various grades of fatness and fitness into health risks and outcomes, rather than the lump-diagnosis by BMI. Research published by Professor Flegel in 2013 suggested no increased risk in mortality in the US population, in those who were overweight compared to those who were healthy-weight. Fat acceptance advocates challenge some of the traditional concepts asserted by health professionals and criticisms of media hectoring of the obese. There is also dismal cynicism of the overall ineffectiveness of dieting in longer-term time periods (see the seminal paper by Traci Mann in American Psychologist, April 2007). Ms Boseley states that fresh debates over treatments for obesity are needed. A significant step in recent discussions was the stance by the American Medical Association to define obesity as a disease (rather than just an outcome of lifestyle). A decision of great consequence for medics and dietitians, but also for lawyers, administrators and American health insurance funders.

The chapter with the title ‘Mexicoke’ is about the dramatic increase of obesity in the population of Mexico (who, at 33 percent obesity, exceed US population figures of 32 percent). And the decision in 2013 to tax all sugarsweetened drinks. Perhaps as an outcome of various trade agreements between the US and Mexico, there has been a massive increase in the consumption of sweet bottled drinks; these products are cheap and attractive status symbols for a poor population, but also solve the real problems of hydration in many rural areas where the water supply is unsafe. Sarah Bose-

ley spent some time in Mexico and gives many anecdotes of the constant messaging supporting sweet drinks; in one small market she went to, every menu board, every fridge, every chair, every waiter’s T-shirt and every chef’s apron in every single café, bore a soft drinks logo.

Additionally, soft drinks are often included for ‘free’ in the all-in price of meals. Sarah Boseley interviewed many of the medical experts and health educators who supported campaigns to reduce intakes of liquid-sugars in the Mexican population, and this chapter in particular will be of interest to dietitians looking for policy details on discussions that are also happening in the UK. In any case, the entire world will be observing the experiment-Mexico, in relation to the effectiveness of fiscal measures to reduce intakes of particular foods.

Great questions about diet and health-ofthe-population are one thing. Great answers are another. The final chapter concludes with thoughts of what to do, and Sarah supports, of course, family meals, more sports and activity facilities, less talk of calories and more of eating well and quality improvement of foods that are available in schools and hospitals.

Changes in social and built environments are the answer on paper, but the ‘how’ is just the start of the next open question that Sarah Boseley has left open.

Dietitians, this is an excellent book that is a zippy read, full of up-to-date and interesting information. The book does not provide detailed and structured answers to the issues raised, but then, that is the baton that is passed to our profession. Sarah Boseley has written a fact-filled but readable book about many of the food and health issues being discussed in the UK, and The Shape We’re In deserves a place on the dietetic bookshelf.

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web watch

web watch Online resources and useful updates.

Improvement in life expectancy for patients with Type 1 diabetes A study of patients in Scotland living with Type 1 diabetes has found that life expectancy has improved in comparison to previous research, although it still lags significantly behind that of the general population without diabetes. The results of the study, ‘Estimated Life Expectancy in a Scottish Cohort with Type 1 Diabetes, 2008-2010’, undertaken jointly by the University of Dundee and the Scottish Diabetes Research Network, have been published in the January edition of The Journal of the American Medical Association.

Tackling the causes and effects of obesity The Local Government Association (LGA) has published Tackling the causes and effects of obesity. The transfer of public health responsibilities to local government and Public Health England provides an opportunity to set out a local approach to tackling obesity and change the focus from treatment to prevention. The LGA

is calling on government to reinvest a fifth of existing VAT raised on sweets and sugary drinks and of the duty raised on alcohol in preventative measures to support an environment and a culture where a balanced and healthy diet is the norm and appropriate physical activity is available to everyone. www.local.gov.uk/ web/guest/publications/-/journal_content/56/10180/6910577/ PUBLICATION

Guide to healthy ageing NHS England has published a Practical guide to healthy ageing.

The evidence-based guide covers key areas that have been identified as the main risk factors for older people living at home, but if they are proactively managed, they can help people stay well for longer and improve their quality of life. Topics include medicines reviews, exercise, preventing falls, general home safety, and keeping warm and staying well in winter, with tips to help older people stay both physically and mentally fit and independent, and pointers on

when to seek medical support and advice. It also signposts people to a range of additional help and advice from Age UK. www.england.nhs. uk/2015/01/21/healthy-ageing/

Personalised care for long-term conditions NHS England has developed three handbooks to provide practical support for long-term conditions management. The handbooks draw on the latest research, best practice and case studies: 1. Case finding and risk stratification - identifying cohorts of people with long-term conditions that are most vulnerable and/or will benefit from tailored care and support.

2. Personalised care and support planning - enabling commissioners and health care practitioners to deliver personalised care.

3. Multidisciplinary team working - supporting health and care professionals to work across professional and organisational boundaries. www.england.nhs.uk/wp-content/ uploads/2015/01/mdt-dev-guidflat-fin.pdf

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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NHDmag.com March 2015 - Issue 102

NHDmag.com

web watch

Does money in adulthood affect adult outcomes?

The Joseph Rowntree Foundation has published Does money in adulthood affect adult outcomes? This research examines the evidence on whether money in adulthood has a causal impact on wider adult outcomes. The review identified 54 studies that were able to test the effect of money on adult outcomes.

This evidence suggests that money in adulthood does itself matter for wider adult outcomes, but this is clearer for some outcomes than for others. www.jrf.org.uk/publications/does-money-adulthoodaffect-adult-outcomes Funding to get people home from hospital and prevent admissions The Department for Communities and Local Government and the Department of Health have announced that new funds will be made available for councils to get people home from hospital more quickly and stop people from being admitted in the first place.

The new funding is from Department for Communities and Local Government underspends in 2014 to 2015 and will be allocated to 87 councils through ring-fenced grants for social services immediately, weighted towards areas with significant demand for home care packages who have not previously received additional funding this winter. www.gov.uk/government/ news/new-funds-to-kickstart-jointworking-with-nhs-and-councilsthis-winter Hospital admissions from care homes The Health Foundation has published Focus on: Hospital admissions from care homes. This report explores whether routinely collected information on hospitalisations from care homes could be used to enhance the understanding of hospital use by care home residents, and thus target areas for shared learning, improvements or regulatory activity. www.health.org. uk/publications/focus-on-hospitaladmissions-from-care-homes/

One in two people will get cancer According to the latest research from Cancer Research UK, one in two people will develop cancer at some point in their lives. This new estimate replaces the previous figure, calculated using a different method, which predicted that more than one in three people would develop cancer at some point in their lives. Trends in the lifetime risk of developing cancer in Great Britain: comparison of risk for those born from 1930 to 1960, is published in The British Journal of Cancer.

Cancer Research UK proposes that the research highlights the urgent need to bolster public health and NHS cancer services so that they can cope with a growing and ageing population and the looming demands for better diagnostics, treatments and earlier diagnosis. www. cancerresearchuk.org/about-us/ cancer-news/press-release/201502-04-1-in-2-people-in-the-uk-willget-cancer; www.nature.com/ bjc/journal/vaop/ncurrent/pdf/ bjc2014606a.pdf

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) NHDmag.com March 2015 - Issue 102

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career

Borders General Hospital & Community Dietetic Service Department of Nutrition & Dietetics

PROJECT DIETITIAN - NUDGE NUTRITION £26-£30K nudge nutrition are providers of expert nutrition and dietetic services to a broad range of clients across the foodservice sector. Following recent growth to our team, we are seeking to recruit a further dietitian to support the delivery of a project to a major global client. Based at Head Office near Bath with regular travel to London area and, less frequently, other parts of the UK. This full-time position provides an excellent opportunity for you to work within industry where your nutrition expertise will be crucial for the successful delivery of a key project. You will have exceptional communication and IT skills and an ability to coordinate activities and manage client expectations. As a key member of the team, the role will involve planning and administering activities to ensure that accurate allergen and nutritional information can be provided for customers. In addition you will use your nutrition and dietetic skills to support us with a range of other nutrition-related activities. To apply please send CV and covering letter to coleen.fraser@nudgenutrition.co.uk Closing Date: 20th March 2015 Community Dietitian - Staffordshire Experienced community dietitian required to cover home visits, nursing homes and clinics. There will also be an element of project work involving training in nursing homes. Starting at the beginning of March, this post will run for two to three months, 30 hours per week. A car is required, Please call Hayley on 01277 849 649, or email hayley@eliterec.com Elite only recruit for dietitians - join us now. www.elitedietitians.com Paediatric Band 6 Dietitian - Surrey Experienced Paediatric Dietitian required to cover neonatal unit, feeding clinics, single and multiple allergies, reflux, special needs and complex feeds. Also covering a busy outpatient clinic. Starting in March for one to two months, this is a full time post (37.5 hours) per week. Please call Hayley on 01277 849 649, or email hayley@eliterec.com Elite only recruit for dietitians join us now. www.elitedietitians.com

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NHDmag.com March 2015 - Issue 102

Catering Specialist Dietitian

Band 6 £26,041 - £34,876 per annum, pro rata Ref: PCS978 12.39 hours/week (flexible) – Permanent post This post offers an excellent opportunity for an experienced Dietitian with an interest in project work and delivering high quality catering provision to patients, to join our dietetic and catering teams within NHS Borders.

The Dietetic service provides Acute and Community Dietetic services, including a range of specialist and health improvement posts. You will be joining join a well-respected team of over 20 Dietitians with good secretarial support, and a commitment to staff development and clinical excellence. Our Catering Service has an excellent reputation, and this post is central to maintaining close working relationships and first-rate care.

You will be based in Borders General Hospital, in a beautiful setting with friendly staff and within commuting distance from Edinburgh. You will be integral to delivering Fluid, Fluid and Nutritional Care standards and meeting legislative requirements, maintaining a strong person centred focus. You will train and support other staff in their roles. Hours can be flexible, including annualised hours and there may be opportunities for additional hours for additional projects and/or for some clinical work.

You will be required to travel occasionally in order to deliver service needs, and given the rural nature of the Borders a driving licence is helpful.

For further Information please contact: Perry Burgess Lead Dietitian on 01896 827231 or email perry.burgess@borders.scot.nhs.uk Caroline Herkes, Catering Manager on 01896 826140 or email: caroline.herkes@borders.scot.nhs.uk Closing date for completed application forms: Monday 16 March 2015 5pm.

For an application pack, for all posts 01896 827728 or email recruitment@borders.scot.nhs.uk.

Please quote appropriate reference number.

(Please note: if you are e-mailing your completed application forms some web based e-mail services are blocked by nhs borders firewall e.g. Hotmail and yahoo.)

If you have not heard from us within 4 weeks of the closing date, then we regret that your application has not been successful on this occasion.

www.nhsborders.org.uk

career Band 6 Community Dietitian - Kent This post is for either a full- or part-time Band 6 Community Dietitian covering adult clinics and home visits. Starting at the beginning of March and running for two months initially. Please call Hayley on 01277 849 649 or email your CV to hayley@eliterec.com www.elitedietitians.com Band 5 Community Dietitian - East London We are currently looking for an experienced Diabetes Dietitian to cover clinics in East London/Essex Boarders. The post will start middle of March and applicants must have access to their own car. Please call Hayley on 01277 849 649 or email your CV to hayley@eliterec.com www.elitedietitians.com Band 5/6 Paediatric Dietitian - Herts Band 5/6 Paediatric Community Dietitian required for four days a week covering general clinics. Caseload will include: allergies, weight management, faltering growth and fussy eating. Experience in children’s diabetes and paediatric home enteral feeding would be an advantage. Caseload is outpatient based, so ability to travel between bases and places of work is required.

Please call 01277 849 649 or email hayley@eliterec.com www.elitedietitians.com

events and courses University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • Paediatric Nutrition - 16th May 2015 • Renal Nutrition - 19th May 2015 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’.

Saturated Fat, Dairy & Cardiovascular Disease: A Fresh Look at the Evidence 10th March - Free one-day Dairy Council conference IET GLASGOW, The Teacher Building, 14 St Enoch Square, Glasgow G1 4DB www.milk.co.uk/ Public Health Nutrition - Everyone’s Business: From Policy to Action 10th March - Public Health Nutrition Network is a specialist group of the British Dietetic Association.

BVSC Centre, Birmingham Contact: SRDejg@aol.com

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 NHDmag.com March 2015 - Issue 102

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the final helping

Neil Donnelly

Are you a Registered Dietitian? If so then you will be aware that you have to perform your professional duties in line with a degree of anticipated standards and expected neutrality by the Health and Care Professions Council (HCPC), otherwise you risk losing your registration, and possibly your livelihood. This is especially true if you work within the National Health Service. You have to be unbiased.

The dietary advice and support you offer to your patients and the general public will be based on the scientific interpretation of the evidence gathered by eminent professionals in the course of their work, which will then be translated into a more meaningful form for your use.

Government dietary guidelines will be produced in ongoing reports which reflect the significance of nutrients in our diet and their implications on the health of the Nation. Then, these headlines emerge in the National Press: ‘Butter isn’t bad for you after all.’

‘By scaring us off butter they’ve made us fatter - and unhealthier.’

‘I gave up the most glorious food on earth FOR A LIE.’

Neil is a Fellow of the BDA and retired Dietetic Services Manager.

His main areas of interest are weight management and eating disorders

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A damning new study in the BMJ publication Open Heart by a team led

by Zoe Harcombe, an obesity researcher at the University of the West of Scotland, states that national warnings over fat consumption to cut heart disease in 1977 and 1983 ‘should not have been introduced’. It concluded that the data did not show that cutting fats significantly reduced heart deaths. Those recommendations stated that we cut dietary fat to less than a third of total energy intake, singling out saturated fat from meat and dairy as particularly perilous.

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The Daily L ie ‘Butter isn’t ba d for you after al l.’

‘By scaring us off butter they’v e made us fatter and unhealthier .’

‘I gave up the most glorious food on earth FOR A LIE.’

How Many A Day?

Three, five, seven or 10 portion s of fruit and veg a day have similar health benefits!

Oh dear, what is the general public going to make of the advice being given out by health professionals in the future when something like this is headline news? We have all heard on numerous occasions about the ‘nanny state’ and how government feed us healthy eating messages that we of course have to endorse and freely advocate. Where do we go from here? Well, it won’t be easy to refute the patient who approaches you with the “why should I follow what you advise when professionals always seem to be changing their minds about what is and isn’t good for you” question.

I leave you with two quotes from recent articles by authors in the national popular press: ‘For myself, these studies have inspired me to put butter back into the fridge’s butter compartment and soft full-fat cheese on my crackers. I’m starting to smile like the cat that has got the cream.”

‘The moral of this saga? Eat a little of whatever you like, don’t listen to government busybodies - and remember that butter‘s not only delicious, it’s also officially good for you.’

Next month: Will new research suggest that eating three, five, seven or 10 portions of fruit and veg a day have similar health benefits!