t en om m .c le ag pp m su HD a tr .N Ex w D ww H N e at lin on
NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
August/September 2017: Issue 127
CROHNâ€™S DISEASE Nutritional Management in Children ADULT FOOD ALLERGY CMPA MANAGEMENT VITAMINS AND MINERALS IMD - LOW PROTEIN DIETS
Introducing our new 'last word' column - p51
Making life easier. Everyday That’s why Vitaflo introduces 10g MCT Solutions. 50ml = 1 sachet = 10g MCT 10g MCT 95kcal 2g protein OR a full carton 3.3g (250ml) carbohydrate = 50g MCT 112kcal 473kcal
Two products containing MCT to help patients manage low LCT diets
MCT in two forms. A powder: MCTprocalTM and a liquid: betaquik® ®
MCTprocalT and betaquik® ® are neutral tasting palatable alternative fat sources. Both can be easily added to hot or cold foods and drinks with minimal impact on taste. No oily residue.
MCTprocal with protein or betaquik® ® without offers flexibility to help meet your patients’ requirements.
MCTprocal: pre-weighed sachets = accurate quantity of MCT. betaquik® ®: ready to use. Both easily transported outside the home.
To find out more about 10g MCT Solutions, simply contact your local Vitaflo® representative, or call our Nutritional Helpline on 0151 702 4937
A Nestlé Health Science Company
® Reg Trademarks of Societé des Produits Nestlé S.A.
Vitaflo International, Suite 1.11, South Harrington Building, 182 Sefton Street Brunswick Business Park, Liverpool, L3 4BQ. MCTprocal™ and betaquik® are foods for special medical purposes to be used under strict medical supervision.
FROM THE EDITOR
WELCOME Emma Coates Editor
Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics. She specialised in clinical paediatrics for six years, working in the NHS. She has recently moved into industry and currently works as Metabolic Dietitian for Dr Schar UK.
The term ‘legend’ is used extensively in conversation these days. It is bandied about as a term of admiration or extreme approval for the qualities of anything from an actor’s performance in film, to a body of work, or sporting achievements. Perhaps more relevant to this Welcome, is the meaning where someone achieves legendary fame through extensive work and dedication to a specific field. In this issue, we bring you several contributions from dietetic legends - and I do not think that is an over exaggeration! Pat Portnoi and Professor Anita MacDonald bring us an update on the 2016 international clinical guidelines for the management of classical galactosaemia, including diagnosis, treatment and followup. Both Anita and Pat have dedicated 57 years between them to patient care and research, with countless publications and contributions to nutrition and dietetics as a profession. With 25 years in nutrition research and expertise in maternal and infant nutrition, Simon Langley-Evans is Chair in Human Nutrition and Head of School of Biosciences at the University of Nottingham. This month he discusses the current evidence and recommendations for maternal obesity in his Prof Blog. Our very own legend, Ursula Arens RD has been a writer and columnist for over 25 years. In her Face to Face column this month, she discusses the career and thoughts of Dr Angela Madden, Nutrition and Dietetics Lead and the University of Hertfordshire. We also have further contributions from Dr Emma Derbyshire, an award winning and vastly experienced public health nutritionist. In addition to her regular Food for Thought column, Emma writes about the modern life phenomenon of feeling Tired all the Time (TATT). We are very excited to welcome some legends in the making who have taken on our ’end’ column in each issue. Dietitian’s Life is going to be put together by rising stars on social media, Louise Robertson and Sarah Howe. Both specialise in inborn errors of metabolism and work at the Queen Elizabeth Hospital in
Birmingham. They will be sharing a whole range of nutritional and dietetic insights in their new column. Our regular contributor, Maeve Hanan, discusses cows’ milk protein allergy this month, including current recommendations for treatment and management. Maeve’s article has been peer reviewed by leading expert on food allergy Dr Rosan Meyer, Paediatric Research Dietitian at King’s College, London. Another expert in her field, Dr Isabel Skypala, Consultant Allergy Dietitian at the Royal Brompton and Harefield NHS Foundation Trust, takes us through key aspects of adult food allergy and the current evidence. Kate Roberts RD gives an insightful case study detailing the treatment and management of a teenage boy requiring home enteral feeding due to Duchenne’s muscular dystrophy, while award winning and multi-talented Priya Tew RD also returns with an overview of vitamin and mineral supplements in childhood. Our IMD Watch article comes from Suzanne Ford, Specialist IMD adult dietitian, who this month talks us through the low protein diet in metabolic disorders. And it doesn’t stop there, as Specialist Paediatric Gastroenterology Dietitian, Rachel Wood, shares her experience and insights in our Cover Story on the nutritional management of Crohn’s disease in childhood. So there we have it, proof that NHD is written by legends and is an essential resource for any dietitian or nutritionist. Emma
www.NHDmag.com August/September 2017 - Issue 127
The only preterm post-discharge formula to contain prebiotic oligosaccharides
For formula-fed infants at greatest risk, including preterm infants, the World Health Organization (WHO) Safe Preparation Guidelines recommend sterile liquid formulas over powder formulas.3
Clinically proven to increase bifidobacteria in the gut and result in softer stools, more consistent with breastfed infants.1,2
IMPORTANT NOTICE: Nutriprem 2 is a food for special medical purposes for the dietary management of preterm and low birthweight infants. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants. References: 1. Mihatsch W et al. Acta Pediatr 2006; 95: 843-848. 2. Boehm G et al. Arch Dis Child Fetal Neonatal Ed 2002; 86: F178-81. 3. World Health Organization. Safe preparation, storage and handling of powdered infant formula [Online] 2007. Available at: http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf (Accessed September 2016).
11 COVER STORY
Crohn's disease: Nutritional management in children 6
Face to Face
33 IMD WATCH Low protein diets
Latest industry and product updates
With Dr Angela Madden, Nutrition and Dietetics Lead, University of Herts
16 ADULT FOOD ALLERGY On the increase in UK and across Europe
38 Galactosaemia New guidelines 43 Case study: enteral feeding In Duchenne's muscular dystrophy
48 PROF BLOG Obesity during pregnancy
19 Vitamin & mineral supplements Are they needed in children? 22 Tired all the time generation Alternative ways to re-energise
25 COWS' MILK PROTEIN ALLERGY
50 Event, courses & dieteticJOBS Dates for your diary
and job opportunities
51 Dietitan's life The last word
by Louise Robertson
Copyright 2017. All rights reserved. NH Publishing Ltd. 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 email@example.com 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.
Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst
Advertising Richard Mair Tel 01342 824073 firstname.lastname@example.org Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email email@example.com www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES
@NHDmagazine ISSN 2398-8754
www.NHDmag.com August/September 2017 - Issue 127
FOOD FOR THOUGHT
Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire
If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk We would love to hear from you.
Dr Emma Derbyshire Independent Consultant
OSTEOPOROSIS PREVENTION: A WHOLEFOODS APPROACH Osteoporosis is a silent and progressive disease affecting the density and quality of bone which, in turn, increases fracture risk. Figures from the International Osteoporosis Foundation reveal that around one in three women and one in five men are at risk of an osteoporotic fracture with wrist, hip and spine fractures being most common. The underpinning causes of osteoporosis are indeed multifaceted with hormone milieu, genetic and environmental factors all having a role to play. Modifiable lifestyle factors also have a valuable role to play in osteoporosis prevention, where the whole diet can play its own part. A new paper published in EFORT Open Reviews looked at evidence from 20 trials evaluating the role of wholefoods on bone health. Whilst it is well recognised that calcium and vitamin D are important bone nutrients, less is known about the roles that other aspects of the diet can play. Some of the main findings include the following: • Fruit and veg continues to be under consumed, yet also provides important micronutrients and phytochemicals that are useful for bone remodeling. • There is emerging evidence that dried fruits, such as prunes, could help to support bone health, mainly by providing meaningful amounts of vitamin K, manganese, boron, copper and potassium. • It appears that just 50g prunes daily could help to reduce bone breakdown after six months when eaten by postmenopausal women with osteopenia. • Nutrients such as selenium, copper and iron may have roles in bone health too. • We should aim to eat a healthy, varied and balanced diet throughout the lifespan, but especially during sensitive windows of bone turnover. The paper was aimed at orthopaedic surgeons who would like to better understand the role of nutrition in osteoporosis prevention. When taken together, a spectrum of nutrients are needed for bone health, not just calcium and vitamin D. Alongside this, phytonutrients and bioactives in foods also appear to have an increasingly important role to play. So, a wholefoods approach, rather than singling out certain vitamins and minerals, seems to be a more assured way of preventing osteoporosis. For further information, see: Higgs J, Derbyshire E and Styles K (2017). Nutrition and osteoporosis prevention for the orthopaedic surgeon: a wholefoods approach. EFORT Open Reviews 2; pg 300-308.
SUPPLEMENTS FOR SCHIZOPHRENIA? It has been shown that certain vitamins and minerals may act as an ‘adjunctive’ (supporting treatment) to antipsychotics, possibly by helping to restore nutritional deficits, lower oxidative stress or altering neurological pathways. Now, a new paper has looked at which supplements, in particular, could be most effective. Data from 18 randomised controlled trials was pooled (832 patients). Results showed that 6
www.NHDmag.com August/September 2017 - Issue 127
supplementation with B vitamins helped to significantly reduce psychiatric symptoms more than controls. No effects, however, were seen from antioxidants, minerals or inositol. These are interesting findings indicating that B vitamin supplementation could act as a helpful adjunctive therapy to those diagnosed with schizophrenia. For further information, see: Firth J et al (2017). Psychol Med Vol 47, no 9; pg 1515-27.
LEARN TO LOVE VEG IF YOU ARE BREASTFEEDING We know that what breastfeeding mums eat influences the flavour of the breast milk that she produces. These ‘flavour exposures’, as such, can then modify the infant's acceptance and likeability of similarly flavoured foods. Now, new research takes this a stage further and looks at the timing and duration of flavour exposures. Research carried out at the Monell Chemical Senses Centre in Philadelphia randomly allocated 97 mums and their infants to drink vegetable, beet, celery and carrot juices. They started to drink these for one month at two weeks, six weeks or 10 weeks after delivery, or for three months for two weeks after birth. A control group was asked to drink just water and avoid vegetable juices. Later on, when infants were seven to nine months old and foods were being introduced, their likability of certain flavours was assessed. Results showed that even a brief ‘one month’ experience with vegetable flavours in mothers’ milk, starting from two weeks after birth, led to children taking to a carrot-flavour cereal better than others. It was also found that one month of exposure was sufficient and even more effective that three months of veg flavour exposures.
OATLY OAT DRINK BARISTA EDITION (formerly called Foamable Oat Drink)
a Totally dairy and soya free a 100% plant-based - cool for vegetarians and vegans
a Fortified with vitamins and calcium
a No added sugar a Low in saturated fat (0.3g/
100ml) and rich in unsaturated fat (2.7g/100ml) a Contains beta-glucan oat fibre
a A sustainable milk alternative For more information: www.oatly.com/hcp
To book your Company's product news for the next issue of NHD call 01342 824 073 So, even before solid foods are introduced, flavour exposures via breast milk can play a key role in infants’ later likability of similar flavours. New mums should be aware that if they eat veg when they breastfeed, this may help their little ones to do the very same once they start eating solid foods. For further information, see: Mennella JA et al (2017). American Journal of Clinical Nutrition Vol 106, no 1; pg 67-76.
TOMATOES FOR HEART DISEASE A new review in the Proceedings of the Nutrition Society has looked at whether tomatoes and related products really can help to reduce heart disease risk. Results from in vitro studies and an evaluation of intervention trials was carried out. In vitro findings showed that carotenoids in tomatoes could help to inhibit oxidation, lower inflammatory markers, prevent tumourigenesis, trigger apoptosis and improve intracellular communication. Results from intervention studies showed that lycopene could help to protect the cardiovascular system by lowering high-density lipoprotein (HDL) inflammation. So, whilst we know that HDL is ‘good cholesterol’, it seems that tomatoes could further help to protect and shield this from inflammation. So, it seems that eating tomatoes appears to be good for HDL cholesterol too. For further information, see: Thies F et al (2017). Proceedings of the Nutrition Society Vol 76; pg 122-29. www.NHDmag.com August/September 2017 - Issue 127
FACE TO FACE Ursula meets: Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
Ursula meets amazing people who influence nutrition policies and practices in the UK.
DR ANGELA MADDEN Dietitian and Academic Nutrition and Dietetics Lead, University of Hertfordshire Co-author/editor: Oxford Handbook of Nutrition and Dietetics
Angela picks me up from Hatfield Station and we find a quiet café (except it is not: the music throbs; but as we are the only customers, our grumpy request for less volume is served, along with tea). Angela has had a dietetic career spanning many years in clinical practice, research and higher education: who better to interview for a cool and calm assessment of our profession? Young Angela was very sciency, achieving A-levels in Biology, Chemistry and Physics, but developing her interest in food at home. “My mother was, and still is, an amazing cook, but I didn’t really appreciate it at the time. Eating at a friend’s house when a ready-meal was served made me aware of how lucky I was.” Angela graduated in dietetics in 1982 from the University of Surrey. She had really enjoyed her student placement at Addenbrooke’s Hospital in Cambridge, as well as a nutrition placement at the MRC Epidemiology Unit in Cardiff. “I was surrounded by great researchers but didn’t realise it at the time. Professor Archie Cochrane was one of many experts who worked in the unit while I was there.” Her first job was at the Hammersmith Hospital in London. Although she was, of course, a basic-grade dietitian, it seemed like being thrown into the deep end of the profession. “The hospital had a postgraduate medical school, so many cases
www.NHDmag.com August/September 2017 - Issue 127
seemed complex, and many of the staff were academics. There was no Manual of Dietetic Practice or PubMed, so we often made clinical decisions about what to do on the basis of discussion between dietitians. But I enjoyed the challenges of work and living in London.” After two years, Angela wanted a change, which a maternity cover post in Saudi Arabia promised and delivered. The hospital was very different from NHS models of care, but very modern and well-funded. “I was wide-eyed and very interested in the different cultures and procedures, so I learnt a huge amount in a short time,” said Angela. Electronic patient records were in place decades before their use in the NHS. Her next job was at the Royal Free Hospital in North London as a specialist dietitian in the liver unit. In addition to lots of clinical care, she was closely involved with many research projects and while sitting on an interview panel to find a PhD candidate, the other panellists realised that the best candidate was not the one sitting across the table, but the woman sat on the panel with them! The post offered gains, of course, but also much hard work and long hours of effort. After much perspiration and a little inspiration, Angela completed her doctorate on the assessment of nutritional status and body composition in patients with chronic liver disease in 1998.
A friend suggested becoming a lecturer for the Dietetics course at what was then the University of North London (now the London Metropolitan University). “I was nervous, but on the first day of my first lecture, a student gave me the biggest smile and then I knew I had made the right decision,” said Angela. The diverse students at North London were often feisty, but it was their enthusiasm and support that Angela enjoyed most. In 2006, the University of Hertfordshire advertised for someone to set up an undergraduate Dietetics programme commissioned by the NHS in the East of England. Angela’s enjoyment of the challenges of living in London had waned. Travel hassle and high house prices exceeded the metropolitan magic and leafy Hertfordshire became more appealing, so she took the plunge and applied for the job at Herts. The HCPC approved the three-year Dietetic course and Angela became the Subject and Lead for Nutrition and Dietetics, which now includes two BSc courses and related research activity. There are currently about 60 students per year registered in Nutrition and Dietetics at Herts. These are interesting times for student recruitment, as changes in the demographic pool of 18-year-olds, withdrawal of NHS funding and Brexit, are all having an impact on the number of applications. The University of Hertfordshire was awarded ‘silver’ in the recent Teaching Excellence Framework (TEF) rankings, but Angela and her colleagues will be pedalling hard to achieve a better gold score in the next assessments. We talk about students. Entry criteria for the Dietetics course are higher for dietetic students than those studying nutrition and require them to be well qualified in science and to demonstrate interpersonal skills suitable to work with patients. Angela is concerned that the subject of Dietetics is still female-dominated and might benefit from more diversity (note our
discussion is between two white, middle-aged females!). A minority of her dietetic students are male and/or come from other ethnic groups and she occasionally wonders whether we make them feel as welcome as possible within our profession. I ask her in contrary spirit, whether this matters - patients want competent professionals; does it matter what gender or race they are? Angela is so thoughtful and tactful and allows that we cannot fully answer that question. But she feels that the dietetic profession might be sometimes held back by an excess of modesty and caution, and some greater diversity of thought and temperament could bring many benefits to propel the whole profession forward. Dietetics, like all professions, has changed over the years with digital tools and fixes. There are so many benefits that none of us would do without. But some blindness can creep in with constant online link-clicking, and information overload is a threat to being able to discern important and significant developments. Angela clearly loves the research side of Dietetics and how this relates to practice. She is co-editor of the Oxford Handbook of Nutrition and Dietetics and constantly contributes to a wide diversity of publications on nutrition science. But she is concerned that all dietitians should be critical thinkers and not just implementers of guidelines (NICE or otherwise). “Dietetics is not a pure science and the skill of the profession is understanding the many shades of grey between food intake and health,” says Angela. “The best way to develop better understanding and support better professional practice, is to encourage open debate. But this is something that many dietitians tend to shy away from.” For once, my argumentative side could not disagree. I was happy to think that future Dietetics graduates from the University of Hertfordshire would be combat-ready to fight for a better nutrition world.
If you would like to suggest a F2F date
(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact:
firstname.lastname@example.org www.NHDmag.com August/September 2017 - Issue 127