uk o. .c BS JO 09 tic 20 te e ie c .d in w S w w
Issue 110 December 2015 / January 2016
Cystic fibrosis related diabetes Sarah Collins p13
ISSN 1756-9567 (Online)
Mindfulness for dietitians. . . p33
Dr Jackie Doyle University College London Hospitals NHS Trust
telemedicine & weight management distal enteral tube feeding focus on early years eras conference report
dieteticJOBS â€˘ web watch â€˘ new research
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The Fortini range are Foods for Special Medical Purposes and must be used under medical supervision.
from the editor It only seems like yesterday that I was writing about Issue 100 and now here is Issue 110 for you! Time certainly seems to be ‘flying by’ and recently I have been reading about ‘Why time flies as you age.’ It was an interesting account and looked at the key to time perception. 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.
We all have routines in our lives, yet routine, although comforting, makes time go faster, whereas unique and memorable events slow down time. Maybe, if we want to ‘slow down’ time, we should focus on changing routine and creating unique experiences for each one. We can also engage in greater mindfulness - focusing on and savouring each passing moment. The old adage of ‘live for the moment’ is the key to slowing down those quickly passing years. You may be thinking, how does this link in with this month’s NHD? Mindfulness for dietitians by Jackie Doyle describes mindfulness interventions and their potential application in healthcare. Two mindfulness interventions that have been developed for people with eating difficulties are also summarised. Early years nutrition is the topic for two articles. Kate Harrod-Wild tells us that the toddler years can be difficult and food can become a big issue with many young children. Kate covers fussy feeders, healthy snacks, ensuring adequate fluid intake and also some common nutrition related problems. Judy More and Melanie Pilcher look at the the role for early years’ providers in encouraging healthy eating habits for life. Food provision within early years’ settings has a significant role to play and the article covers the importance of investing in clear guidance, specific nutritional standards and training on healthy food provision in the early years of life as paramount.
For those of you working in the NHS you will know that innovative ways of working are being encouraged. Telemedicine is becoming more common. Noelle Cooper and Carolyn Jones share their experience of introducing and evaluating Skype clinics in Telemedicine and weight management. It seems that the patients had positive experiences and both the staff and Trust could see the benefits. Moving on to novel procedures, Karen Jackson tells us about Fistuloclysis or Distal Enteral Tube Feeding (DETF). If you are not familiar with this form of nutritional support then please read on. Karen also includes a case study with a lady who experienced problems with tolerance and compliance. Did you know that 27.6% of the cystic fibrosis population (1,924 people) has cystic fibrosis related diabetes? Cystic fibrosis related diabetes by Sarah Collins tells us more about pathophysiology, drug and nutritional management and their challenges and the importance of a MDT approach which can help reduce complications of the disease. Neil Donnelly has a nostalgic look at the dietetic past and present in The Final Helping to complete NHD for 2015. Finally, I hope that you all enjoy the festive celebrations and may I wish you all a very Merry Christmas and a Happy New Year. I wonder if 2016 will fly by as quickly as 2015 has.
NHDmag.com December 2015 /January 2016 - Issue 110
Cystic fibrosis related diabetes 6
36 Book review
Dietetic services: e-clinics
39 Web watch
Latest industry and product updates
Telemedicine and weight management
Proteinaholic by Garth Davis
Online resources and updates
19 Fistuloclysis or DETF Nutritional challenges and management
40 ERAS UK
23 Nutrition in the early years
30 Pre-school food provision
45 Events and courses
33 Skills and learning
46 The final helping
The challenges faced
The role for early yearsâ€™ providers
Mindfulness for dietitians
Editorial Panel Chris Rudd, Dietetic Advisor Neil Donnelly, Fellow of the BDA Ursula Arens, Writer, Nutrition & Dietetics Dr Emma Derbyshire, Nutritionist, Health Writer Emma Coates, Senior Paediatric Dietitian Noelle Cooper, Specialist Community Dietitian Carolyn Jones, Specialist Community Dietitian Sarah Collins, CF Specialist Dietitian Karen Jackson, Registered Dietitian Kate Harrod-Wild, Specialist Paediatric Dietitian Judy More, Dietitian and Registered Nutritionist Melanie Pilcher, Policy and Standards Manager, PLA Dr Jackie Doyle, University College London Hospitals Dr Fiona Carter, ERAS UK Manager
NHDmag.com December 2015 /January 2016 - Issue 110
Latest career opportunities
Upcoming dates for your diary
The last word from Neil Donnelly Editor Chris Rudd RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dawson Design Heather Dewhurst Advertisement Sales Richard Mair Tel 01342 824073 firstname.lastname@example.org Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email email@example.com @NHDmagazine www.NHDmag.com www.dieteticJOBS.co.uk All rights reserved. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to firstname.lastname@example.org and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.
From birth to discharge and beyond, the ESPGHAN-compliant1 Nutriprem range is designed to aid the development of preterm babies. For products that support feeding with breastmilk and contain ingredients to help babies thrive, choose Nutriprem.
Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortiﬁer is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low–birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85–91.
NeW fluid iNtake aNalysis
Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd
Fluids, but especially water, are essential to life. Unfortunately, fluid intakes are often overlooked from studies in favour of food and nutrient intakes. Now, new research has focused solely on evaluating fluid intakes. A systematic review of studies was undertaken, focusing on healthy children, teens and adults living in cities. It was found that total beverage intakes ranged between 0.6 and 3.5 litres per day. Plain water contributed to 58%, 75% and 80% of total beverage intakes in children, teen and adults, respectively. Milk was consumed more often in childhood, soft drinks during the teenage years and tea, coffee and alcohol in adulthood. Overall, water contributed most to total fluid intakes, while the consumption of other drinks tended to vary according to life stage.
For more information, see: Ozen AE et al (2015). Journal
of Human Nutrition & Dietetics Vol 28, Issue 5 pg 417-22.
Eat fish to improve vitamin D status?
Fish is an important natural source of vitamin D. However, it’s still out on the jury whether habitual intakes alone are enough to maintain adequate status. A new paper has looked at this in detail. A meta-analysis published in the American Journal of Clinical Nutrition analysed data from seven RCTs and two unpublished studies (640 subjects in total), all measuring fish intakes in relation to vitamin D status (as 25(OH)D). When compared with controls, it was found that eating fish increased vitamin D levels by an average of 4.4nmol/L. Eating fatty fish led to a mean difference of 6.8nmol/L when compared with controls. These findings show that while fish (particularly oily fish) is an importance source of vitamin D, current intakes and, indeed, recommendations are unlikely to lead to the attainment of optimal 25(OH)D status.
For more information, see: Lehmann U et al (2015). Amer-
ican Journal of Clinical Nutrition Vol 102, no 4, pg 837-47.
Latest studies on sugar
Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk email@example.com
Sugar has been a hot topic in the news recently. This has largely been driven by the SACN report on Carbohydrates and Health which has led to a number of new publications in this area. Two new papers published in Nutrition Reviews have focused on the roles of ‘added sugars’ (those added to foods and drinks during processing and preparation) in relation to dietary quality and health. The first paper reviewed evidence from 22 studies, with all but one suggesting that higher intakes of added sugars were associated with reduced diet quality. A further 21 out of 30 studies found higher intakes of added sugars to be associated with lower micronutrient intakes.
NHDmag.com December 2015 /January 2016 - Issue 110
A second paper looked at the effect of added sugar intakes in relation to ectopic fat (fat that builds up in places other than beneath the skin). Findings from 14 RCTs suggested that excess sugar intakes were linked to larger fat depots, especially in the liver and muscle fat. That said, report bias was likely in some of these studies. Subjects were also tested under hypercaloric conditions, i.e. when they ate more calories than needed. Taken together, these are interesting findings suggesting that ‘added’ rather than total or intrinsic sugars pose most risks to health. Now further well designed RCTs with adequate power and duration are needed.
For more information, see: Louie JC and Tapsell LC
(2015). Nutrition Reviews [Epub ahead of print] and Ma J et al (2015.) Nutrition Reviews. [Epub ahead of print].
Choline intakes of Europeans
Choline is a B vitamin and an important nutrient. Nevertheless, it is often omitted from dietary surveys. Now, new work has estimated habitual choline intakes across a European population. Choline intakes were calculated using the European Food Safety Authority European Comprehensive Food Consumption Database and food values derived using the US Department of Agriculture Nutrient Database. Interestingly, average choline intake ranges were: 151-210mg/d for toddlers (1 to ≤3 years old), 177-304mg/d for other children (3 to ≤10 years old), 244-373mg/d for teens (10 to ≤18 years old), 291-468mg/d for adults (18 to ≤65 years old), 284450mg/d among elderly people (65 to ≤75 years old) and 269-444mg/d among very elderly people (≥75 years old). In most population groups, average choline intakes were lower than adequate intakes set by the Institute of Medicine, with meat, milk, grains and eggs providing most choline. While these findings are a useful guide to how much choline people are eating, more work is needed to improve choline food composition databases. That way, the accuracy of future work in this area can be optimised.
Berries to improve memory?
Berries are a great source of polyphenols, which are thought to support brain neurogenesis (the growth and development of nerves), which in turn, is involved in learning and memory. Now, new animal research has studied this further. Aged Fischer rats (n=344) were fed a control 2.0% strawberry or 2.0% blueberry-supplemented diet for eight weeks. Behavioural changes and brain function were monitored. It was found that rats eating the berry diets had improved cognition (brain function), with working memory found to improve the most. Improvements in brain neureogenesis were also seen. While human trials are clearly needed, these are interesting findings suggesting that polyphenols found in berry fruits may help to support cognition and memory with advancing age.
For more information, see: Shukitt-Hale B et al (2015). British Journal of Nutrition Vol 114, Issue 10, pg 1542-49.
For more information, see: Vennemann FB et al (2015). British
Journal of Nutrition [Epub ahead of print].
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NHDmag.com NHDmag.com December 2015 /January 2016 - Issue 110
Dietietic services - e-clinics
Telemedicine and weight management
Noelle Cooper Specialist Community Dietitian, Berkshire Healthcare NHS Foundation Trust
Carolyn Jones Specialist Community Dietitian, Berkshire Healthcare NHS Foundation Trust
Noelle and Carolyn have both worked in dietetics for over 20 years, with experience of working in acute and community settings. They currently work for Berkshire Healthcare Foundation Trust.
From mobile working to Skype consultations, Berkshire Healthcare NHS Foundation Trust community dietitians have embraced the use of technology to offer more patient choice in their weight management consultation venues. This article looks at how they did this, how the processes they introduced are working one year on and asks you to consider whether you might apply this to your setting. The NHS is challenged to move with the times to offer innovative solutions to meet the demand of the expanding population and healthcare costs. The use of and confidence with technology is increasing, with a rising number of homes having access to the internet. In Great Britain, 84% had internet access in 2014 compared to 27% in 2006.1 Skype and other forms of video conferencing also continue to grow. To address this, our service was interested to find out whether our patients wanted to access the dietetic service via interactive technologies. A three-month survey showed that 33% of new patients were interested in having a dietetic Skype appointment. Following on from this, from August 2014, Berkshire Healthcare dietitians introduced Skype consultations to our patients in addition to face-to-face outpatient appointments. The rationale behind offering these e-clinics was to make our dietetic service more accessible to patients. Benefits include reducing time off work, transport problems, clinic car park pressures and stress/anxiety, particularly in time of acute illness. Telemedicine
Telemedicine is defined as the use of technology to deliver care at a distance. It is rapidly growing and can potentially access more patients, enhance patient/ healthcare professional collaboration, improve health outcomes and reduce medical costs. Examples include:
NHDmag.com December 2015 /January 2016 - Issue 110
• remote patient monitoring using technological devices which can be transmitted back to a monitoring centre for evaluation and stored in patients’ medical records, e.g. undernutrition monitoring using ‘Health Call’ from Focus on Undernutrition Team (County Durham and Darlington NHS Foundation Trust);2 • mobile technology such as smartphone applications and text messages to manage and track health conditions or promote healthy behaviours; • real-time interactive technologies such as a two-way video, e.g. Skype. Approval process
As part of a staff engagement programme (Listening into Action), our application was chosen by the Trust’s Executive Committee. We became a pioneer team with ongoing support from senior managers over a period of six months. Our team included an IT specialist who guided us through gaining clinical governance approval and creating a Standard Operating Procedure (SOP). We obtained Caldicott Guardian approval from our Clinical Director. Patient information leaflets were created to support Skype consultations, including guidance on how to download Skype. Patients were instructed that the dietitian would initiate the Skype call at their appointment time.
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Dietietic services - e-clinics Figure 1: Technology Dietitian Workflow Dietitians E-Clinic: Clinical Governance 29/07/14
Offering Skype and Booking
Remote clinic consultations, e.g. e-clinic, telephone, should maintain the clinical standards set for 1:1 clinic interventions. If by telephone, hands free ideal to avoid back injuries when typing. To ensure these standards are met, outlined below is a process to follow;
At appointment booking; Offer Skype appointment
Dietitians make contact with patient (Keep within 5 min slot)
Take details and record, create appointment letter, including Dietitian’s Skype name. Upload to RiO documents
Book appointment and add to comments box in the clinic
Offer standard appointment
Send Skype account information (by email)
Ask patient to contact service with Skype username and record in RiO (separate process)
Verify connection, audio and visual, (can they see & hear you/can you see & hear them) IM patient if problems are experienced
Call quality OK?
Identify yourself and confirm patient identifiers e.g. name, DOB, address
Ask patient if they are happy to continue consultation (e.g. they are comfortable/in a private place)
Cancel Skype call and telephone patient to arrange appointment through alternative medium. Record on RiO and outcome as ‘Session Cancelled’
Yes Clearly outline length of session and confirm reason for referral
Begin consultation, checking their understanding throughout particularly if no video (body language)
Agree next steps and whether review required, whether 1:1 or e-clinic. IM patient survey monkey hyperlink
IT uploaded Skype software onto department computers and sourced both headphones and web cameras. The aim was to ensure that the quality of our virtual consultations were on a par with face-to-face consultations. Staff training
Staff were offered in-house Skype training to ensure competency and confidence in delivering a good virtual consultation. Team members already using Skype on a personal basis were good advocates. As expected, there were some initial staff reservations for those unfamiliar with this form of communication, particularly around dealing with technical problems. These were overcome by the development of an SOP, enabling a consistent approach, along with troubleshooting tips. Marketing
Administrative staff play a key role in recruiting and booking Skype appointments into our community outpatient clinics. These appointments are well promoted and once agreed, further details are collected including a patient’s Skype 10
Patient has Skype account
NHDmag.com December 2015 /January 2016 - Issue 110
Thank them, say good bye and end the call
Document outcome in RiO and use the ‘Consultation medium: Telemedicine web camera’ and book any follow-up/discharge as required.
username and contact phone number in case of failed technology. There are clear benefits to virtual consultations including a greater choice of where they are seen. Patients who are not able to attend an outpatient appointment and do not meet domiciliary criteria are now being offered a Skype appointment instead of a phone call. Clinic utilisation has also improved, as patients are being offered a Skype appointment when they phone to cancel their appointment. Skype appointments were first introduced in August 2014 and have now been running a year. Recruitment was initially slower than anticipated, partly due to the waiting times. For new patients, there is still a preference to be seen faceto-face whenever possible. The numbers are now increasing with approximately seven patients receiving dietetic advice via Skype per month. Patient feedback
Following a Skype appointment, patients were asked to complete an online survey. To date, 24 patients have reported their experience to be as follows:
Dietietic services - e-clinics Table 1: The benefits of offering Skype appointments to patients, staff and the Trust Patient outcomes
Saves on time off work and travel.
Good patient clinic attendance.
Efficiency and cost savings, e.g. less car park congestion.
Saves on fuel and parking costs.
Superior to email or telephone as can see body language and cooking environment. Better understanding of portion sizes through seeing plate sizes, etc.
Positive patient experience.
Safe alternative in adverse weather conditions.
Saves on clinical time due reduction in clinic travel.
Working together increasing patient choice.
More choice where to be seen with increased access for some patients.
Better able to meet patient needs in timely manner.
Optimal clinical outcomes, seeing patients at right time and place.
• 100% requested a future appointment and would recommend a friend • 100% said the appointment was convenient • 95% rated the experience as ‘good’ or ‘excellent’ • 67% reported time off work was not needed • 63% would have been unable to attend a faceto-face appointment • 78% did not experience any technical issues Staff feedback
Overall, the experience has been positive with increasing staff confidence and competence. Technical issues were overcome by training as well as following the SOP and clinical governance pathway. In our favour, technology is an important part of our working day with all staff having access to mobile working and using an electronic patient record system (RiO) to document dietetic intervention. A disadvantage of Skype appointments is the reliance on patient self-reporting, e.g. body weight. However, there is recent evidence that self-reporting has become more accurate amongst overweight and obese patients.3 For those unable to self-weigh, other measures could include clothes or waist size. Outcomes
A wide variety of clinical conditions are being seen including nutritional support, weight management, gastroenterology, diabetes and paediatrics. Over the last year (Sept 2014 to August 2015), we have seen 66 patients (28 new patients and 38 follow ups) from all age groups (early 20s to late 70ss).
The following table shows the benefits of offering Skype appointments to patients, staff and the Trust: Conclusions
Over the last year we have shown that Skype appointments can be successfully applied to our dietetic practice without impacting on service delivery. Although Skype consultations are not suitable for everyone, they are an addition to and not a replacement for the traditional face-to-face appointments, hence giving wider patient choice. We have been fortunate to have Trust support in introducing Skype appointments early on and we envisage that, as patient demand increases, we will have the expertise and confidence to be able to meet this demand. As technology has become the norm in most people’s lives, the public is becoming more open to telemedicine as a form of healthcare delivery for preventive care, acute care and chronic disease management. Through the use of Skype appointments, we have raised the profile of the dietetics service across Berkshire Healthcare. The opportunity to run Skype clinics is now being opened up to other services within the organisation. We would encourage other dietetic services to consider patient benefits and introduce virtual consultations. For the future, dietetic e-clinic consultations could one day complement evidence-based online programmes and approved smart phone apps. For article references please email: firstname.lastname@example.org NHDmag.com December 2015 /January 2016 - Issue 110
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Cystic fibrosis related diabetes Cystic fibrosis related diabetes (CFRD) affects 40-50% of adults with cystic fibrosis.1 Its presence has a significant impact on nutritional status, lung function, morbidity and mortality.
Sarah Collins CF Specialist Dietitian Royal Brompton & Harefield NHS Foundation Trust
Cystic fibrosis (CF) is the most common life-threatening inherited disease in the Caucasian population, affecting 10,583 people in the UK. It is a progressive, multisystem disease affecting vital organs of the body, especially the lungs and digestive system. It is usually diagnosed soon after birth, although symptoms occur throughout life. In the 1930s, when CF was first described, 70% of babies with CF died within the first year of life; today the median age of survival is a 40.1 years.2,3 Improvement in survival has led to the development of more complications, with diabetes being the most common co-morbidity of CF. Prevalence
Sarah works as a Specialist Dietitian with adults who have cystic fibrosis and has done for the past 19 years. She has a particular interest in the management of CF related diabetes.
In the UK, 27.6% of the CF population (1924 people) have cystic fibrosis related diabetes (CFRD).3 The prevalence of CFRD increases with age; with 2.0% children, 19% adolescents and 40-50% of adults having CFRD.1 Pathophysiology
Whilst CFRD shares features of Type 1 and Type 2 diabetes, it is a distinct clinical
entity (Table 1). Its pathophysiology is not fully understood, however, the primary defect in CFRD is insulin deficiency. Destruction of the pancreatic tissue, with accompanying fibrosis and disorganisation of the islet cells gradually results in a reduction in insulin production. Insulin resistance can also contribute to the development of CFRD and it is variable over time due to changes in clinical status. Factors that contribute to increased insulin resistance include: acute respiratory exacerbations, chronic severe lung disease and glucocorticoid therapy4. The presence of CF liver disease may also affect glucose handling in people with CF. Clinical significance
The early stages of insulin deficiency contribute to morbidity and mortality due to a catabolic decline in weight and respiratory muscle function, as well as the promotion of bacterial growth by the presence of hyperglycaemia.5 A decline in clinical status and lung function has been observed several years before CFRD is diagnosed.6-8 Improvement in
Table 1: Comparison between CFRD, Type1and Type 2 diabetes Average age of onset
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Cystic fibrosis related diabetes is part of a continuum of abnormalities in glucose tolerance, with only a few people with CF having completely normal glucose tolerance. weight has been seen prior to the development of overt CFRD with the early initiation of insulin.9-12 The presence of CFRD is linked to worse lung function in people with CF regardless of age. Targeting CF specific outcomes such as BMI and lung function provides evidence for supporting early treatment of CFRD, particularly before advanced lung disease occurs. The risk of death has also been shown to be higher in patients with CFRD - three times greater in those with HbA1c >6.5% (48mmol/ mol), indicating that glycaemic control may also be a contributory factor.13 Optimising glycaemic control results in improvements in nutritional status and lung function, reduces mortality14 and the development of long-term microvascular complications.15,16
secretion in CF and values can fall to normal by 120 minutes. The cut off is based on criteria for reducing cardiovascular complications in treatment of Type 2 diabetes. In CFRD, we are treating hyperglycaemia with insulin for the clinical benefit. Serial blood glucose monitoring and/or continuous glucose monitoring systems (CGMS) are, therefore, essential when assessing the need for treatment. Women with CF are at increased risk of developing gestational diabetes and screening using the OGTT should take place in the preconception period.17,18 It should be repeated between 12-16 weeks and 24-28 weeks gestation and if random blood glucose levels are elevated.17
Insulin is the recommended treatment of choice for people with CFRD as insulin deficiency is the primary cause of CFRD. The aims of management of CFRD are to maintain optimal growth, nutritional status and lung function, to achieve good control of blood glucose levels and to avoid long-term microvascular complications.18 Varying insulin regimens are used, they should be tailored according to individual requirements, taking into account clinical and nutritional status, appetite and level of physical activity. In our centre, we tend to give insulin in the following situations: â€˘ In those patients who have been found to have minor abnormalities in their glucose metabolism (identified through OGTT, serial blood glucose monitoring and in some cases CGMS) and who have poor nutritional and clinical status. Insulin will be initiated for its anabolic enhancing properties; this will usually be on a low dose of basal insulin taken once daily.
Early detection of abnormalities of glucose levels is important to prevent weight loss and decline in lung function. Cystic fibrosis related diabetes is part of a continuum of abnormalities in glucose tolerance, with only a few people with CF having completely normal glucose tolerance. In early stages of glucose intolerance the diagnosis of CFRD is difficult to make with the majority of people not presenting with overt clinical symptoms. The initial abnormality seen in CFRD is a delayed first-phase insulin response with the preservation of basal insulin. It is recommended that CFRD should be diagnosed based on response to a standard 75g oral glucose tolerance test (OGTT), and that screening should be done annually in all people with CF greater than 10 years.17 There is, however, several problems with this test in people with CF. Firstly, fasting glycaemia is often normal in the early stages of CFRD and secondly, glucose levels can vary widely due to patterns of insulin 14
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Achieving and maintaining a good nutritional status is an essential part of survival in CF â€˘ In patients with intermittent glucose tolerance who only show elevations in their blood glucose levels during respiratory exacerbations or glucocorticoid therapy. These patients will be on either a low dose of basal insulin or quick acting insulin analogues with some but not all meals. â€˘ In patients on supplementary enteral feeds who experience elevated blood glucose when receiving their feed due to the increased carbohydrate load. The insulin prescribed will be dependent on the duration and type of the supplementary feed used. â€˘ In those patients who have post-prandial rises in blood glucose quick acting insulin analogues will be given with food (initially this may not be with all meals). Many patients do not need basal insulin initially or indeed for many years in some cases. Eventually they will progress to requiring a basal bolus insulin regimen. A collaborative multidisciplinary approach between CF specialists and a diabetes team that is familiar with CFRD and its unique features is advised.17,18 People with CFRD need education and support tailored to their nutritional requirements, insulin regimen and clinical status. The number of people with CF requiring insulin will increase because the CF population is growing and ageing and survival rates are improving. Currently 59.3% of the UK CF population is 16 years and over. 3 Cystic fibrosis teams are very aware of the consequences of hyperglycaemia and insulin is initiated much earlier, before overt hyperglycaemia occurs, to reduce morbidity and mortality.
Challenges in the management of CFRD
The diagnosis and onset of diabetes in people with CF signifies the development of a second chronic illness, with it comes its own burden of treatment and monitoring in addition to the meticulous daily treatments associated with the management of CF. People with CF have a high treatment burden with increased complexity in treatments seen in adulthood; this in itself poses challenges for self-management and concordance19. People with CFRD are not a homogenous population; their therapeutic needs are diverse, challenging and continually evolving. Nutritional management
Achieving and maintaining a good nutritional status is an essential part of survival in CF; there is a strong link between lung function and nutritional status. Regular dietetic input is a critical component of CF care so that any nutritional decline can be minimised and dietetic intervention can be adjusted to meet changes in physical, clinical and psychosocial needs. The majority of people with CF can achieve good nutritional status by following a high-energy diet however a minority may need oral nutritional supplements or artificial nutritional support. Management must be individualised as the nutritional needs of people with CF vary greatly. NHDmag.com December 2015 /January 2016 - Issue 110
Cystic fibrosis Table 2: Dietary recommendations for people with CFRD Underweight (BMI <20kg/m2)
Healthy weight (BMI 20-25kg/m2)
Overweight (BMI >25kg/m2
Improve nutritional status
Maintain nutritional status
Prevent further weight gain or promote weight loss
Modify timing of simple carbohydrate
Restrict simple carbohydrates to meal times
Restrict simple carbohydrates
As required (PUFA/MUFA)
Modify intake (PUFA/MUFA)
Monitor - particularly in people on anti-hypertensive therapy
People with CFRD are advised that dietary guidelines of modified energy, low-protein, lowfat and low-salt intakes, as recommended for people with Type 1 and Type 2 diabetes, are not always appropriate.18,20 A detailed dietary review should be conducted by a CF specialist dietitian and advice given on a diet appropriate to meet individual nutritional requirements taking into account clinical and nutritional status, appetite and physical activity (Table 2). Often, people with CF can have erratic dietary intakes and some have a heavy reliance on foods high in simple carbohydrates such as jelly-type sweets and sugary energy drinks, making management of CFRD challenging. Advice given on carbohydrate intakes will be based upon nutritional status and requirements, with the majority being advised to have regular meals containing complex carbohydrates and to modify the quantity and timing of simple carbohydrates. People with CFRD are taught carbohydrate awareness with some being taught how to carbohydrate count and adjust their insulin doses according to their carbohydrate intake. This is particularly useful if they have very variable and erratic eating habits. To maintain or improve nutritional status, some people with CF will need to take oral nutritional supplements on a routine basis. The majority of oral nutritional supplements contain carbohydrates and, therefore, insulin will be required. The type and amount of insulin required will vary according to the supplement used, when it is taken and the volume consumed. 16
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For those people with CF who receive supplementary enteral tube feeds their insulin regimens will need to be modified to optimise glycaemic control, taking into account the composition, volume and duration of the feed. A diet high in fat and energy has been part of the nutritional management of CF for the past 35 years and, recently, the over-reliance on saturated fat in the diet has been highlighted.21 With the improvements in survival seen in people with CF, this is of concern and a diet more cardio-protective may therefore be of benefit. The use of mono- and polyunsaturated fats is, therefore, encouraged in all people with CF. Overweight and obesity are also becoming increasingly common problems in CF.22,23 Nutritional advice should, therefore, be individualised to meet changes in nutritional requirements and dietary modifications may be required to support long-term health and well-being. Conclusions
Cystic fibrosis related diabetes is a common complication of CF affecting 40-50% of adults; its presence has a significant impact on nutritional status, lung function and survival. People with CFRD should be treated at specialist CF centre by a multidisciplinary team with expert knowledge of the management of CFRD. They should receive individualised dietary advice and be given appropriate insulin regimens in order to gain optimal control of their CFRD and prevent the risk of long-term microvascular complications. For article references please email: email@example.com
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A solution for all your CMA needs Reference: 1. Burks W et al. J Pediatr 2008;153:266–271. †This study was conducted with Nutramigen AA without MCT oil. IMPORTANT NOTICE: Breast milk is the best nutrition for babies. The decision to discontinue breastfeeding may be difﬁcult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2015 Mead Johnson & Company, LLC. All rights reserved. This material is for healthcare professionals only. EU15.509. January 2015
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FISTULOCLYSIS OR DISTAL ENTERAL TUBE FEEDING The management of intestinal failure is complex and there are limited options for patients dependent on nutrient and fluid support. The emergence of fistuloclysis, or distal enteral tube feeding (DETF), is a relatively novel procedure involving a distal form of enteral nutrition (EN) that offers the appropriate patient an alternative feeding method over parenteral nutrition. Karen Jackson Registered Dietitian, Oxford University NHS Foundation Trust
Several specialist intestinal units in the UK have successfully managed patients using DETF. The aim of this article is to relay the practical experience of using DETF in an intestinal failure patient in an attempt to wean parenteral nutrition (PN) with the added advantage of avoiding the complications associated with PN. Intestinal failure
Karen qualified as a dietitian 10 years ago and currently works in acute gastrosurgery and critical care.
A recent definition of intestinal failure (IF) involves reduced intestinal absorption so that macronutrient and/or water and electrolyte supplements are needed to maintain health and/or growth.1 Intestinal failure is now categorised into three types and causes are varied incorporating a wide variety of medical and surgical conditions (refer to Table 1). Enterocutaneous fistulae (ECF) are abnormal communications between the lumen of the gastrointestinal tract and the skin which may occur in various disease processes or iatrogenically. Approximately 20-30% of all ECFs arise
secondary to Crohn’s disease following bowel resection.2,3 The majority of fistulae occur post-operatively as a result of bowel injury during surgery, an anastomotic leak, missed enterotomy or erosion of foreign material into adjacent bowel (e.g. mesh for hernia repair, vascular graft).4 A number of pre-operative factors increasing the likelihood of developing a fistula include malnutrition, traumatic injury, infection, immunosuppression and emergency procedures.5,6 Enteric fistulas are classified in relation to the effluent output of the fistula: • a low output fistula drains less than 200mL/day • a moderate output fistula drains between 200 and 500mL/day • a high output fistula drains more than 500mL/day. High output fistulas are associated with an increased risk of morbidity and mortality and greater macronutrient, fluid and electrolyte deficiencies.7 Reportedly, up to 70% of patients with fis-
Table 1: Categorisation of intestinal failure Type 1
This type of IF is short-term, self-limiting and often peri-operative in nature. Type I IF is common and patients on high dependency units and intensive care units will also fall into this category.
Occurs in metabolically unstable patients in hospital and requires prolonged PN over weeks or months. Often associated with sepsis and may be associated with renal impairment. These patients often need the facilities of an intensive care or high dependency unit for some or much of their stay in hospital. Poor management of Type 2 IF increases mortality and increases the likelihood of developing Type 3 IF
A chronic condition requiring long-term PN. The patient is characteristically metabolically stable but cannot maintain their nutrition adequately by absorbing food or nutrients via the intestinal tract. These are, in the main, the group of patients for which HPN or Electrolytes (HPE) indicated.
Adapted from NHS England23
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Clinical nutrition Table 2: Factors affecting liklihood of closure
tulas are malnourished8 primarily due to postoperative ileus, sepsis, loss of bowel integrity and absorptive surface area, and the external loss of essential nutrients, electrolytes and fluid in the protein-rich enteric contents.9 Ultimately, the goal is for the ECF to close spontaneously and if it occurs, it is usually within six to eight weeks of its first appearance.10 Authors of case series recommend waiting between three and six months if the fistula warrants surgical repair11,11a,12, 12a to prevent further collateral damage at surgery. For the patient where spontaneous fistula closure is not possible, optimal management is paramount. The SNAP (sepsis, nutrition, anatomy and surgical procedure) protocol aids early detection and treatment of sepsis, optimising patient nutrition through oral, enteral and parenteral routes, identifying the fistula anatomy, optimising fistula management and proceeding to definitive surgery when appropriate.13 Nutrition
The nutritional and metabolic needs of a patient with a high-output ECF during the period pending surgery has historically been met by the provision of PN, which is frequently provided at home. PN is complex, expensive and highly demanding requiring individualised management by an experienced multidisciplinary nutrition team. In addition, it may not be possible to train all patients such as the elderly and those with 20
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impaired vision or dexterity, to administer home PN, necessitating prolonged hospital admission or discharge with community nursing support. In the selected patient, PN can be avoided with EN administered via a fistula. Several published studies have shown that EN can be safely implemented in patients with an ECF without complicating the treatment of the open abdomen and fistula itself.14,15 Knowledge of the origin of the fistula is critical for the possibility of feeding via the gastrointestinal tract to succeed, and it is recommended that all patients with Type 2 intestinal failure undergo detailed anatomical assessment with oral and enema contrast studies, as well as fistulography. DETF
DETF involves nutrition provision via an enteral feeding tube. A tube placed directly into the distal lumen of a fistula utilises the bowel distal to the fistula to absorb nutrients and fluid, thus offering the benefits of EN. Evidence suggests that EN has considerable advantages over PN in encouraging distal intestinal adaptation and reducing the risk of anastomotic dehissence.16 Although DETF is not feasible for all patients with ECF, for those who are eligible, the method appears to be an acceptable and safe method of maintaining and improving nutritional status. In order for this method to be successful, there must be enough unobstructed bowel distal to the fis-
Clinical nutrition tula in continuity for adequate nutrient absorption. The suggested length is at least 75cm and patients should also be without infection and hemodynamically stable.17 Contrast radiology is the most reliable method to determine anatomy and clarify any drainage into the abdominal cavity, which would contraindicate the use of this feeding technique. It is essential before commencing DETF that spontaneous closure of the ECF is ruled out. It is uncertain, in the absence of a randomised control trial, whether this method of feeding would hinder the closure of an ECF but, it has been suggested that evidence of mucocutaneous continuity at the site of an intestinal fistula is a clear indication that spontaneous closure will not occur.17 Table 2 details factors that may predict spontaneous closure. For those patients in whom spontaneous entercutaneous closure is unlikely, DETF may enable nutritional optimisation pending surgery. The following case study outlines the practical experience of DETF. It demonstrates the required perseverance by the patient and MDT for it to be successful. Case study Mrs X was referred for nutritional and surgical assessment following a large incisional hernia repair with mesh reconstruction. A burst periumbilical abscess resulted in a high output ECF. An assessment using the SNAP tool identified: Sepsis: None present Nutrition: Weight 39.2kg, BMI: 18.6kg/m2; Weight loss %: 52% over two years MUAC: 20cm; MAMC: 17.87cm; Handgrip Strength: 15.3cm; TSF: 7mm Mrs X drank ~1500mls daily, dietary intake on admission calculated to ~650kcals and ~30g protein. Anatomy (radiology): A CT abdomen and pelvis with contrast and fistulogram were conducted to confirm the presence of an ECF, >75cm of small bowel below the fistula and no evidence of obstruction distal to the fistula. Surgical assessment: Type 2 intestinal failure and required a surgical laparotomy for the removal of existing mesh, repair of fistula and reconstruction of the abdominal wall with a biological mesh.
On admission, Mrs X was initially made NBM to assess her basal ECF output. She was then commenced on PN to meet her full estimated nutritional requirements pending planned surgery. Improving her nutritional status was imperative before any surgery intervention could be considered. The patient wished to return home pending her surgical procedure to be near her family. Her limited dexterity deemed that she was not a candidate for home PN training. Subsequent discussions with the patient following review of her radiology indicated DETF feeding was a distinct possibility. Thus, it was agreed with the patient to commence nutritional support with PN followed by transition to enteral nutrition via DETF. Radiology confirmed the length of the small intestine beyond the fistula opening, and the possibility of placing a feeding tube distal to the fistula, using a percutaneous gastrostomy. St Markâ€™s and the Royal Salford Intestinal Failure Unit have produced handbooks and guidelines for healthcare professionals and include a stepby-step guide to equipment assembly.18 Technique of DETF
Under radiological guidance, the fistula tract was cannulated and dilated with a 5.0mm angioplasty balloon and then intubated with 12F gastrostomy. The catheter was advanced into the lumen of the distal intestine and 3.0ml water was placed in the catheter balloon. The fistula was enclosed within a stoma appliance linked to a universal catheter access port which allowed collection and measurement of proximal enteric content as enteral feed was infused via the fistula. The external flange was removed from the gastrostomy and a Hollister was punctured through the stoma bag window. Selection of enteral feed
The nutritional goal for Mrs X was to improve and then maintain her nutritional status to allow for the best surgical outcome by maximising macro- and micronutrient and electrolyte provision. She had been on PN for several weeks prior to commencing DETF. Initially, a standard polymeric feed 1.0kcal/ml (288mOsm/kg) was commenced at 25mls/hr over 20 hours to provide 500kcal energy and 20g protein. Studies have NHDmag.com December 2015 /January 2016 - Issue 110
Clinical nutrition shown in patients with residual bowel length of 60-150cm that macronutrient, micronutrient, electrolyte and fluid absorption were unaffected by the type of feed administered.19 These findings have also been supported by larger studies.20 Joly et al21 in a randomised crossover study found that using continuous feeding improved lipid and protein absorption, but this needs to be tempered with the impact that carrying feed around for 24 hours has on an individual, in particular, in someone who is elderly and frail. An important factor when deciding upon an enteral feed, is the osmolality. The osmolality of bowel contents effects secretion and absorption of fluid and sodium and may be fundamental in the fluid management of the patient. Teubner15 suggested commencing patients on a polymeric feed and in the event of intolerance, change to a peptide feed taking into account feed osmolality. A polymeric feed offers the advantage of a higher macronutrient content to offset any increased nutritional requirements. Progress
Day 1: Mrs X continued on PN throughout the trial of DETF. EN was commenced at 25mls/ hr for ~10 hours, but following the development of nausea, overnight nursing staff stopped the feed. Day 2: The feed was recommenced but stopped again due to ongoing nausea. A tubogram confirmed the position of the gastrostomy had moved and required re-insertion. Day 3: Interventional radiology inserted a second 12F gastrostomy and feeding recommenced at 25mls/hr with Osmolite 1.0kcal. Mrs X developed diarrhoea and vomiting and the tube dislodged and fell out. The patient was reluctant for a further tube replacement. Day 7: Mrs X agreed to re-attempt fistuloclysis and, following a very difficult and painful procedure using fluoroscopy, a third 12F gastrostomy was placed. Day 8: EN was recommenced at 25mls/hr and tolerated. The feed was increased to 40mls/ hr but Mrs X quickly developed nausea and reported abdominal discomfort. There was no evidence of diarrhoea and no increase in fistula output. Feeding was discontinued and the tube then fell out for a second time. A decision 22
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was then made with the patient and multidisciplinary team not for further insertion. Monitoring
The key to successful DETF is close monitoring of hydration, nutritional status and biochemistry. In this instance, Mrs X was continued on PN during the DETF trial so hydration, nutritional and electrolyte status were maintained. However, should DETF have succeeded and Mrs X weaned off PN, continuous monitoring is fundamental. Oral dietary and fluid intake
As spontaneous healing of Mrs Xâ€™s ECF was unlikely, there was no reason to restrict oral dietary intake. A high energy, high protein and low fibre diet was advocated. It is beneficial for patients with reduced bowel length to consume a low fibre diet to prevent the occlusion of the proximal fistula.22 There is little evidence supporting the practise of advising patients to avoid fluid intake at mealtimes to aid absorption. However, balancing against the impact of the fluid and electrolyte losses that Mrs X experienced, this recommendation was discussed with the patient along with the consumption of an isotonic fluid. Despite daily counselling and education with the patient discussing the effects of fluid intake on fistula output, Mrs X refused to limit her intake of oral hypotonic fluids (tea, coffee, water) to 500mls and consumption of an isotonic solution resulting in a high output fistula. If our recommendations were followed, we may have achieved a lower output. Conclusion
In this example, DETF feeding was unsuccessful on account of the difficulties in successfully placing a tube and patient tolerance. I wanted to use this particular example to demonstrate the potential pitfalls that may be encountered, but not to be deterred by some failures. Even in the intestinal failure centres that have high usage of DETF, not every case is a success. It requires an experienced MDT and a motivated patient who has been appropriately counselled and educated; it can be successful and offers an alternative for the appropriate patient. For article references please email: firstname.lastname@example.org
FOCUS ON EARLY YEARS
Nutrition in the early years: the challenges faced From their first birthday to when they start school, children start to assert their independence and explore their boundaries and that includes with food. However, this is not the case for some children and this can lead to many of the challenges of toddler nutrition as described in this article. Kate Harrod-Wild Specialist Paediatric Dietitian, Betsi Cadwaladr University Health Board
By their first birthday children should be eating foods from all food groups; eating family foods that are the broadly the same texture as the rest of the family and drinking from a cup instead of a bottle. However, this is not the case for some children and feeding and mealtimes can be a challenge. Fussy feeders
Kate Harrod-Wild is a Paediatric Dietitian with over 20 years’ experience of working with children in acute and community settings. Kate has also written and spoken extensively on child nutrition.
Fussy eating is undoubtedly the issue that causes the most stress for parents and carers. It is very common and minor food refusal and fussiness is entirely expected at this stage. Neophobia - or fear of new foods - is a totally normal developmental phase. This may have emerged as a survival mechanism to ensure that increasingly mobile children did not poison themselves. It is, therefore, important to introduce older infants to as many flavours and textures as possible while they are open to try them. In addition, children will be testing the boundaries and attempting to assert their independence during the toddler years. How parents respond to their fussy feeder can have an impact on the duration and severity of this common issue. Key tips to parents/carers include the following: • Provide an element of choice - for instance, let them choose the flavour of their yoghurt or what to have in their sandwich between two options. This allows them to assert their independence and develop opinions within clear boundaries. • Offer very small portions so that the child has a realistic chance of finishing what is on their plate; they can always ask for more.
• Ignore food refusal and take the plate away without comment. Don’t give endless alternatives, but do give foods that the child has accepted before; now is not the time to experiment. • Praise any food eaten. • Limit mealtimes to 20 to 30 minutes; you will both have had enough by then. • If meals are not being eaten, avoid snacks between meals, as this will just reduce their appetite for the next meal as well. • Watch drinking - it is tempting to offer a drink, particularly milk, if food is refused, but this will reduce their appetite for food. Cows’ milk is a good source of protein and calories, but a poor source of iron. Children who drink large quantities of milk thrive, but become iron deficient, establishing a vicious circle of poor appetite and increasing iron deficiency. • Do try to eat all together as much as possible at a table without distractions such as the television. This will help to show that eating is a relaxed and pleasant activity. • Don’t force, coax or bribe the child to eat - this can put a child off eating altogether; or they may simply realise that not eating is a good way of getting attention. • For older toddlers, a star chart can work well (in conjunction with reasonable portion sizes). Make sure rewards are not food related – ideas include swimming, a trip to the park, colouring book, stickers - whatever the child sees as a treat.
NHDmag.com December 2015 /January 2016 - Issue 110
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FOCUS ON EARLY YEARS Table 1: Food groups Food group
Servings per day
Meat and alternatives
Lamb, beef, pork, chicken, turkey, fish, eggs, pulses (peas, beans, lentils, dahl), nuts. Includes mince, cold meats, meat products etc.
Protein, iron and other minerals
Breakfast cereals, bread products (including tea cakes, bagels, pitta, bread muffins, crumpets, malt bread, bagels etc), crackers, potatoes, rice, pasta, chapatti, plantain, yam.
Energy, fibre (if higher fibre alternatives), B vitamins
Milk and dairy products
Milk, yoghurt, cheese, fromage frais, custard, cheese sauce etc.
3 - one serving = cup of milk = pot yogurt, = 4 x small pots fromage frais, = 30g cheese
Fruit and vegetables
All fresh, frozen, tinned and dried fruit and vegetables.
5 - (portion equivalent to a handful)
Vitamins A and C, fibre
Ultimately, parents need to be reassured that a healthy child will eat enough calories and protein if viewed over the longer term - even if they have days when they eat almost nothing, they will make up for it at a later stage. Children grow in â€˜spurtsâ€™ and this drives the variable appetite. Parents should be advised to consult their Health Visitor if they are concerned. Often weight gain can reassure parents. Professionals should avoid weighing too often as toddlers grow much more slowly than infants. To provide all the nutrition a toddler needs, they should eat foods from each of the food groups every day, as can be seen in Table 1. They may not eat a large range in each group at times, but parents can be reassured that they are meeting their requirements as long as they eat some food from each group. Healthy Snacks
Toddlers may need snacks in addition to their meals, as they still have small stomachs and high requirements. However, snack times should be at least two hours before the next meal; constant grazing should be discouraged, as it can lead to both poor appetite and overeating in different children. Many popular snacks such as crisps, biscuits, cakes and chocolate are high in fat, sugar and/or salt. Families need advice on suitable alternatives. Drinks
Toddlers need about four to six cups of drink per day, more if it is very hot or they have a tempera26
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ture. The best drinks to offer are milk and water; however, offer a maximum of two to three cups of milk per day, as more can affect appetite. Whole milk should be given until two years, when semiskimmed milk can be introduced if a child is gaining weight appropriately. One percent and skimmed milk should not be introduced before school age, except on the advice of a dietitian. Fresh fruit juice can be offered at mealtimes. If parents use fresh fruit juice or squash between meals, they should dilute 1 in 10 with water. If a child is still using a bottle, they should gradually be moved over to a cup to protect their teeth and discourage excessive drinking. Avoid valve type cups, which have all the same disadvantages as bottles. COMMON PROBLEMS
Constipation Children with poor bowel habits often have a poor fluid intake. If the child will not drink enough, parents can try high fluid foods such as jelly, custard, gravy and ice lollies made with fruit juice or fruit puree. Also, increase the amount of fibre the child eats, e.g. high fibre breakfast cereals such as Weetabix, puffed wheat, porridge, wholemeal bread, wholewheat pasta, all fruit and vegetables. If these simple measures do not correct the problem, then laxative medication should be prescribed. It should be increased until the child is passing soft stool every day and may be needed for a considerable period of time. It is important that young children do not habitually struggle to
FOCUS ON EARLY YEARS Table 2: Iron sources Meat
Liver and kidney are the richest sources of iron. Beef (including mince, beef burgers, sausages, corned beef and meatballs), lamb, pork and pate (not for children under one year) are also good sources.
Tuna, salmon, mackerel, sardines, pilchards or kippers.
Bread & cereals
Iron fortified breakfast cereals are a popular choice with children (e.g. Weetabix, Rice Krispies, Shreddies). Wholemeal bread, brown pasta and brown rice all provide more iron than the white types.
Apricots, peaches and prunes are the best sources. Dates, raisins and currants also contain some iron.
Baked beans, kidney beans, lentils and soya beans.
Spinach, broccoli, spring greens, kale, okra, watercress and rocket all contain some iron. Cooking vegetables for too long destroys their vitamin C content, so try steaming or stir frying instead.
Nuts and seeds
Cashew nuts, sesame seeds and tahini are particularly good sources (avoid whole nuts for toddlers).
Egg yolk contains iron, but the iron is not easily used in the body. Curry powder, Quorn and tofu are particularly good sources of iron for vegetarians. Bombay mix, plain chocolate, liquorice and treacle all contain iron - but should only be eaten in moderation, as they are high in fat and/or sugar.
open their bowels as this can lead to fear of opening their bowels and difficulties with toilet training. Withholding stool also causes a megacolon, which then makes it very difficult for a child to evacuate their bowels even when they try to do so. If problems persist, children should be referred to a constipation clinic or a paediatrician. Iron deficiency anaemia This is the most common deficiency in young children. Using figures from the National Diet and Nutrition Survey, SACN (Scientific Advisory Committee on Nutrition),1 the survey found that the majority of children aged 1½ to 3½ years (73-81%) had iron intakes <90% of the RNI for iron. They also found that one of the highest risk groups for iron deficiency anaemia (haemoglobin and serum ferritin concentration below WHO thresholds haemoglobin <110g/l; ferritin <12ug/l for children aged six months to five years2) was children aged 1½ to 2½ years (5.0 to 6.0%). This is probably because children have variable appetites and often have poor intakes of meat, possibly because many find it a difficult texture. However, many families do not seem to offer their children meat routinely as part of the weaning diet, which will place children at risk of iron deficiency in late infancy and the toddler years. SACN found evidence from randomised controlled trials of iron supplementation,
suggesting that iron deficiency anaemia is a cause of poor motor development in children in the first three years of life, although the long-term effects are unknown. There was insufficient evidence to determine whether iron deficiency or iron deficiency anaemia affects cognitive or language development in children aged three years or under. Evidence from randomised controlled trials also suggested that iron treatment has beneficial effects on cognitive development in anaemic children aged over three years, but it is not known whether these benefits are sustained in the long term. Symptoms of iron deficiency anaemia include poor appetite, lethargy and irritability. If iron deficiency is suspected, a blood test to check serum haemoglobin and ferritin should be performed. If it is confirmed, the child will be prescribed iron medicine to correct the problem; it is not very well tolerated, but it is important that the toddler takes the medicine until the doctor confirms that they can stop. If iron medication is refused, an alternative is to use sachets of iron rich water. This is classed as a food supplement and is not usually prescribable, but due to the high bioavailability of the iron, it can be a useful alternative to boost iron stores. After four to six weeks on iron therapy, appetite should start to improve. Parents should be advised to offer iron rich foods at least twice a day (see Table 2). In addition to the extra iron, they should offer NHDmag.com December 2015 /January 2016 - Issue 110
BREASTFEEDING IS BEST FOR BABIES
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Discover more at hipp4hcps.co.uk @hipp_for_hcps 1 Contains 1.89g/100kcal of protein, including _-lactalbumin, making the protein level and quality closer to that found in breastmilk (1.7g/100kcal). Nommsen LA et al. Am J Clin Nutr 1991; 53: 457–465. 2 Koletzko B et al. Am J Clin Nutr 2009; 89(5):1502S–8S. 3 Price per 100g of infant milk powder: HiPP £1.06, Aptamil £1.11. Price per case of 24 infant milk hospital formula: HiPP £8.36, Aptamil £8.84. Prices correct as at April 2015. Important Notice: Breastfeeding is best for babies. Breastmilk provides babies with the best source of nourishment. Infant formula milks and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle feeding may reduce breastmilk supply. The financial benefits of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.
FOCUS ON EARLY YEARS Table 3: Ten Steps for Healthy Toddlers (Infant and Toddler Forum)6 1 Eat together as a family and mealtimes relaxed happy occasions. 2 You decide which nutritious foods to offer but let your toddler decide how much to eat. 3 Offer foods from all five food groups each day. 4 Have a routine and offer three meals and two to three snacks each day. 5 Offer six to eight drinks a day. 6 Give vitamins A and D each day. 7 Respect your toddlers’ tastes and preferences - don’t force feed 8 Reward your toddler with your attention - never give food and drink as a reward, treat or for comfort. 9 Limit fried foods, high fat and high sugar foods to very small amounts a day and avoid sweetened drinks, undiluted fruit juices (well diluted at mealtimes only) and whole nuts. 10 Encourage physical activity for at least three hours every day and about 12 hours sleep.
a source of vitamin C, such as fruit or vegetables, with every meal, as this improves iron absorption. Vitamin D Problems relating to vitamin D deficiency are increasingly being recognised in all age groups. As well as the traditionally recognised problems of vitamin D and osteomalacia in young children, vitamin D deficiency has been implicated in other conditions such as cardiovascular disease and multiple sclerosis. Many populations in northern latitudes (usually described as 52 degrees north - above Birmingham in the UK) do not receive sufficient annual sunlight to synthesise enough vitamin D in the skin to meet their requirements and, additionally, anyone who has darker skin or habitually covers most of their skin is also at risk. Currently, apart from groups who are thought to be at risk (including young children), there is no RNI for vitamin D. However, a draft SACN report3 has recommended that a RNI for all age groups aged four and over should be set at 10ug/d and a safe intake (due to there being less evidence to make the recommendation) of 10ug/d for younger children and 8.5-10ug for infants to be established. In effect, population supplementation of vitamin D is being proposed. This would mean recommending a vitamin supplement containing sufficient vitamin D to every infant, child and adult that we encounter in our professional practice. Obesity Unfortunately, this is an increasing problem, even among toddlers. The Child Measurement Programme for England 2013/14,4 found that by school entry, over a fifth of children (22.5%) were already overweight or obese and results in the other
countries of the UK are similar. If a health professional (or parent) is concerned that their child’s weight is increasing too fast, their weight and height (length under two years) should be measured and plotted on a Body Mass Index (BMI) chart. Unlike in adults, a healthy BMI varies throughout childhood; a value above the 91st centile is overweight and above the 98th centile is obese. If there are concerns about a child’s weight, or to prevent weight becoming excessive in a child who comes from a family which is overweight (and is therefore known to be at higher risk), the following advice may help: • Offer three meals a day - avoid high fat foods and increase vegetables. • Offer fruit or salad only in between meals. • Reduce the amount of high fat and sugar foods in the house. • Don’t use food as a reward. • Encourage the child to drink water rather than juice or milk between meals. • Limit the amount of time the child spends in front of screens. • Encourage the child in active play - inside and outside. • Make efforts as a whole family to adopt a healthy lifestyle - see Change 4 Life for more details.5 IN SUMMARY
The toddler years can be difficult and food can become a big issue with many young children. However, a firm foundation of good nutrition and healthy lifestyle will effectively prepare toddlers for the challenges of the school years. For article references please email: firstname.lastname@example.org NHDmag.com December 2015 /January 2016 - Issue 110
FOCUS ON EARLY YEARS
Pre-school food provision The role for early years’ providers in encouraging healthy eating habits for life.
Judy More Dietitian & Registered Nutritionist, Member of the Infant & Toddler Forum (ITF)
Melanie Pilcher Policy & Standards Manager, Pre-school Learning Alliance, Registered Charity (PSLA)
Judy More is a Paediatric Dietitian and Registered Nutritionist who specialises in children’s nutrition. She is a member of the ITF. She has worked in the NHS but now runs her own private clinics. Melanie has nearly 25 years’ experience in early years. She writes articles and resources to support early years’ practitioners and represents the work of the PSLA as a speaker at conferences and seminars.
The UK obesity crisis has beginnings early in life. The latest figures from the National Child Measuring Programme reported that 22.5% children in Reception year (four- to five-year-olds) in England in 2013-2014 were overweight or obese.1 The figures rise to 33% for Year 6 children and probably involve the same children who were used in a UK study that found that overweight children carry their excess weight gained by five years through to at least nine years of age.2 The causes of obesity are multifactorial, but preventing excess energy intakes in the early years is one key way to tackle obesity. Food provision within early years’ settings has a significant role to play. The number of early years’ providers, including childminders, nurseries and children’s centres, totals 78,286, providing care to around 1.3 million under-fives.3 Some children eat all three meals on five days in these settings and the food provided is key in developing the food preferences and eating habits of these children. Positive food preferences and eating habits developed in early life can help shape the habits that older children adopt when they start to make their own food choices. This, in turn, can influence their risk of obesity, heart disease, diabetes and cancer later in life. Varying standards and guidance on nutrition within settings
Although there are guidelines from various agencies, there are no statutory requirements on meals, drinks and snacks provided in these settings. Decisions regarding the nutrition of these children are usually made by the
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early years’ managers and in-house cooks or chefs, although some providers outsource their catering service. The minimal training on nutrition for early years’ practitioners, along with the lack of statutory guidance standards, means that the quality of nutritional provision can vary. Some chains of early years’ settings, such as the PSLA, have developed their own in-house guidance with support from experts, while other groups use online or hard copy guidance from providers including: • Infant & Toddler Forum (ITF) • British Nutrition Foundation (BNF) • Caroline Walker Trust (CWT) • First Steps Nutrition • Local Authority Public Health Services • Private consultants and nutritionists • The Children’s Food Trust Some early years’ settings develop menus in-house without recourse to guidance or standards. There have been many calls to have Ofsted inspect food provision in early years’ settings as well as in schools, but this has so far not been added to inspection criteria. The All Party Parliamentary Group on a Fit and Healthy Childhood has recently called for this to be part of the Government’s National Obesity Strategy which is currently being developed.4 Despite the lack of statutory guidance and inspection, the PSLA believes that attitudes to food provision in early years’ settings continue to improve, with many recognising the need to budget for and provide fresh food. There is a marked awareness about what constitutes a healthy diet for very young children, which has increased in the last few
FOCUS ON EARLY YEARS years as new resources have become available. However, these need to be accessible and easy to interpret by managers, chefs and cooks within the early years’ settings, as well as parents. Consistent easy-to-follow guidance is most useful. Challenges of food provision in early years settings
The PSLA highlights the following ongoing challenges: • The costs in providing healthy foods, versus what parents are willing to pay. They report the average spend is between less than £1 and over £3 per child per day.5 • Perceived training needs, particularly in how to support parents and carers in their understanding of good nutrition.5 For example, while some providers employ a chef, some do not have that option and nominate a member of staff to provide the food and snacks for the day. • Food storage - fresh foods need cold storage, which is often difficult in smaller nurseries, where kitchens are very small. • Poor parental understanding of nutrition - the
PSLA understands the need to work together with parents. It provides online resources and publications that are suitable for parents as well as early years’ providers to help them understand what constitutes a healthy meal. There is a strong focus on supporting and educating parents on healthy attitudes to food and eating. Managing food allergies
A key challenge for early years’ settings identified by the PSLA is parental reporting of food preferences as food allergies or intolerances. The PSLA’s advice is to manage this by ensuring that key persons in the early years’ setting gain accurate information from parents from the outset, asking if a clinical diagnosis has been made, the symptoms a child can experience and any medical devices, such as adrenaline autoinjection pens, that must be used to alleviate symptoms. This becomes part of a healthcare plan for that child, ensuring that their needs are met at all times, which helps to put a parents’ minds at ease. In some instances, this is the first time parents will have left their children in the
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NHDmag.com December 2015 /January 2016 - Issue 110
FOCUS ON EARLY YEARS care of someone else, so managers need to be very aware of parents’ anxieties. The PSLA sees a need for better information for both practitioners and parents about what the differences are between a child’s intolerance and preference for foods over a medically diagnosed allergy. Nutritional needs for under-fives
As with older children and adults, under-fives need a diet based on the balance of the five food groups and a vitamin D supplement. The iron intakes of under-fives are more critical as iron deficiency anaemia (IDA) is still common in this age group and affects their growth and development.6 The combination of the five food groups is, therefore, more important with those who over consume cows’ milk as they are the most at risk of IDA.7 Within early years’ settings, vegetarians may be most at risk, as not all settings provide iron-rich alternatives to meat and oily fish, often providing excess cheese rather than dishes based on eggs or pulses in combination with a high vitamin C food. There is varying guidance on portion sizes for this age group, but guidance from the ITF and BNF are evidence based and were developed by More and Emmett to meet nutrient requirements within recommended energy intakes.8 Improving nursery food provision through training and resources
The PSLA in association with the BNF and Danone are trying to fill gaps in this area by creating new early years’ nutritionist roles, using external respected resources to guide their training. PSLA members currently use BNF and ITF ‘Ten Steps for Healthy Toddlers’ (see Table 3 page 29) portion sizes and the meal planning resources, among others. They are evidence based and targeted at under-fives. Many other
resources are for school-age children who have different requirements. Assessing the effectiveness of guidance
Despite the number of guidance documents, few have been assessed for their effectiveness. One resource that has been is ‘Ten Steps for Healthy Toddlers’ launched by the ITF in 2010. The ‘Ten Steps’ guide parents and carers on how best to provide a balanced diet with appropriate portion sizes from each food group and how to best manage mealtimes. PSLA practitioners were invited to complete a baseline survey when the project was initiated in 2011 and six months later a follow-up survey was issued to capture their experiences in implementing the ‘Ten Steps’; 32 managers of PSLA settings completed the baseline survey and 23 setting managers completed the follow-up survey. The survey found significant improvements in behaviours around food and feeding and also more confidence among the early years’ practitioners in dealing with allergies and issues around food. Conclusion
The importance of investing in guidance and training on healthy food provision in the early years of life is paramount as the foods that under-fives are offered are the foods that they become familiar with and learn to like. This shapes their food and drink preferences which can affect their long-term health. Early years settings can and do play a vital role in educating children in their care and their parents on healthy lifestyles habits, but without statutory guidance, standards are variable. For more information: ITF and resources for early years’ professionals: www.infantandtoddlerforum.org; PSLA: www.pre-school.org.uk
References 1 Health and Social Care Information Centre, National Child Measurement Programme 2013-14 (2014) 2 Gardner DS, Hosking J, Metcalf BS, Jeffery AN, Voss LD, Wilkin TJ. Contribution of early weight gain to childhood overweight and metabolic health: a longitudinal study (EarlyBird 36). Pediatrics. 2009 Jan; 123(1): e67-73. doi: 10.1542/peds 2008-1292 3 Ofsted, Department of Education, Early Years Annual Report: 2012/13 (September 2014) 4 The All-Party Parliamentary Group on a Fit and Healthy Childhood, Food in School and the Teaching of Food (2015) 5 Pre-school Learning Alliance survey of early years’ practitioners and food provision (internally published) (2015) 6 Eussen S, Alles M, Uijterschout L, Brus F, van der Horst-Graat J. Iron intake and status of children aged 6-36 months in Europe: a systematic review. Ann Nutr Metab. 2015; 66(2-3): 80-92. doi: 10.1159/000371357. Epub 2015 Jan 21 7 Parkin PC, DeGroot J, Maguire JL, Birken CS, Zlotkin S. Severe iron-deficiency anaemia and feeding practices in young children. Public Health Nutr. 2015 Jun 1:1-7 [Epub ahead of print] 8 More JA, Emmett PM (2015). Evidenced-based, practical food portion sizes for preschool children and how they fit into a well-balanced, nutritionally adequate diet. Journal of Human Nutrition and Dietetics, Apr; 28(2): 135-54. doi: 10.1111/jhn.12228. Epub 2014 Mar 24
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Skills and learning
Mindfulness for dietitians The practice of ‘mindfulness’ is now very much in fashion, so much so that it has caught the attention of the UK Parliament. In fact, by the time this article is published, the final ‘Mindful Nation’, report will also be available: an all-party parliamentary group inquiry providing recommendations into how mindfulness training could help meet government objectives. Dr Jackie Doyle BSc (Hons) PhD, ClinPsyD University College London Hospitals, NHS Trust and private sector
The purpose of this paper is to describe mindfulness interventions, their potential application in healthcare, but also to summarise two mindfulness interventions that have been developed for people with eating difficulties. Mindfulness Based Stress Reduction (MBSR)
As a clinical psychologist, Jackie has worked in a variety of medical specialties, including within the Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals NHS Trust. She is a qualified teacher of Mindfulness Based Stress Reduction (MBSR) and runs Mindfulness Based Eating Awareness Training (MBEAT) groups for individuals who have had bariatric surgery.
Although meditation as a practice is a feature of many religions, mindfulness meditation is often seen as having its routes from within the Buddhist tradition. Dr Jon Kabat-Zinn brought mindfulness meditation to mainstream Western medicine and clinical practice, just over 40 years ago. His programme of Mindfulness Based Stress Reduction (MBSR) was designed for people with chronic health problems which were difficult to diagnose and treat medically.1 Kabat-Zin defines mindfulness as, ‘paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.’ The value of this for a person in pain or in difficulty may not be immediately apparent. However, in a carefully crafted eight-week group course, people are guided through a range of meditational practices designed to bring a gentle curiosity and awareness of habitual patterns of the mind and body. Through this awareness, people are assisted to respond more kindly and skilfully to pain or illness and have a different relationship with suffering. The course includes teaching in a range of formal mindfulness meditation practices such as the body
scan, mindful movement and sitting meditations, plus practices which emphasise loving kindness, compassion and self-care. Informal mindfulness practices are also encouraged, in which participants are invited to bring the same non-judgmental, present-moment awareness to daily activities, such as walking, eating, household chores and work. Session length is typically two to two and a half hours and includes: 1 didactic teaching related to mindfulness; 2 guided formal mindfulness meditation practice(s), often lasting up to 40 minutes each; 3 a facilitated inquiry process in which participants are invited to share their experiences of the meditation and make links between these experiences and their usual habitual patterns and behaviours; 4 discussion of home-based practices, obstacles to practice and what they reveal for everyday life. Many programs also include a daylong retreat half way through the course, which is conducted in silence for most of the day and offers an opportunity for participants to deepen their meditational skills. Participants are given workbooks and audio CDs to support home-based practices. A recent systematic review and meta-analysis of randomised control trials using MBSR or MBCT (an adaptation of MBSR designed originally for people with chronic depression),
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Skills and learning concluded that the evidence supports the use of MBSR and MBCT to alleviate symptoms, both mental and physical, in the adjunct treatment of cancer, cardiovascular disease, chronic pain, depression, anxiety disorders and in prevention in healthy adults and children.2 Mindfulness for healthcare professionals: ‘Not just a technique’
As a clinician working within the NHS, I often hear that colleagues have “tried a bit of mindfulness” with their clients. In order to be effective; however, mindfulness has to be more than just a technique which is imparted through didactic teaching. Proponents of clinical mindfulness interventions argue that mindfulness instructors must have substantial personal experience with mindfulness practice and should teach from their own direct experience of mindfulness. Institutions in the UK, which train professionals to teach mindfulness, such as the Centre for Mindfulness Research and Practice, Bangor University and the Oxford Centre for Mindfulness, Oxford University, offer a structured MBSR teacher training pathway, which includes daily personal mindfulness practice, often in a residential retreat environment. The expectation is that mindfulness teachers will have their own regular mindfulness practice, to ensure that the teaching is authentic, such that teachers are able to act as role models and embody a mindful presence with their clients. In the words of Jon Kabat-Zin, “Our cardinal working principle is that the teaching has to come out of one’s practice. Thus, to the bones of the curriculum need to be added the flesh and sinews of one’s own experience with practice.”3 Busy healthcare professionals may, therefore, be interested in knowing the benefits for themselves. Mindfulness practice promotes qualities that patients value in their healthcare professionals, including attentiveness, nonjudgmental listening, compassion, presence and creative and collaborative problem solving.4 Mindfulness practice may also be a powerful self-care and stress management tool to manage burnout and enhance work satisfaction. One study of 30 primary care physicians who underwent a short mindfulness training course, showed improvements in job satisfaction and 34
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quality of life, as well as reduced levels of emotional exhaustion, depression, anxiety and stress, for up to nine months after the course.5 Mindfulness and eating
Two of the most well-known mindfulness approaches that are designed for people with eating difficulties are: i) the Mindfulness Based Eating Awareness Training (MB-EAT)6 and ii) Mindful Eating, Conscious Living (ME-CL), designed by Dr Jan Chozen Bays, a paediatrician and Zen Abbot and Char Wilkins, MBSR instructor and psychotherapist.7 The programme is based on the book written by Chozen-Bays, previously 2009.8 Both interventions are group treatments of nine sessions of 2.5 hours in duration, developed for people with binge eating or a disordered relationship with food. Neither approach has been used with people with anorexia nervosa. Both programmes involve training in the core meditations practices, plus specific mindful eating practices to encourage an awareness of physical hunger and satiety, an in-depth exploration of the range of triggers to eating that are not related to physical hunger and using mindfulness practices to respond to these skilfully. The cultivation of self-acceptance and compassion is a core component of both programmes. Unlike MB-EAT, ME-CL does not focus on weight or advocate specific energy balance reduction techniques. For example, the MB-EAT programme includes the ‘500 calorie challenge’ in which participants are encouraged to challenge themselves to find ways in which they can create an energy deficit of 500 calories per day. The ME-CL programme does not draw upon these more standard weight management techniques. One study of 150 overweight or obese (body mass index = 40.3) individuals, 66% of whom met the full DSM-IV-R criteria for binge eating disorder (BED), were randomised to MBEAT, Psychoeducation/Cognitive Behavioural Therapy (PECB) or waiting list controls (WL). MBEAT and PECB showed generally comparable improvement after one and four months postintervention on binge days per month, the Binge Eating Scale, and depression. At four months post-intervention, 95% of those individuals with BED in MB-EAT no longer met the BED criteria vs 76% receiving PECB. Furthermore, binges that
Skills and learning occurred were likely to be significantly smaller. The results suggested that MB-EAT decreased binge eating and related symptoms at a clinically meaningful level, with improvement related to the degree of mindfulness practice. Robinson et al has conducted a systematic review and meta-analysis of studies of ‘attentive eating’ and concluded that ‘attentive eating is likely to influence food intake and incorporation of attentive-eating principles into interventions provides a novel approach to aid weight loss and maintenance without the need for conscious calorie counting’.10
Professional training in both MB-EAT and MECL is available for individuals who are working in relevant professions, have participated in at least one MBSR course or similar and have their own person mindfulness practice. For details of training locations, see the Centre for Mindful Eating website.11 BCT online based in the UK also provides mindfulness taster days for dietitians wishing to experience mindfulness for themselves before committing to additional training.12
References 1 Kabat-Zin J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York: Delacorte Press 1990 2 Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL and Hunink MG (2015). Standardised mindfulness based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One, 16: 10 (4). DOI: 10.1371/journal.pone.0124344 3 Kabat-Zinn J. Foreword. In: Segal ZV, Williams JMG, Teasdale JD, eds. Mindfulness-Based Cognitive Therapy for Depression. 2nd ed. New York, NY: Guilford Press; 2012 4 Dzung XV, Doyle J and Christie D (2014). Mindfulness and Adolescence: A clinical review of recent Mindfulness-based Studies in Clinical and Non-clinical Adolescent populations. Adolescent Medicine: State of the Art Reviews, 15, 455-472 5 Fortney L, Luchterhand C, Zakletskaia L (2013). Abbreviated mindfulness intervention for job satisfaction, quality of life and compassion in primary care clinicians: a pilot study. Ann Fam Med, 11(5): 412-420 6 Kristeller JL and Wolever, RQ (2011). Mindfulness-Based Eating Awareness Training for Treating Binge Eating Disorder: The Conceptual Foundation, Eating Disorders, 19: 1, 49-61. DOI: 10.1080/10640266.2011.533605 7 www.me-cl.com/ 8 Mindful Eating: A Guide to Rediscovering a Healthy and Joyful Relationship with Food. By Jan Chozen Bays. Shambhala publications 9 Kristeller J, Wolever RQ and Sheets V (2014). Mindfulness-Based Eating Awareness Training (MB-EAT) for Binge Eating: A Randomised Clinical Trial. Mindfulness, Volume 5, Issue 3, 282-297. DOI: 10.1007/s12671-012-0179-1 10 Robinson E, Aveyard P, Daley A, Jolly K, Lewis A, Lycett D and Higgs S (2013). Eating attentively: a systematic review and meta-analysis of the effect of food intake memory and awareness on eating. Am J Clin Nutrition. DOI: 10.3945/ajcn.112.045245 11 www.thecenterformindfuleating.org 12 www.bctonline.co.uk
NHDmag.com . . .
. . . Your essential resource NHDmag.com December 2015 /January 2016 - Issue 110
PROTEINAHOLIC author: Garth Davis MD publisher: HarperOne 2015 ISBN: 978-0062279309 Price: £14.88
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 guides the NHD features agenda as well as contributing features and reviews
The pendulum of judgment about fiend nutrients (in excess) has been swinging from carbohydrates to fats and back. Until now, protein has enjoyed a virtuous halo. As the dangers of too much fat and/or too much carb have been so consistently communicated to the public, protein seemed the only dietary escape. But now Dr Davis has pulled in this nutrient for critical inspection and chastisement. Too much protein is not a good thing; it is bad. And many of the currently popular critiques of carbohydrates are muddled and misleading > come back potatoes (all is forgiven). By chance, I was behind a very wellmuscled young man in the shopping queue this morning. My basket held an uninspiring mix of groceries and a newspaper. Of course I could not restrain myself from a quick auditory glance at his basket: it held many packets of skinless chicken breasts, bags of biltong and dozens of eggs. My guess is that he was the title of this book being reviewed, or, in the description of Dr Davis, an adherent of ‘Bro-Science’. Dr Davis is a weight-loss surgeon, with a well-known health and weightloss clinic in Houston, Texas. This is not his first book: The Expert’s Guide to Weight-Loss Surgery was published in 2008 and is the most popular book on Amazon for patients considering this unfortunate choice. However, Dr Davis was uncomfortably exposed when a journalist phoned and asked him about his own health practices. “Oh, I run up and down stairs at the University,” was what he said. What he meant to say was, “I used to, occasionally walk some
NHDmag.com December 2015 /January 2016 - Issue 110
stairs at the University”. An immediate photo shoot was set up, leading the worst day of Dr Davis’s life. Squeezing into a tracksuit, he had to huff and puff at stair running for a photographer. Dr Davis was aware that he was overweight and unfit and he more than anyone in Houston should have known better. His subsequent medical check confirmed high blood pressure, elevated cholesterol and fatty liver. He was viewed as an expert on health and weight and felt like a hypocrite. One reason he researched and wrote the book Proteinaholic, is because of the success of his previous book in which he advocated a diet high in protein and fat and low-ish in carbohydrate. He felt that he had contributed to misleading his patients and, because he is such a close witness to the distress of obesity, he felt doubly responsible to conveying his insights that have led to his current excellent health and super fitness. Photographers and stair runs are now welcome. With the demonisation of fats and carbohydrates, Americans have been led to believe that protein is the answer. A survey by the Food Information Council reported that about 60% of Americans based all their meal choices around protein and that most were looking to consume ‘as much as possible’. Sales of protein bars and
book review drinks are doing well, beyond just the market of people seeking muscle gain or fat loss. The tags claiming protein content are also increasingly visible on UK food packaging. But typical diets in the US are far from deficient in protein. Dr Davis reviews historic and current calculations for protein requirements, and most American diets contain nearly double the requirements: the RDAs are 46/56g for adult women/men, whereas latest US dietary surveys report intakes of 70/102g. There are some population subgroups that may benefit from greater intakes and Dr Davis describes the scientific data in depth. Infants, athletes, the bedridden and the elderly may all need more protein than the average citizen, but increases from 0.8g/kg reference levels are modest, with little data supporting requirements above 1.0g/ kg, so still comfortably within typical intakes (and no need for supplementary sources). He cites some studies concluding benefits from higher intakes of protein, but concludes that these are fully contradicted by other larger, better studies, and that the higher-proteinneeds studies are quoted in isolation from more comprehensive reviews. In contrast, there are few studies demonstrating inadequate intakes in US diets where energy intakes are achieved. Interest in protein as a dietary theme to allow weight control developed strongly via Dr Atkins. There are many permutations to his original diet book published in 1972, with the latest variants described as paleo diets. Dr Davis challenges the romantic concepts of healthy primitive man and is also very mocking of rose-tinted descriptions of the health of the Masai tribes in Kenya and Inuits in Canada, much cited by those advocating eating diets high in animal flesh. Any differences in health compared to US citizens are despite, not because of, high intakes of meat, and differences are dramatically explainable by amounts of foods consumed and energy expenditures. Besides which, the health and life expectancies of both these particular population groups are poor; infection and environmental dangers kill them before chronic diseases can appear, so there is little valid data for comparison. Also, there are many other healthy, mainly starch-eating population groups that form valid contrasts to data cited by the protein-plus theorists.
The largest section of the book, pages 115 to 236, is a discussion and review of high intakes of protein in relation to diabetes, hypertension, heart disease, cancer and obesity risk. The difficulty of tackling these conditions in relation to protein is that there are thousands of studies and research parameters include meat and non-meat diets (but higher in fruits and vegetables). The complexity is untangling what effects may be specific to high intakes of protein, high intakes of meat and/or high intakes of veg. Dr Davis fully sets out these webs of influence and attempts to carefully follow through what the data shows (and what it does not show). He finds many repeated examples of incorrectly and over cited studies and other equally valid and meticulous studies that appear lost in public debate. He seems to particularly admire the European Prospective Investigation into Cancer (EPIC) studies, but pulls in a wealth of many other robust data to demonstrate the adverse effects of too much protein. His references, from Abelow on cross-cultural association between dietary animal protein and hip fracture, to Zur Hausen on reasons to suspect bovine infectious factors in colorectal cancer, are authoritative and comprehensive and allow detailed scrutiny of his claims. So, for example, what is the evidence on protein and cancer? Dr Davis describes both probable risks due to animal proteins in the diet and also reviews the epidemiological observations. He does not say that animal protein causes cancer, but he does say that animal protein causes various reactions in the body that have been shown to be carcinogenic, and that animal protein has been strongly correlated with some cancers. He cites a study in which the breast
Three books to give away We have three copies of Proteinaholic by Garth Davis to give away in a free prize draw. Send an email to email@example.com with your name, address and occupation. Alternatively, you can enter the prize draw at
www.NHDmag.com NHDmag.com December 2015 /January 2016 - Issue 110
book review tissue of women undergoing breast reduction surgery not related to any medical condition was examined. The study found a correlation between intakes of heterocyclic amines (HCAs), found in cooked meat, and the presence of pre-cancer DNA adducts in breast tissue. Or are intakes of heme iron, found in meat, linked to the development of unstable N-nitroso compounds, which may increase the risks of gastrointestinal cancer? Another smoking gun is insulin-like growth factor 1 (IGF1). Many studies have correlated increased intakes of animal protein with increased circulating IGF1 and increased IGF1 with higher rates of certain cancers. Plus, high protein diets have shown reduced (protective) butyrate production in the colon, although this could rather be because of concomitant lower starch intakes. Further culprits in relation to cancer risk are described as acidosis, methionine, Neu5Ge, changes in hormone levels, slaughter house chemicals and thermo-resistant viruses. He concludes the cancer chapter with reviews of epidemiological data in relation to particular individual cancers, with reference especially to the much discussed associations between red and processed meat and the increased risk of colorectal cancers.
Nine tenths of the book Proteinaholic, is excellent. The book provides a very readable and comprehensive review of nutrition science data and provides a detailed â€˜meatyâ€™ discussion of interpretation and application to public health messages. Dr Davies has delved deep into the research, and has pulled together a rich text for dietitians and nutritionists to consider and to use in support of challenging proteinmisinformation. One tenth of the book is awkwardly evangelical. If you went out to lunch with Dr Davies, you would not actually be able to see him over his salad plate, which consists of three cups of kale, broccoli, mushrooms, artichoke, topped with chickpeas, almonds and flaxseedsâ€Ś and a baked potato. A final chapter of meal plans, written with Dana McDonald, who describes herself as a â€˜rebel dietitianâ€™, is really too earnest and cranky to be helpful to the average reader. Not eating meat does not mean that you need to live on hemp seeds or sprouted pulses or coconut palm sugar. Healthy diets do not need the inclusion of bizarre and unfamiliar ingredients, and are an unfortunate conclusion to an excellent book.
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resources & guidance
web watch Online resources and useful updates. Visit www.NHDmag.com for full listings.
NICE shared learning: lifestyle changes can benefit health and social care staff NICE has added a new case study to its local practice database: How training on positive lifestyle changes can benefit health and social care staff. Published by Bolton Council Staff, this case study relates to NICE guidance NG18 on disability, dementia and frailty in later life, where recommendation 13 advises training on brief interventions for all health and social care staff, and that this this training should help participants change their own behaviour to reduce their own health risks. www.nice. org.uk/sharedlearning/howtraining-on-positive-lifestylechanges-can-benefit-health-andsocial-care-staff
sugar reduCtioN rePort Public Health England has published Sugar Reduction: from evidence to action. This document brings together the international evidence on interventions to help reduce the nation’s sugar consumption, as requested by the Department of Health. It contains options including further regulation of promotions, restrictions on the marketing of high sugar products, the impact of fiscal measures and a voluntary reformulation programme; www. gov.uk/government/publications/ sugar-reduction-from-evidenceinto-action
MANAGING ADULT MALNUTRITION IN THE COMMUNITY Summary Report by the Patients Association providing a spotlight on information about malnutrition, help and support available for Patients and Carers in England and 21 recommendations and calls for action; www.patients-association.org. uk/wp-content/uploads/2015/11/ managing-adult-malnutrition-in-thecommunity-summary-nov2015.pdf
breastfeediNg iN PubliC Public Health England has released data from a Star4Life poll which shows that more than a third of breastfeeding mothers shy away from doing so in public with 21% feeling that people do not want them to breastfeed in public. The findings aim to raise awareness of the issue, alongside the launch of new animated short films supporting the campaign for breastfeeding in public. The short films share real life experiences of mothers breastfeeding in public, to help break down the barriers and stigma that prevent many mothers doing so themselves; www.gov.uk/ government/news/new-mothers-areanxious-about-breastfeeding-in-public NICE Bites: Type 1 diabetes The October 2015 NICE Bites bulletin from the North West Medicines Information Service covers Type 1 diabetes (NG17). This guideline discusses the management of Type 1 diabetes in adults. The aim of this publication is to provide
healthcare professionals with a clear and succinct summary of key prescribing points taken from NICE guidance; www.elmmb.nhs. uk/newsletters-minutes/nicebites/?assetdetesctl486923=54926 Evidence on who is more likely to become obese 2020 Health has published Fat Chance? Exploring the evidence on who becomes obese. This report examines the current knowledge and data on obesity with the study looking at 16 datasets to determine ‘who’ is obese in the UK and what are the key correlates linked to rising levels of obesity; www.2020health. org/2020health/Press/LatestNews/Obesity-PR-4-11-15.html Carcinogenicity of consumption of red and processed meat The International Agency for Research on Cancer (IARC) has evaluated the carcinogenicity of the consumption of red meat and processed meat. A Working Group of 22 experts from 10 countries convened by IARC classified the consumption of red meat as probably carcinogenic to humans and processed meat as carcinogenic to humans; www.iarc.fr/en/mediacentre/pr/2015/pdfs/pr240_E.pdf A summary of the final evaluations is available online in The Lancet Oncology (register for free to view the article) and the detailed assessments will be published as volume 114 of the IARC Monographs; www.thelancet.com/ journals/lanonc/article/PIIS14702045%2815%2900444-1/fulltext
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ERAS UK: Conference Report A report on the 5th Enhanced Recovery after Surgery Society (UK) Conference held in Edinburgh on 6th November 2015 Dr Fiona Carter ERAS UK Manager, South West Surgical Training Network cic
Fiona is passionate about medical education, with over 20 years experience in the field.
The ERAS UK Conference organising committee were delighted to see 200 people gather in the James Watt Conference Centre of Herriot-Watt University in Edinburgh for our fifth UK Conference. Delegates had travelled from across Scotland, England, Wales and Northern Ireland to share their knowledge and experiences of enhanced recovery. This year, the Conference was chaired by Professor Ken Fearon, a consultant surgeon at the Western General Hospital and Professor of Surgical Oncology at Edinburgh University. Professor Fearon opened the Conference with a call for everyone to “move towards value based healthcare together”. He emphasised the important role that audit and research must play in the ongoing implementation and sustainability for ERAS programmes across the UK. The first session of the conference aimed to give us a reality check on the actual progress of ERAS across the UK in the last five years. Using the same reporting methodology as the Enhanced Recovery Partnership Programme (see www.gov.uk/ government/uploads/system/uploads/ attachment_data/file/215511/dh_128707. pdf for more details), volumes of specific procedures, mean and median length of stay (LOS) and the range of the mean LOS were presented. The data for primary hip and knee replacement, colectomy and excision of rectum, prostatectomy and bladder resection and abdominal and vaginal hysterectomy from 2009 to 2015. Tom Wainwright (Bournemouth University) discussed the data for England and illustrated the ongoing
NHDmag.com December 2015 /January 2016 - Issue 110
Figure 1: Professor Ken Fearon delivering the opening address.
improvements for some procedures and the wide variability in mean LOS, particularly for colorectal procedures and bladder resection. It was fascinating to compare this data with that from Scotland (presented by David McDonald, Whole Patient Flow Programme, Scottish Government) and from Wales (from Dr Rachael Barlow, Cardiff University), with similar issues highlighted for the same surgical specialties. A full report of this work will be published in the near future. Before each of our conferences, ERAS UK undertakes an online survey of their members to canvas opinion on key issues. This year, our survey focused on research priorities and the role of ERAS nurses. The second half of our ‘reality check’ session was led by Angie Balfour (Western General Hospital) and Imogen Fecher-Jones (University Hospitals Southampton), who presented the outcomes of the survey on the ERAS nurse role. The main areas of responsibility reported by the 33 ERAS nurses who responded (37.1% of those invited to take part), were: 1 Data collection or audit 2 Patient education 3 Support throughout the pathway 4 Staff Education 5 Project management
eras report Table 1: Oral presentations at the 5th ERAS UK Conference Abstract title
Self-medicating of over the counter analgesics for enhanced recovery programme
Poole Hospital NHS Foundation Trust
Pre-operative carbohydrate supplementation in patients undergoing lung resection: a pilot study
Golden Jubilee National Hospital
Use of wound infiltration catheters for enhanced Tim Brown recovery in laparoscopic live donor nephrectomies
Belfast City Hospital
Does intracostal suture placement reduce postoperative pain in patients undergoing thoracotomy under paravertebral analgesia
Golden Jubilee National Hospital
National implementation of enhanced recovery programme: anaesthetists opinion
Royal Free Hospital Second
Enhanced recovery programme for knee arthroplasty within the NHS
Oxford University Clinical Academic Graduate School
6 7 8 9
Pathway development Pre-assessment Post-operative support Post-discharge follow up
The majority of the audit tools used are local databases, with a small number of staff using the Encare system (see www.encare.se/ for more details) or national/regional toolkits. Delegates were encouraged to tweet their thoughts during the session (#ERASUK). The survey respondents reported a very wide variation in pay band for ERAS nurses (from band 4 to band 8), with almost three quarters working on week days only and roughly half being the only ERAS nurse in their trust. It should be stressed that the number of responses to the survey was relatively small and ERAS UK will send a second round of questions to this staff group, with the aim of gathering a more representative response. This session closed with an assurance that a reinvigorated forum would be established for ERAS nurses and those working in similar roles. The morning break featured a poster walk with over 30 abstracts presented and three marketplace stands covering enhanced recovery for elderly care, nutritional aspects of ERAS and a discussion point for an ERASapp. There was also a trade exhibition from the conference sponsors: Medtronic, Deltex, Nutricia, Halyard Health, Vitaflo and MSD. The second conference session began with another presentation based on our pre-conference survey.
Mr Nader Francis (ERAS UK Chair, Yeovil District Hospital) led an interactive voting session to determine the most important research questions related to enhanced recovery. The open text responses in the initial survey were categorised and the most frequent suggestions were used as the basis for the voting session: • Short, mid and long-term patient outcomes • Implementation of guidelines and protocols for each specialty • Optimal postoperative analgesia • Postoperative ileus • Fluid therapy within ERAS (including for high risk surgery) • Patient experience/satisfaction • Prehabilitation • Compliance and minimising variability • Data recording and sharing • ERAS in emergency surgery (including abdominal surgery) • ER for elderly care • Patient education/expectations The full results of this session will be provided on the ERAS UK website (www.erasuk.org). Six oral abstract presentations then followed, which displayed the wide variety of excellent work being undertaken in this field across the UK. Many of these presentations led to some interesting debate with the audience and on twitter (#ERASUK). The abstracts and authors are listed in Table 1. NHDmag.com December 2015 /January 2016 - Issue 110
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1 Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery:A randomized controlled trial. Colorectal Disease: 8, 563-569. 2 Sharma, M., Wahed, S., Oâ€™Dair, G., Gemmell, L., Hainsworth, P., & Horgan, A. F. (2013) A randomised controlled trial comparing standard postoperative diet with low-volume high-calorie oral supplements following colorectal surgery. Colorectal Disease: 15, 885-891.
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eras conference Delegates were able to spend more time networking and looking at the posters during the lunch break, when the judging panel were also able to reach their decisions on the top three: 3rd poster prize went to Kirsty Fraser from NHS Greater Glasgow and Clyde for a poster on ‘A new frontier: establishing a QI framework for enhanced recovery following elective caesarean delivery, a Scottish Government pilot at the Princess Royal Maternity’. Ceri Rowlands from Yeovil District Hospital won the 2nd poster prize for a ‘Feasibility study of volatile biomarker detection of anastomotic dehiscence in colorectal surgery (VERDDICT)’. The 1st poster prize was awarded to Jessica Whibley from Royal Marsden NHS Trust for an abstract titled ‘A decline in the incremental shuttle walk test result following chemo is associated with an increased risk of postoperative complications’. Full details of all the abstracts presented at this conference are available on the ERAS UK website at: www.erasuk.net/ uploads/2/6/4/0/26401678/5th_eras_uk_conference_programme__low_res_.pdf The third conference session began with three contrasting presentations on different tools for audit of ERAS compliance. Professor Olle Ljungqvist (Chair of International ERAS Society, Orebro University Hospital, Sweden) gave an overview of the implementation programme that is recommended by the ERAS Society, which makes use of the Encare database. David McDonald (Scottish Government) then presented the national toolkit that has been developed for use in five surgical specialties in Scotland. The final presentation on this topic was from Christine Ball (Head of National Clinical Analysis and Specialised Applications Team, NATCANSAT), who described the toolkit developed for use in England as part of the Enhanced Recovery Partnership programme and discussed the possible future uses of this system and the stored data. Session three then moved on to an update on the current and forthcoming UK studies on Prehabilitation, presented by Professor Mike Grocott (University Hospitals Southampton). The potential impact of modifying lifestyle factors (smoking and alcohol cessation, diet and activity) in the preoperative period was emphasised and these messages made a big impact with the audience. Dr Elizabeth MacDonald (Western General Hospital) then presented a talk on some of the practical challenges
Figure 2: Mr Nader Francis leading the interactive voting session on research priorities.
with pre-operative optimisation, with particular focus on frail, elderly patients. The importance of utilising a comprehensive geriatric assessment in the pre-operative period was raised, with many of the delegates reporting their intention to look at this in more detail (in the conference feedback). The final session of this one-day conference began with an overview of the latest advances in Pain Management from Jayne Balson (Western General Hospital). This talk examined the effect of optimal analgesia on post-operative mobilisation, fluid balance, gut function, return to normal diet and, ultimately, a good quality recovery. A multidisciplinary group of experts then took to the stage to discuss a series of tricky case scenarios with the audience. The initial section was led by Nader Francis and Angie Balfour and look at key stages in a typical recovery for a colorectal patient. The issues discussed included training of junior staff in ERAS, leadership and empowerment of ERAS nurses, the challenges of post-operative ileus and tackling negative attitudes in senior colleagues. Andrew Kinninmonth then presented a case scenario which illustrated long-term problems that can arise for knee replacement patients in an ERAS unit. After presentation of the poster and oral presentation prizes, Professor Fearon gave us a short summary of the day before closing the Conference. With very positive feedback from the participants, this 5th ERAS UK Conference was felt to be a success and work now starts to prepare the next Annual Meeting in Wales on 4th November 2016. If you want to get involved in shaping the content of the next conference or present your own work, please get in touch via the website (www.erasuk.net) or email (firstname.lastname@example.org). Twitter @ERASsocietyUK #ERASUK NHDmag.com December 2015 /January 2016 - Issue 110
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the final helping
Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders.
It was a wet Sunday in November and a job needed doing. Here I was in my loft, cup of tea in hand, sitting on the floor near the loft ladder listening to the first single I ever bought, You Really Got Me by the Kinks, being played on my original 1964 Dansette Standing Record Player. It had been a hard day decluttering, essentially because the Christmas decorations, placed at the far end of where was sitting, could not even be seen, let alone brought downstairs for the forthcoming celebrations. It was a day unintentionally filled with memories of my time as a student, as books and journals were unearthed from the loft and tough decisions had to be made as to what I should and should not keep, to the sound of music! Now this process had essentially taken place some years earlier, when most of my University notes had been removed, but now our loft seemed once again to be full of a combination of ‘dietetic memorabilia’ and grandparenting ‘furniture’! I have to admit that much of the former memorabilia had seen better days, so they subsequently found their place in the black recycling bin bag following a quick flick through. There were copies of the vivid orange BDA journal which I had arranged in chronological order going back to my starting date in 1966, until it ceased to be published in that form many years later. The dusty journals met the same fate. In the bin. It all reminded me though, of how hard we had to work to find information in those days. If you wanted to borrow a book from the library you virtually had to order it a couple of weeks in advance to secure its use. Either that or spend some of your student grant (not a
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loan) on the aforementioned item rather than luxury commodities like alcohol and entertainment. Not likely. How times have changed on both accounts. Back in the NHD office they have been working really hard at pulling together lots of useful resources and tools for our subscribers giving them their own subscriber zone with so much information and resource literally just a click away. Anyway, getting rid of pretty much everything dietetic from that time, which of course with advancing know ledge has now been superseded, was very cathartic both for myself and my growing family furniture. The journey to the modernised council tip to dispose of the contents of my four-year degree course provided an unexpected ignominy. I was expecting to literally post each item through an enclosed hole similar in size to that of a post box as on a previous visit, but when I asked where this now was I was told that now “all paper and books go in the cardboard skip”. I know that getting rid of those relics from the past was long overdue, but emptying en masse those black bin bags in the Fylde countryside into an open skip in darkening skies and heavy rain, certainly brought a damp final closure on that particular chapter. Watch out for a new and exciting chapter beginning 50 years later in 2016! The Dansette will carry on playing.
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The Dietitians' Magazine Issue 110