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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals

October 2017: Issue 128


Non-alcoholic fatty liver disease page 37-41


WELCOME Emma Coates Editor

“It is the task of dietitians to provide constant, consistent, clear clarification and correction (the 5Cs of dietetics?).” Ursula Arens

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.

I think our very own Ursula Arens is on to something. She’s been a busy bee for us this month bringing us a book review on How Food Works and her Face to face column this month, with Susan Church, Food composition expert and contributor to McCance and Widdowson publications. Ursula’s 5Cs are paramount to patient safety in dysphagia and texture modification. In this issue, we welcome Jenni Woolrich with her informative overview of dysphagia, providing us with the most up-to-date texture modification descriptors and recommendations. We welcome Penny Doyle too, who, 20 months into her role at REACT, a multidisciplinary team operating at the ‘front door’ of busy Stoke Mandeville Hospital, reflects on the challenges of obtaining useful nutritional screening at this dynamic Acute hospital. Penny reflects on compliance of the Malnutrition Universal Screening Tool (MUST) and ways in which compliance could be improved. In the last issue of NHD we touched on the new international Milk Allergy in Primary Care (iMAP) guidelines which are essential in the management of cows’ milk allergy. Dr Carina Venter and Dr Trevor Brown, both experts in the field of paediatric and adult food allergies, update us on the iMAP guidelines on pages 23-30 of this issue. In a trio of articles discussing the significant challenges involved in the management of maternal IMD patients, Una Hendroff, Mel Hill and Suzanne Ford, share their experiences of working

with this complex patient group. Read Mel and Una’s case studies in this print issue and follow-up with Suzanne’s in the November digital-only issue of NHD which will be available to view at Registered Nutritionist Dr Laura Wyness takes us through nutrition and lifestyle advice for non-alcoholic fatty liver disease (NAFLD). Until recently, NAFLD was considered to be quite rare and harmless, but it’s on the increase due to rising obesity figures. A day in the life of . . . feature aims to highlight the diverse roles and places dietitians and nutritionists work and play. This month Liz Waters tells us about her role as a Macmillan Dietitian and Nutrition Course Facilitator for Maggie’s Merseyside. Do you have an unusual or interesting role that you’d like to share with us for our A day in the life . . . feature? Take a read of Michele Sadler’s tips on Learning to write articles in NHD Extra, then get in touch and tell us more at Finally, in an interesting and thoughtprovoking article, Ruth Sullivan joins us this month to share her experiences of living without a sense of smell. Anosmia is a condition, which affects up to 5-6% of the population to some degree. Ruth describes the impact it has had on her appetite and sense of taste. The 5Cs run throughout this October issue of NHD – it’s a fascinating read. Emma October 2017 - Issue 128



11 COVER STORY Malnutrition: nutritional screening




Face to face

Latest industry and product updates With Susan Church

17 Opinion Estimating prevalence of dysphagia 19 Dysphagia Texture modification in patients

37 NAFLD Nutrition and lifestyle advice

42 ANOSMIA Living without a sense of smell 44 Book review How food works: The


46 Day in the life of . . . Liz Waters,

31 IMD watch: Case study Nutritional requirements in pregnancy


Macmillan Dietitian

48 BDA update Impact in the media 50 Events, courses & dieteticJOBS Dates for your diary &

Propionic acidaemia & twin pregnancy

facts visually explained

career updates

51 A dietitian'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 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


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SACN FOLIC ACID UPDATE The Scientific Advisory Committee on Nutrition (SACN) published a report in July this year, in response to a request by Food Standards Scotland, to update their recommendations regarding folic acid fortification. Folate is a B vitamin, found in food sources such as liver, yeast extract and green leafy vegetables. In contrast, folic acid is a synthetic form used for food fortification and supplements. Food fortification has a long history of use in industrialised countries for the successful control of nutrient deficiencies. In recent years, folic acid fortification of wheat has become widespread in the US, Canada and several Latin American Countries; however, in the UK, fortification remains on a voluntary basis. FINDINGS

Conclusive evidence from randomised controlled trials indicates that folic acid supplementation during early pregnancy can reduce the risk of neural tube defects (NTD), i.e. spina bifida. Subsequently, all women planning a pregnancy are currently advised to take a daily supplement of folic acid (400µg) prior to conception and until the 12th week of pregnancy. Unfortunately, evidence suggests that this advice has not been followed, with the proportion of women taking supplements falling from 35% in 1999-2001 to 31% in 2011-2012. RECOMMENDATION

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 We would love to hear from you.

In light of these findings, the SACN back their previous recommendation (2006) supporting mandatory fortification of flour with folic, but stipulating that it should only be introduced alongside restrictions on voluntary fortification to avoid intakes above current guidelines. SACN also concluded that uncertainties remained regarding folic acid and cancer risk and that ongoing research would be needed to monitor folic acid intakes and blood concentration in the general population. It should be noted that general guidelines remain the same as summarised below. SUPPLEMENTATION GUIDANCE TO STILL APPLY

Current government advice for all women who could become pregnant is to take 400μg/d of folic acid prior to conception and until the 12th week of pregnancy. Women with a history of a previous NTD-affected pregnancy (or diabetes) are advised to take 5mg/d of folic acid prior to conception and until the 12th week of pregnancy. This advice was endorsed by SACN in 2006 and 2009 and remains unchanged.

For more information, see: SACN (2017). Update on Folic Acid. Available at: Lo gi n to w w our w.N Su H bscr Dm ib ag er zo .com ne

NETW ORK Nutritionists for Dietitians, The Magazine July 2017: Issue


Professionals and Healthcare

system/uploads/attachment_data/file/637111/SACN_Update_on_folic_acid.pdf at




Children's eating disorder Page 41

NHD Digital

Don’t miss out on our digital-only issues of NHD. They are full of informative articles from our experts and essential information for all dietitians, nutritionists and healthcare professionals. View every issue online at October 2017 - Issue 128


Another new consultation: since there has been no comprehensive risk assessment of infant and young child feeding in the UK since 1994, SACN requested its Subgroup on Maternal and Child Nutrition (SMCN) to review recent developments in this area.

Breastfeeding lowdown So far, it is apparent that breastfeeding does indeed make a significant contribution to infant and lifelong health. It has a key role in the development of the immune system, with strong evidence showing that not breastfeeding can drive up hospital admissions of gastroenteritis and lower respiratory illness. Equally, early introduction of solid foods, at three to four months has been linked to increased likelihood of the same conditions.

Complementary feeding The introduction of complementary foods after six months was not associated with later difficulty in acceptance of solid foods; in fact, repeated exposure to new foods enhanced acceptance. As expected, it was evident that risks links to adding salt and free sugars to infants’ foods need to be re-emphasised. It was also raised that the introduction of peanut and hen’s eggs earlier than around six months may not only present an allergy risk, but their inclusion displaces breast milk. Micronutrients Iron status at birth is an important determinant of iron status throughout infancy. The report emphasised that during the first six months, breastfeeding provides sufficient dietary iron for healthy term infants. Standard advice that unfortified cows’ milk should not be introduced before 12 months of age still applies. This new report helps to document some of our latest concerns and inklings. That said, ongoing work is needed to delve much deeper into early years nutrition and the sheer significance of eating well during this fundamental life stage.

PRODUCT / INDUSTRY NEWS MEVALIA LOW PROTEIN LAUNCH ANOTHER ITALIAN CLASSIC Another Italian classic! Rigatoni pasta is an ideal option to smother in low protein sauces and fill up on. It’s high in fibre, just like the other pastas in our range. Now available as from 1st August 2017 on prescription. PIP code 404-8096. 500g pack size. Samples will be available. Find out more information at our website

To book your Company's product news for the next issue of NHD call 01342 824 073 NIACIN (B3) AND BIRTH DEFECT PREVENTION As discussed above, it is well recognised that folate and folic acid can help to cut birth defects such as NTDs. Now some exciting new work has looked at the potential role of niacin (aka vitamin B3) and how this may also help to reduce birth defects. The study published in the New England Journal of Medicine used genomic sequencing to identify potential pathogenic gene variants in families where birth defects were apparent. In particular, nicotinamide adenine dinucleotide (NAD) is synthesised from vitamin B3 and deficiency of this molecule is thought to trigger birth defects. Overall, authors and the results of the genomic sequencing showed that disruptions in NAD synthesis caused a deficiency of NAD and congenital malformations in humans and mice. It was also found that niacin supplementation during pregnancy prevented such malformations in mice. Clearly, repeated and human studies are needed. However, just as NTDs can have a strong genetic aetiology, there also appear to be genetic flaws leading to NAD shortfalls and possible birth defects linked to this. For more information, see: Shi H et al (2017). The New England Journal of Medicine Vol 377, issue 6; pg: 544-52 October 2017 - Issue 128



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.

SUSAN CHURCH Food composition expert Nutrition analysis trainer and food industry consultant

It was the end of the last day of the Nutrition Society summer meeting and Susan and I walked the 100 steps to the café at Somerset House, by the Thames. Little did we know that this was to be the venue for a live concert by the singer ‘Birdy’ in a few hours, and her musicians were setting up the sound systems. Cups of tea to Skinny Love. All dietitians have much loved, dogeared copies of McCance and Widdowson’s (M&W) The Composition of Foods. Perhaps it is the now obsolete edition six, published in 2002, or is it edition seven, published in 2014? In either case, Susan Church is listed among the compilers. These tomes are the fruits of huge efforts of time, money and expertise. “Most people, perhaps including dietitians, do not realise how much work goes into the development of a food composition database,” said Susan. She is very insistent that she is only a small part of the team and repeatedly says that I misunderstand her importance. But I know that she has been the most constant presence over a very long time in the development of the UK food composition database. Susan’s A-Levels were in Home Economics and Physics and Maths, perhaps some hint that her future career would bring together food and numbers. Her degree was in Food Science and Nutrition at the University of Nottingham and her first job was as an information scientist at the food industry body, the Leatherhead October 2017 - Issue 128

Food Research Association. “The job must have been from an advertisement in New Scientist magazine - it’s where I have found all my jobs,” said Susan. After three years and three thousand food science questions from food industry staff, it was time to move on. In 1991, she joined the nutrition department of the now-no-longer Ministry of Agriculture, Fisheries and Food (MAFF). The main job was the development of the food composition database which was needed for the assessment of government surveys of the nutrient intake and status of the UK population. The first survey Susan supported was that of food intakes of preschool children, allowing her an insight into every kind of toddler food. She was also closely involved in the fifth supplement of the fifth edition of M&W on Meat, Poultry and Game published in 1995. This was an essential update, because consumer preferences and intakes of meat had changed, leading to modifications in breeding and butchery specifications. Experts from the meat industries and food analysis helped to design the sampling to best reflect the types of meat being consumed in the UK at the time. An update of this information is now overdue! In 2000, this work was partly merged into the new more consumer-focused Food Standards Agency (FSA). For Susan it was same-job, different employer. Her

biggest project was the national survey of diet and nutrition in those on low incomes, published in 2007. The project was the outcome of a decade of research, and included experts from the National Centre for Social Research, King’s College London, the Royal Free and the University College London Medical School. This was a difficult project, as many of the interviewees reported long-term illness, no educational qualifications or poor understanding of the English language. But the challenging procedures in obtaining the information makes the outcomes very valuable: the report is still the most comprehensive assessment of diets of people with low incomes and remains the bedrock of discussions to support diet and nutrition policies in the UK. The development of accuracy and consistency of food composition data has been Susan’s most constant mission. From 2005, she joined the brigade of freelancers. In addition to supporting the ongoing development of the food database needed for the government National Diet and Nutrition Survey (NDNS), she consulted on the most recent, 7th summary edition of The Composition of Foods. This avocado-edition with feasts of new data was funded by Public Health England (PHE) and produced by a consortium led by the Institute of Food Research (IFR, now Quadram Institute). “There are constant changes to the supply and composition of food, and we try to make sure that the information we have is as accurate as possible. New foods arrive in the UK diet: think hummus or falafels. And there are many reformulation changes that have reduced trans fats, salt and sugar contents,” said Susan. There have also been methodology changes in food analysis over many years. “Fibre used to be measured by the Southgate method. Then the UK adopted the Englyst method.

Now the AOAC method is used for both labelling and the new DRVs. These different methods can give very different results, that dietitians should be aware of,” said Susan. At the moment, funding for the food composition database is on hold, and food composition professionals are anxious that the accuracy of information may drift. The team need to look at new ways to keep the database updated, including collaboration with industry. Susan seems anxious that the future is not rosy. Another freelancer project was the European Food Information Resource (FIR) association. This network of expertise from many European countries worked to develop a single online platform of upto-date food composition data. This has now been expanded into an international member-based association (EuroFIR AISBL). A current project is the development of validated information about bioactive plant compounds in the diet. “Dietitians should consider joining as individual members; a small fee of about £60 gives members access to a huge database of nutrient and food component information,” said Susan. Recipe analysis is easy-as-pie for Susan, but a scary crisis for pie manufacturers. She undertakes analysis and offers expert advice to many organisations and companies that need to declare nutrition information. But there are too many food companies and not enough Susans, and she also runs a twice-yearly course on Recipe Analysis, Maximizing Accuracy, for dietitians and nutritionists whose job requires this skill (see NHD’s events and courses page at for more information on these). As we leave Somerset House, there are queues of young people waiting to see the celebrity. Little do they realise that she is walking next to me.

If you would like to suggest a F2F date

(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact: October 2017 - Issue 128





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References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.

All information correct at the time of print. December 2016


MALNUTRITION: NUTRITIONAL SCREENING AT THE NHS ‘FRONT DOOR’ - A REVIEW Penny Doyle Registered Dietitian Buckinghamshire Healthcare NHS Trust (BHT) at Stoke Mandeville Hospital (SMH), Aylesbury Penny has worked part-time for BHT for 20 months as a REACT dietitian and has had previous NHS roles within West Hertfordshire including elderly rehabilitation, GP clinics and FODMAP groups. She is a member of the BDA Specialist Group for Older People and the BDA Freelance Group. Penny is author of four health cookbooks.

REACT (Rapid Emergency Assessment and Care Team) is a multidisciplinary team operating at the ‘front door’ of busy Stoke Mandeville Hospital serving over 48,000 inpatients and 219,000 outpatients a year. Penny’s unique post was created in 2016 with the aim of providing nutritional support to a team of physiotherapists, OTs, SLTs, nurses, social workers and HCAs assessing new admissions to Assessment and Observation Unit (AOU), Short stay ward and A&E. The philosophy of REACT is to limit unnecessary hospital stays, facilitate earlier and safer discharges and prevent readmissions by multidisciplinary working. Whilst Penny is aware of similar NHS dietetic roles that are split between the Acute and Community, she is not aware of other roles that are solely hospital based. She would, therefore, love to hear from other departments who have experience of comparable roles to discuss all aspects, including nutritional screening. Twenty months into her role at REACT, Penny reflects on the challenges of obtaining useful nutritional screening at the dynamic, ‘front door’ of a busy Acute hospital. The Malnutrition Universal Screening Tool (MUST) is the BHT tool on Acute wards, but compliance on Acute admissions and short stay wards could be improved, which would more readily identify suitable patients for intervention. If you would like to get in touch with Penny regarding this article, please email

Malnutrition is a large problem within the NHS and nutritional screening data has demonstrated that malnutrition remains a significant public health issue in both hospitals and the community. The British Association of Parenteral and Enteral Nutrition (BAPEN) cites that more than 10% of those aged over 65 years are at medium to high risk of malnutrition and amongst residents in care homes as many as 40% could be suffering from malnutrition,1 which can rise to 60% amongst those in hospital.2 Even obese people can become malnourished when acutely unwell and will show symptoms of lethargy, poor concentration, altered mood and poor physical status. We

know that in both the under- and overweight, malnutrition and loss of weight are associated with falls, increased infection risk, worse surgical outcomes and loss of independence. Primarily through the work of BAPEN, it is no surprise to fellow dietitians that malnutrition is often unrecognised and untreated in hospitals (both in- and out-patients), nursing homes and in the community. This is a great cause for concern for healthcare professionals, national October 2017 - Issue 128


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Stoke Mandeville Hospital (SMH) currently uses MUST which should be completed within 24 hours of admission . . . and which identifies patients at risk of undernutrition and who might benefit from nutrition support either with or without input from a dietitian. organisations and colleges, UK government departments, and the Council of Europe. Nutritional screening, which is the focus of this article, refers to a rapid, general, often initial evaluation undertaken by nurses, medical or other staff, to detect significant risk of malnutrition and to implement a clear plan of action, such as simple dietary measures, or referral for expert advice.1 NICE advises that there are conflicting views on the value of nutritional screening in any setting, and there is no clear evidence as to whether screening in primary care or the wider community is really beneficial, or how it should be carried out - a Guideline Development Group (GDG) is taking this forward.3 In the meantime, and mindful of my remit to reduce undernutrition risk to BHT patients, accurate nutritional screening was always going to be a big part of my plan. However, I am too encouraged and grateful for the key role that other ‘nutrition savvy’ health professionals play in helping to identify suitable patients. My REACT colleagues in all disciplines have proved helpful and supportive by encouraging MUST screening, but also simply by promoting excellent communication about a patient’s background, weight, and oral intake and sharing this appropriately in MDT and ward meetings. MUST IN BUCKINGHAMSHIRE HEALTHCARE

Stoke Mandeville Hospital (SMH) currently uses MUST which should be completed within 24 hours of admission, following Buckinghamshire Healthcare NHS Trust (BHT)

policy and which identifies patients at risk of undernutrition who might benefit from nutrition support either with or without input from a dietitian. BHT process is that dietitians are only asked to see patients with scores of 2 or more who have ongoing weight loss, and/ or who are more complex patients, e.g. with dysphagia, diabetes or other diagnoses, though in practice many more are referred. Local MUST training to Ward staff (RGNs, HCAs and Housekeepers) is provided by ward dietitians and also by some Nutrition Link Nurses (NLNs) where possible; SMH is also lucky to have an experienced Nutrition Specialist Nurse who provides annual training to NLNs and Housekeepers. The aim, in line with BAPEN advice, is that all staff can help identify patients who may benefit from input by a dietitian either in hospital or in the community. My REACT colleagues (HCPs and HCAs) have also proved supportive and willing to promote MUST scoring by ward staff (this score is including in the ‘Single Joint Assessment’ paperwork) and also in referring patients for dietetic assessment. Annual BHT audit of MUST in 2016 looked at records of 301 patients over 22 wards (including SMH, Wycombe Hospital and three rehabilitation wards at Amersham Hospital) and indicated poor compliance of nutritional screening in SMH short stay and assessment wards. At a snapshot in time, the audit measured parts of all five steps of MUST including % completion of patient MUST forms in nursing notes, which included patient’s October 2017 - Issue 128


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MALNUTRITION weight, height, BMI score, weight loss score, acute disease effect score and total risk score.3 The audit also looked at whether MUST plans (0, 1 or 2) were correctly instigated and if repeat screening had taken place weekly. A CASE FOR SUBJECTIVE MUST?

Subjective MUST – three questions Answering ‘Yes’ to one or more question indicates raised nutrition risk and can help assign a score to patients for whom weight/ height is not readily available. • Clinical impression: does the patient look like they have a low BMI (note MUAC can be used to estimate this)? • Does the patient look like they’ve had unplanned weight loss, e.g. loose rings or clothing and/or report recent limited food intake? • Acute disease effect, i.e. Is their condition likely to limit their intake for five days or more, e.g. dysphagia, delirium?4

Unfortunately, this (and previous) audits have identified that some Acute admissions don't always receive screening within the first 24 hours of admission. Ward managers are aware of this and are keen to address this by enabling further staff training, but have also queried the applicability of MUST in this setting. Patient turnover and clinical pressures are high, patients often staying in AOU <23 hours, though usually up to three to four days on short ARE THERE OTHER TOOLS FOR NUTRITIONAL stay wards. Lack of staff time and knowledge, SCREENING AT THE ‘FRONT DOOR’? clinical pressures and limited knowledge The difficulties in completing MUST in Acute about weight, height admissions/short stay or diet history, are all wards (SMH wards), as The difficulties in completing contributing factors with in any setting, should which many dietitians be addressed, as factors MUST in Acute admissions/ will resonate. However, contributing could include short stay wards (SMH I believe that we should limited understanding continue to support ward of benefit, time and wards), as in any setting, staff and also encourage opportunity. Acute Team should be addressed, use of ‘Subjective’ MUST dietitians, as good leaders, as factors contributing (see below), which should need to help overcome be valued equally, not as barriers which could could include limited a lesser tool. Subjective include training, improved understanding of benefit, MUST can also be quickly paperwork, adequate completed at bedside by equipment, e.g. scales and time and opportunity. any trained member of measures, and awareness the care team and can be of alternatives, e.g. equally useful in initiating a MUST care plan (1 Subjective MUST. Naturally, this will also lead to or 2) which is the crux of what we’re trying to consideration of other screening tools and whilst achieve. I would also argue that answering the this search wasn’t exhaustive, ones that I found three questions outlined below is a reasonable of interest included SNAQ (Short Nutritional part of the ‘receiving’ ward’s role in helping Assessment Questionnaire) and SGA (Subjective initiate good communication with family, carers Global Assessment). and other professionals. Ambulance crews In 2013, a large Dutch study5 concluded are usually excellent sources of information that the validity of both MUST and SNAQ is and, if relevant information is frequently insufficient for hospital outpatients, which communicated, it will become commonplace is possibly the most closely matched setting for all. for my REACT work and so is interesting to Nutrition assessment is key to any patient’s consider: 2,236 outpatients over a number of treatment and can start in the most basic form hospitals and departments were screened using by visual assessment at the time of a patient’s SNAQ and MUST to compare tools in this emergency admission. setting, and whilst SNAQ identified too few October 2017 - Issue 128


MALNUTRITION patients as undernourished, MUST identified too many. It was suggested that this is due to the MUST score’s weighting of acute disease effect; patients may well be misinterpreting this, so being classified as ‘high risk’ even with normal BMI and no known weight loss. By comparison, SNAQ’s underestimation can be most likely explained by the large number of patients who were classified as undernourished based on a low BMI. SNAQ was designed for inpatients for whom unintentional weight loss is measured and doesn’t include BMI, so would be missed. This study, therefore, advises simply to measure body weight, height and inquire about weight loss to determine undernutrition in hospital outpatients. However, a study by University Hospital Southampton NHS Trust in conjunction with Southampton University, published a study which used SNAQ to conclude that poor appetite was common among the older hospitalised women and was associated with a higher risk of poor healthcare outcomes.6 SGA is marketed as ‘a simple bedside method of assessing the risk of malnutrition and identifying those who would benefit from nutritional support’.7 It was founded by some international medics in 2004 and is validated in some settings including surgical, oncology and dialysis and ICU patients. SGA establishes predictive malnutrition risk using medical history and some physical measurements, but having briefly reviewed supporting literature, it strikes me as being more complex to train and

execute than MUST, so is not suitable for ‘front door’ screening. SUMMARY

Whilst nutritional screening tools are helpful, BAPEN 1 acknowledges that ‘there is no gold standard for the assessment of nutritional status, and no tool can replace a clinician’s judgment in interpreting information obtained from history, physical examination, anthropometric measurements and laboratory’. This resonates well with me as I find that liaison with my colleagues has been a very powerful tool in helping to identifying patients at risk. BAPEN also advises that screening should be repeated at regular intervals and that the same tool should be used to screen patients as they move from one healthcare setting to another. For the moment, therefore, I will continue to promote the use of MUST, using Subjective as needed, partly because it remains the most validated, user-friendly tool and is relatively easy to train, but also because it is widely used in the community and change would require a whole Trust review. In the future, and maybe initiated by this article, I hope to liaise with other departments and consider other tools, possibly even something bespoke for REACT, to help identify the most suitable patients for dietetic input. Do write to me with your comments and feedback via email:

References: 1 MUST Nutritional Screening of Adults - a multidisciplinary responsibility. BAPEN Executive Summary (June 2012) 2 Development of a screening tool for assessing risk of undernutrition for patients in the community. Journal Human Nutrition & Dietetics (1998); 11 323-330 3 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE CG 32- 2006 4 MUST Explanatory Booklet; BAPEN (2011). ISBN 978-1-899467-71-6 5 Leistra et al (2013). Validity of nutritional screening with MUST and SNAQ in hospital outpatients. Eur J Clin Nut 2013 6 Pilgrim et al (2015). Measuring Appetite with the Simplified Nutritional Appetite Questionnaire identifies hospitalised older people at risk of worse health outcomes. Journal of Nutrition Health and Ageing (2015) 7

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Helen Willis BSc, RD apetito Dietitian Helen Willis is a member of the British Dietetic Association and National Association of Care Catering. She previously worked in the NHS in both Acute and Community Dietetics.

WHY DYSPHAGIA SHOULD BE CAREFULLY CONSIDERED BY DIETITIANS Estimating the prevalence of dysphagia is a difficult task. A secondary condition, it is a common symptom of a huge number of disorders and diseases and can occur at varying severities. Dysphagia can be caused by neurological conditions such as dementia, stroke and motor neurone, congenital and development conditions such as cerebral palsy, muscular conditions and learning difficulties, or by obstructions resulting from cancers or GORD. This makes calculating the number of cases a challenge, but it is clear that dysphagia is a common problem, which can affect people of any age. However, it is the older population who are most susceptible. Up to 30% of over 65s are living with some form of dysphagia and there are a number of reasons behind this. It is this age group which is most likely to suffer from the most common underlying causes of dysphagia; dementia, stroke and multiple sclerosis, for example. Furthermore, the muscles used for swallowing can become weaker with age, so much so that elderly people often struggle to eat. It is no surprise then, that between 50 and 70% of care home residents in the UK are living with the swallowing condition. Considering the demographic profile of the UK, these percentages will undoubtedly rise. The population aged 65 and over grew by 47% between mid-1974 and mid-2014, to make up nearly 18% of the total population. The number of people aged 75 and over had increased by 89% over this period, now making up 8% of the total population. The ageing population will result in a

higher occurrence of the underlying causes of dysphagia; dementia, Parkinson’s and strokes, to name but a few, and so the prevalence of dysphagia will proportionately increase. This means that dysphagia will continue to rise on the dietitian’s agenda. Older patient’s nutritional intake is a concern under normal circumstances, but when swallowing difficulties arise, this can be particularly challenging. Changes in swallowing can lead to loss of appetite and enjoyment in eating, subsequently resulting in malnutrition and dehydration. In serious cases, aspiration can occur, leading to aspiration pneumonia and other infections. Whilst a speech and language therapist (SLT) can identify the specific problem and make recommendations on posture, exercises, techniques and food consistency, the nutritional value of meals is of upmost importance. Food needs to be appealing, satisfying, safe and nutritious. Yet texture modification, a common treatment of dysphagia, can raise challenges in meeting these criteria. The dietitian is often the professional in the best position to advise on each of these important elements. It is, therefore, essential that dietitians work collaboratively with SLTs, recognising their own work as a vital constituent of the management and treatment of dysphagia, a condition which will have an increasing prevalence in coming years. October 2017 - Issue 128


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TEXTURE MODIFICATION IN DYSPHAGIA PATIENTS Jenni Woolrich Highly Specialist Speech and Language Therapist, Betsi Cadwaladr University Health Board (NHS) Jenni has worked as a Paediatric Speech and Language Therapist for eight years. She currently works with children with complex needs, assessing and providing intervention to develop both communication and feeding skills.

For full article references please email info@ networkhealth

The Royal College of Speech and Language Therapists defines dysphagia as ‘a swallowing disorder usually resulting from a neurological or physical impairment of the oral, pharyngeal or oesophageal mechanisms’. Dysphagia is associated with increased morbidity, mortality and reduced quality of life. 1 Swallowing difficulties can lead to an increased risk of aspiration, when food or drink goes the ‘wrong’ way into the windpipe and enters the lungs, instead of going into the oesophagus and into the stomach; this in turn can lead to chest infections and pneumonia. So why does this happen? The normal swallow requires a combination of many things to work in harmony, ensuring that the food or drink entering our mouths is moved safely from the lips to the stomach. It relies on many anatomical structures working together alongside the motor and nervous systems. When one of the areas becomes less effective, or signals become less clear, it can have a huge impact on the process. Swallowing difficulties can be a result of physical changes such as a trauma to head or neck, neurological complications, or injury to the nervous system, respiratory disease, or due to psychological or behavioural factors. In both children and adults, dysphagia can be present as acute or chronic and within these categories, static or progressive in presentation.1 WHAT CAN WE DO TO HELP THIS?

There are a range of interventions that can be advised from education and training to feeding strategies to swallowing techniques to texture modification. Texture modification will be the focus of this article. The Francis report states that patients should have food and drink that is, as far as possible,

palatable to patients and this must be made available and delivered to them at a time and in a form that they are able to consume.2 WHAT IS TEXTURE MODIFICATION?

Texture modification is an intervention that may be advised by a speech and language therapist (SLT) for a client who has difficulties with their swallow. Following assessment, it may be recommended that changing the texture of the person’s drinks or food may increase the effectiveness of their swallow, but also and more importantly increase the safety of their swallow. For example, a person may find thin fluids such as water difficult because of the speed the water travels from the front to the back of the mouth and into the throat; their difficulty may mean that they are unable to control the liquid sufficiently to swallow and simultaneously protect their airway. By thickening the liquid to a different consistency, the liquid will move more slowly and, therefore, the patient may have more control over the liquid and have more time to coordinate their swallow more effectively and safely. With regard to food, different textures may have different impacts on the swallow. We often take the process of swallowing for granted, but it requires a lot of skill. Infants are taught over time how to move from a pureed diet to one that requires chewing and a lot more oral control. Once an area of the swallow is impacted, this may mean that some textures are more October 2017 - Issue 128


CONDITIONS & DISORDERS Table 1: Fluid Texture Descriptors4 Stage 1


Should pour like single cream.

Stage 2


Should easily drop off, not pour from a teaspoon.

Stage 3


Should stay on the spoon like whipped cream.

Table 2: Food Texture Descriptors5 Descriptor Code

Descriptor Name

What does it look like?


Thin Puree

Smooth consistency, no bits/lumps. It may need to be sieved to achieve consistency. It does not require chewing. There are no loose fluids that have separated off. Does not hold its shape on a plate. Cannot be eaten with a fork because it slowly drops through the prongs. Can be poured.


Thick Puree

Smooth consistency, no bits/lumps. It may need to be sieved to achieve consistency. It does not require chewing. There are no loose fluids that have separated off. Holds its shape on a plate or when scooped. Can be eaten with a fork as it does not drop through the prongs. Cannot be poured.



Food is soft, tender and moist. Needs very little chewing. It has been mashed up with a fork before serving. No mixed textures (thick and thin). Any fluid, gravy, sauce or custard in or on the food is very thick. No loose fluids.



Food is soft, tender and moist but needs some chewing. It can be mashed with a fork. No mixed textures (thick and thin). Any fluid, gravy, sauce or custard in or on the food is thick. No loose fluids.

difficult for them. As you would expect, and similarly to the typical feeding development pattern, the less textured a food is the easier it is to control and move around the mouth and swallow. So, when people are diagnosed with a swallowing problem it may be recommended that the texture of their food is modified. HOW DO WE MODIFY TEXTURE?

We can use thickening agents to change the consistency of both fluids and food: the more thickener that is added, the thicker the fluid or food gets. Thickeners are approved by the Advisory Committee on Borderline substances for the treatment of dysphagia.3 20 October 2017 - Issue 128

There are two types of thickener: • Starch based products - these have been available for longer and generally are cheaper. The downside of these is that studies have concluded that patients have experienced a ‘starchy’ flavour and these can cause lumps when mixed with some fluids. The thickener is also not stable and will continue to thicken over time; however, when mixed with saliva, the thickener can be broken down by amylase in saliva, leading to a potential safety risk.3 • Gum based products - have been found to be more stable and not change consistency. They have also been found to be more palatable and less grainy.

Figure 1: IDDSI definitions of texture modified foods and thickened liquids

Thickener can be recommended for a patient by an appropriate trained healthcare professional, e.g. an SLT, and is then usually prescribed by their GP or consultant, or prescribing dietitian. We can also change the texture of food by using a blender to produce a puree, or a fork to mash down the food into a smoother but lumpy consistency. HOW DO WE CATEGORISE THE VARIOUS TEXTURES?

Textures are defined by different terms to ensure consistency. With fluids, the varying consistencies are categorised into three stages (see Table 1). These are not currently included in the national descriptors, but are guidelines which are readily adopted across departments. Although used to describe fluids, thickener can also be added to food stuffs to increase the consistency, e.g. a runny yoghurt or sauce could have thickener added to increase its viscosity. With regards to food, there are national descriptors. These are the Dysphagia Diet Food Texture Descriptors published in March 2012 by the National Patient Safety Agency. The descriptors were developed in response to concerns relating to patient safety and a request

from industry and in-house caterers for detailed guidance on categories of texture.5 Table 2 summarises the descriptors. Although the descriptors in Table 2 are national, there is ongoing rally for international terminology and definitions for texture modified food and thickened liquids. Terminology does vary from country to country. Cichero et al comment that the use of globally recognised terms for food and liquids has clear advantages for facilitating the delivery of safe and quality therapeutic products to individuals with dysphagia.6 Since Cichero et al’s paper, the International Dysphagia Diet Standardisation Initiative (IDDSI) has been launched. It is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia for all ages, in all care settings and for all cultures7 (see Figure 1). It claims that the standardised descriptors and testing methods will allow for consistent production and easy testing of thickened liquids and texture modified foods.7 According to the IDDSI website, the UK is reviewing the framework in relation to current national standards and implementation discussions are underway. October 2017 - Issue 128



The majority of thickeners are intended for children over three years of age . . . For under threes, carob bean-based products can be used to thicken fluids. WHAT DO WE NEED TO CONSIDER WHEN MODIFYING A DIET?

Although thickener is prescribed to increase safety and reduce harm to the patient, as with many things, there are some considerations. The majority of thickeners are intended for children over three years of age, this is due to the sodium content. There have been a small number of reports of gum-based thickened fluids causing infant death4 due to tissues in the intestine becoming inflamed and its contents leaking into the abdomen. For under threes, carob bean-based products can be used to thicken fluids. Another concern is that a high proportion of people with dysphagia are considered to be dehydrated. Research has concluded that water is made bioavailable from all thickeners to even extreme levels of thickness.8 So, if this isn’t the reason for the dehydration, it could be suggested that the dehydration may be due to physiological expectations that thick fluids make [patients] feel full.8 In addition, thickener can suppress the flavour of the fluid and can leave the mouth feeling ‘sticky rather than wet’,8 resulting in the patient having reduced motivation to drink. Often, recommendations from medical staff would be for small amounts to be taken; this, in conjunction with the lack of motivation to drink, may mean that fluids are taken little but perhaps not often. Cichero et al recommend that clinicians should strive to prescribe only the least thickened liquid required for swallowing safety and aggressively pursue treatments to improve functional return to normal, unthickened liquids.8 Similarly to fluids, research has also raised concerns with modified textured foods that although it should be easier for patients to consume, a pureed diet has been implicated in the high prevalence of undernutrition in longterm care residents.9 It is suggested that this population may resist consuming modified textured food because it is often unappealing in appearance, texture and taste.9 22 October 2017 - Issue 128

To ensure that food and drink is consumed to the level that ensures hydration and appropriate nutrition, dysphagia patients, adults and children alike, need a support system in place to assist and encourage them. Staff in hospitals and school settings, family and others involved in their daily care would require training in the correct use of the thickener to ensure safety.4 Texture modified training should also be offered to catering staff in hospitals, care homes and schools to develop their knowledge of texture modified food and their awareness of dysphagia. Dysphagia is poorly understood by many frontline health professionals and this exposes people to avoidable discomfort, pain or even death. Practical education will help increase staff awareness and ensure thickeners are used consistently, thereby helping to improve safety.4 Patient’s recommendations also need to be reviewed and potentially updated; the timing and frequency of this will be dependent on a patient’s individual needs and circumstances. For example, a person with a progressive illness may be reviewed and their recommendations altered more frequently than a person with a more stable diagnosis. The recommendations should always meet the needs of the patient to ensure safety. SUMMARY

Texture modification is a recognised treatment for both children and adults with swallowing difficulties. It works by reducing the transit of food to allow the patient to coordinate their swallow more effectively and safely. This helps prevent food going the ‘wrong way’ into the lungs which could lead to complications such as choking or pneumonia. The recommendations for this intervention should be based on the needs of the patient, e.g. the degree of the dysphagia, the texture required and the palatability of the products. The competency and confidence of significant others, carers and other professionals in regard to texture modification also need to be considered to ensure the needs of the patient is met and their safety is maintained.


THE MAP MILK ALLERGY GUIDELINES: WHAT’S NEW? Carina Venter PhD, RD Assistant Professor University of Colorado Denver School of Medicine USA

Dr Trevor Brown MRCP (UK), FRCPCH Honorary Consultant in Paediatric Allergy, Children’s Allergy Service, Ulster Hospital, Northern Ireland Carina and Trevor are the joint first authors of the new updated version of the MAP guideline.

Carina is currently working in the Section of Allergy and Immunology at the Children's Hospital Colorado where she is conducting research and working with children and adults.

Trevor has acted as an advisor to the UK National Care Pathway for food allergy in children, the NICE food allergy guideline, NICE quality standard for food allergy and the NICE e-learning programme for food allergy.

In 2011, the UK Department of Health commissioned a National Institute for Health and Care Excellence (NICE) Guideline on Food Allergy with a very specific and targeted scope: the ‘Diagnosis and assessment of food allergy in children and young people in primary care and community settings’.1 They recommended that many presentations of food allergy should be managed in primary care UK, but no particular focus was placed on cows’ milk allergy (CMA). CMA is the most common cause of food allergy in the early months of life and its diagnosis and management is complex.2 For example, the majority of infants in the UK and Europe present as suspected mild to moderate non-IgE-mediated CMA,3,4 which then requires challenges at home to confirm or exclude the diagnosis. Additionally, with regard to the initial elimination trial prior to the required challenge, there are added complexities; in the formula-fed infant, choosing the most appropriate formula and in the exclusively breastfed infant, advising and supporting a strict maternal elimination diet.5 Given these particular complexities in the initial assessment and diagnosis of CMA, and the then ongoing need to practically advise on the management of mild to moderate non-IgE-mediated CMA within UK primary care, a subgroup of the clinicians on the NICE Food Allergy guideline development group published the MAP (Milk Allergy in Primary Care) guidelines. MAP particularly focused on the following questions:5 • How to distinguish between: i) IgE-mediated and non-IgEmediated presentations of CMA; ii) Severe and mild to moderate clinical expressions of CMA. • Which children should be considered for early specialist referral.

• How to provide guidance on formula choice in the initial diagnosis of CMA, based on the current international guidelines. • How to provide guidance about confirming the diagnosis and then the ongoing management of mild to moderate non-IgE-mediated CMA in primary care. To answer these questions, the MAP guideline authors developed a simple algorithm-based pathway covering the initial clinical presentations of CMA in infancy (both non-IgE and IgE), followed by the management in primary care of those children with confirmed mild to moderate nonIgE-mediated CMA. Since 2013, UK NICE followed up with two more publications: in 2015, a NICE Clinical Knowledge Summary (CKS) on the diagnosis and management in primary care of ‘Cows’ milk protein allergy in children’6 and in 2016, a NICE Quality Standard for food allergy.7 Since the publication of the MAP guideline in 2013, the British Society for Allergy and Clinical Immunology also published their specialist guidelines on cows’ milk allergy.8 The initial group of MAP guidelines authors therefore felt an update of the MAP guidelines was required to incorporate these. Further, it became increasingly apparent that the MAP guideline was being used much more widely October 2017 - Issue 128


THIS IS HUGE After months of coping with the sleepless worry and heartbreaking cries of his cow’s milk allergy, suddenly, a little moment like this doesn’t seem so little after all. • Proven efficacy – hypoallergenic and has been shown to relieve symptoms1,2 • Proven to be well tolerated – 96% of infants tolerated Similac Alimentum3 • Palm oil and palm olein oil free – supports calcium absorption and bone mineralisation4 SIMILAC ALIMENTUM. FOR BIG LITTLE MOMENTS.

REFERENCES: 1. Sampson HA et al. J Pediatr 1991;118(4): 520-525. 2. Data on file. Abbott Laboratories Ltd., 2013 (Similac Alimentum case studies). 3. Borschel MW and Baggs GE. T O Nutr J 2015;9:1-4. 4. Koo WWK et al. J Am Coll Nutr 2006;25(2):117-122. IMPORTANT NOTICE: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Date of preparation: July 2015 RXANI150143

than the UK, with almost 65,000 downloads worldwide from the Clinical and Translational Allergy website since 2013. To respond to this, the MAP authors decided to expand their guidelines development group to include authors from North America, South America, Africa, Asia and Australia. This has led to iMAP - an ‘international’ interpretation of the MAP (Milk Allergy in Primary Care) guidelines.9 iMAP went through an extensive review process, taking almost two years to reach consensus on this very complex clinical presentation of CMA, mild to moderate non-IgE-mediated allergy. We have summarised the changes we have made in the algorithms, formula choice and the milk ladder in Tables 1-5. The iMAP guidelines9 also now include a parent handout with information on non-IgE-mediated CMA. Some of the main changes that will particularly effect dietetic practice include: Symptoms of non-IgE-mediated CMA Although this will continue to be a topic of debate, the symptoms of ‘perianal redness’ and ‘respiratory symptoms’ have been removed. Maternal diet when breastfeeding In the new iMAP guidelines, only the mother who is exclusively breastfeeding her child will be advised to remove all forms of cows’ milk from her diet, as opposed to any breastfeeding mother. The authors realise that if a child only presents with symptoms upon introduction of formula or food, the amount of cows’ milk protein in breast milk is unlikely to trigger a reaction. Formula choice The iMAP guidelines focus on the use of extensively hydrolysed formulas as they are most suited for this population group. The guidelines do not distinguish between whey and casein-based formulas. The authors added in the option of using soy formula as that is often used as a first line treatment for non-IgE-mediated CMA outside of the UK. Reference to calcium and vitamin D supplements Actual doses for these recommended daily

supplements have been removed to allow for adhering to national guidance. Elimination period The guidelines now recommend a four-week elimination period, with a minimum of two weeks. Nomenclature change The guidelines now refer to home Reintroduction as opposed to home Challenge to confirm or exclude the diagnosis. However, the biggest change in the iMAP guidelines relates to the Milk Ladder. THE MILK LADDER

The revised Milk Ladder now has six steps opposed to 12 steps. • The doses of milk protein have also been changed to allow reducing from 12 to six steps. • Cultural foods, such as malted milk biscuit, digestive biscuits, shepherd’s pie, lasagna and Scotch pancakes, have been removed. • Baked/heated cheese has been removed due to parent feedback highlighting ongoing confusion and frustration, e.g. allowing lasagna but not grilled cheese sandwiches. • The recipes are now in units of grams, ounces and cups, to allow for international use. • Sugar has been removed/reduced from the recipes to comply with WHO guidance. • Commercial alternatives (malted milk biscuits, digestives) have been removed and the following statement was added: ‘Should you wish to consider locally available store-bought alternatives - seek the advice of your healthcare professional for availability’. IN SUMMARY

The new iMAP guidelines have a range of authors with international expertise. An initial fact sheet for parents is provided. The latest cows’ milk allergy guidelines from the UK have been incorporated. Some slight changes have been made to symptoms relating to mild to moderate non-IgE-mediated cows’ milk allergy. October 2017 - Issue 128



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For more information, call our Healthcare Professional Helpline on 0800 996 1234, or visit References: 1. Keohane PP et al. Gut 1985;26(9):907-13. 2. Bach AC, Babayan VK. Am J Clin Nutr 1982;36(5):950-62. 3. Mabin DC et al. Arch Dis Child 1995;73(3):208-10. 4. Pedrosa M et al. J Investig Allergol Clin Immunol 2006;16(6):351-6. 5. Miraglia Del Giudice M et al. Ital J Pediatr 2015;41:42. 6. Shaw V, Lawson M (eds). Clinical Paediatric Dietetics. 4th ed. Oxford: Blackwell Publishing, 2015.

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Formula milk choice now focuses on extensively hydrolysed formulas and reference to soya milk is made for countries where this is used. Maternal cows’ milk avoidance is only recommended when exclusively breastfed and daily calcium and vitamin D supplements should be prescribed in doses according to national guidance.

The Milk Ladder covers six steps instead of 12 steps (see Table 4) and the recipes have been adapted to comply with WHO standards, parental needs for savoury options, international cooking/ baking practices and cultural food preferences. Milk protein doses have been adapted to allow for six steps instead of 12 steps.

Table 1: MAP and iMAP guidelines - details MAP


Year of publication




MAP - Milk Allergy in Primary Care guideline

iMAP - an international interpretation of the MAP (Milk Allergy in Primary Care) guideline

Healthcare professional key target groups

Primary Care

Primary Care and ‘First Contact’ clinicians


Five UK-based clinicians representing UK primary, secondary and tertiary level clinical allergy (no industry sponsorship)

Original five UK authors plus seven international tertiary care level paediatric allergy colleagues from USA, China, Australia, South Africa, and Brazil (no industry sponsorship)

Source material

UK NICE Food Allergy Guideline for children and young people in primary care and community settings CG 116 2011 World Allergy Organisation Guideline on cows’ milk allergy (DRACMA) 2010 USA NIAID Food Allergy Guideline 2010 USA AAP Guideline on Hypoallergenic Infant Formulas 2000 ESPGHAN Guidelines on the diagnosis and management of cows’ milk allergy 2012 Vandenplas et al ‘European’ Guideline on cows’ milk allergy 2007 Australian Consensus Statement on the diagnosis and management of cows’ milk allergy 2009

As per MAP Guideline development Constructive clinical feedback from widespread UK use of MAP Input from seven international co-authors UK NICE Clinical Knowledge Summary (CKS) on managing cows’ milk allergy in children under five years of age 2015 UK NICE Quality Standard for Food Allergy in Children for primary care healthcare professionals 2016 UK BSACI Specialist Guideline on cows’ milk allergy 2014

Centred on 2 Algorithms

1. ‘Presentation’ 2. ‘Management’

1. ‘Presentation’ 2. ‘Diagnosis and Management’

Table 2: Presentation Algorithm: symptoms MAP


Initial advice

Initially advises on the need for an Allergy-focused Clinical History

Initially advises on the need for both an Allergy-focused Clinical History and Physical Examination

Mild to moderate non-IgE-mediated Symptom Box

‘One or more of these symptoms’

‘Usually several of these symptoms will be present’.‘Treatment resistance, e.g. to atopic dermatitis or reflux, increases likelihood of allergy’ Table continued overleaf October 2017 - Issue 128


PAEDIATRIC Table 2: Presentation Algorithm: symptoms - continued Mild to moderate non-IgE-mediated Symptom Box

Mild to moderate IgE-mediated Symptom Box

Gastrointestinal ‘Colic’ ‘Reflux’ – GORD Food refusal or aversion Loose or frequent stools Perianal redness Constipation Abdominal discomfort Blood and/or mucus in stools in an otherwise well infant

Gastrointestinal Irritability -‘Colic’ Vomiting - ‘Reflux’ - GORD Food refusal or aversion Diarrhoea-like stools loose and/or more frequent Constipation - especially soft stools with excessive straining Abdominal discomfort, painful flatus Blood and/or mucus in stools in an otherwise well infant (Perianal redness-removed)

Skin Pruritus, erythema Significant atopic eczema

Skin Pruritus (itching), Erythema (flushing) Non-specific rashes Moderate persistent atopic dermatitis

Respiratory ‘Catarrhal’ airway symptoms (usually in combination with one or more of the above symptoms)

Respiratory Symptoms-removed

‘One or more of these symptoms’ Skin Gastrointestinal Respiratory

‘One or more of these symptoms’ Skin - one or more usually present Gastrointestinal Respiratory

Table 3: Presentation Algorithm: initial dietary guidance and early referral to specialist care Initial dietary guidance



‘Advise breastfeeding mother to exclude all cows’ milk containing foods from her own diet’, ‘and to take daily calcium (1000mg) and vitamin D (10mcg) supplements

‘Advise exclusively breastfeeding mother to exclude all cows’ milk containing foods from her own diet’ ‘and to take daily supplements of Calcium and Vitamin D according to local recommendations’

With suspected mild to moderate nonIgE-mediated CMA: ‘Can be managed in Primary Care See Management Algorithm’

With suspected mild to moderate NonIgE-mediated CMA: ‘Cows’ Milk Free Diet Extensively Hydrolysed Formula-eHF See Management Algorithm’

With suspected mild to moderate IgEmediated CMA: ‘Cows’ Milk Free Diet Extensively Hydrolysed Formula-eHF (Initial choice, but some infants may then need an Amino Acid Formula - AAF trial if not settling’

With suspected mild to moderate IgEmediated CMA: ‘Cows’ Milk Free Diet Initial 1st choice Extensively Hydrolysed Formula-eHF Soy may be used in some settings if not sensitised’ (There is little reference within the Algorithms on the role of amino acid-based hypoallergenic formulas as they are not initially indicated in children with suspected clinically mild to moderate cows’ milk allergy) Table continued opposite

28 October 2017 - Issue 128

Cows' milk allergy is the most common cause of food allergy in the early months of life and its diagnosis and management is complex. Table 3 continued Early referral to specialist care

When advised: ‘to a paediatrician with an interest in allergy’

When advised: ‘to local paediatric allergy service’ (emphasising need for multidisciplinary assessment and ongoing management)’

Table 4: Diagnosis and Management Algorithm: initial guidance to confirm the diagnosis of mild to moderate non-IgE-mediated CMA MAP


‘Strict exclusion of cows’ milk containing foods from the maternal diet’

‘Strict exclusion of cow’s milk containing foods from the maternal diet’

‘Maternal supplements of calcium (1000mg) and vitamin D (10mcg) daily’

‘Maternal daily supplements of calcium and vitamin D according to local recommendations’ A maternal substitute milk should be advised’ ‘If atopic dermatitis or more severe gut symptoms, consider egg avoidance as well’

On confirmation of the diagnosis: ‘If top-up formula feeds needed use an AAF’

On confirmation of the diagnosis: ‘If top-up formula feeds should later be needed, eHF may well be tolerated. If not, replace with an AAF’

Formula feeding or ‘mixed feeding’ (breast and formula)

Mixed feeding - ‘Trial of a cows’ milk free Maternal Diet With eHF top-ups for infant if needed’

Mixed Feeding - ‘If symptoms only with introduction of top-up feeds, replace with eHF top-ups – mother can continue to consume cows’ milk containing foods in her diet’

All feeding categories

‘Agreed 2-4 week Elimination Diet’

‘An agreed Elimination Trial of up to 4 weeks - with a minimum of 2 weeks’

Re: Symptoms ‘Improvement’ - ‘No Improvement’

Re: Symptoms ‘Clear Improvement’ - ‘No Clear Improvement’

The diagnosis still needs to be confirmed by reintroduction of cows’ milk protein referred to as a ‘Home Challenge’

The diagnosis still needs to be confirmed by reintroduction of cows’ milk protein referred to as a ‘Home Reintroduction’

Involvement of dietetic support

When milk allergy is initially suspected:

When milk allergy is initially suspected:

Exclusively breastfeeding

‘Refer to dietitian’

‘Refer to dietitian’

Formula feeding or ‘mixed feeding’ (breast and formula)

‘Refer to dietitian’

Only: ‘If weaned - may need advice and support from dietitian’. Otherwise - on confirmation of CMA diagnosis following Home Reintroduction

Exclusively breastfeeding October 2017 - Issue 128


PAEDIATRIC Table 5: Diagnosis and Management Algorithm: on confirmation of diagnosis, later reintroduction at home using a Milk Ladder to test for acquired tolerance MAP


iMAP Milk Ladder Indication for use

‘For children with mild to moderate non-IgE cows’ milk allergy under the supervision of a healthcare professional, ideally a dietitian’

‘To be used only for children with mild to moderate non-IgE cows’ milk allergy under the supervision of a healthcare professional’

Number of steps

12 Steps

6 Steps

The recipes

Those more culturally limited milk products, such as Scotch pancakes and shepherd’s pie, have been removed The necessary accompanying home recipes for the differing baked milk products have been more carefully researched with regard to exact amounts of cows’ milk protein - the timing and temperature of heating, the possible matrix effect of wheat and fat and also with regard to the effect of flour and other ingredients from UK, France, USA and Ireland The use of sugar in the recipes has been restricted in accordance with WHO guidance and plain/savoury options have been provided for those who choose not to use the sweeter recipes Allowance has been given where home baking may not be feasible: ‘Should you wish to consider locally available store-bought alternatives, seek the advice of your healthcare professional for availability’

References 1 Excellence NIfHaC: Diagnosis and assessment of food allergy in children and young people in primary care and community settings. Walsh J, O'Flynn N (2011) 2 Fiocchi A, Brozek J, Schunemann H, Bahna SL, von Berg A, Beyer K, Bozzola M, Bradsher J, Compalati E, Ebisawa M et al. World Allergy Organisation (WAO). Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) Guidelines. Pediatr Allergy Immunol 2010, 21 Suppl 21:1-125 3 Venter C, Pereira B, Voigt K, Grundy J, Clayton CB, Higgins B, Arshad SH, Dean T: Prevalence and cumulative incidence of food hypersensitivity in the first 3 years of life. Allergy 2008, 63:354-359 4 Schoemaker AA, Sprikkelman AB, Grimshaw KE, Roberts G, Grabenhenrich L, Rosenfeld L, Siegert S, Dubakiene R, Rudzeviciene O, Reche M et al.: Incidence and natural history of challenge-proven cows' milk allergy in European children. EuroPrevall birth cohort. Allergy 2015, 70:963-972 5 Venter C, Brown T, Shah N, Walsh J, Fox AT: Diagnosis and management of non-IgE-mediated cows' milk allergy in infancy - a UK primary care practical guide. Clin Transl Allergy 2013, 3:23 6 Excellence NIfHaC: Cows' milk protein allergy in children. NICE: Clinical Knowledge Summaries. Edited by; 2015 7 Excellence NIfHaC: NICE: Quality standard for food allergy NICE Quality Standard 118. Edited by; 2016 8 Luyt D, Ball H, Makwana N, Green MR, Bravin K, Nasser SM, Clark AT, Standards of Care Committee of the British Society for A, Clinical I: BSACI guideline for the diagnosis and management of cows' milk allergy. Clin Exp Allergy 2014, 44:642-672. 9 Venter C, Brown T, Meyer R, Walsh J, Shah N, Nowak-Wegrzyn A, Chen TX, Fleischer DM, Heine RG, Levin M, Vieira MC, Fox AT: Better recognition, diagnosis and management of non-IgE-mediated cows' milk allergy in infancy: iMAP - an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy 2017, 7:26

30 October 2017 - Issue 128


IMD AND PREGNANCY - CASE STUDY Una Hendroff RD Clinical Specialist Dietitian, National Centre for Inherited Disorders (NCIMD) Adult Service, Dublin Una works with Inherited Metabolic Disorders, at the, Mater Misericordiae University Hospital, Dublin, Ireland. She has more than 18 years of experience in this area and has been working as a dietitian since 1996.

For full article references please email info@ networkhealth

Phenylketonuria (PKU) is a disorder of protein metabolism arising from a deficiency in the enzyme phenylalanine hydroxylase (PAH). It is a genetically inherited condition requiring adherence to a phenylalanine (Phe) restricted diet for life.1,2

Figure 1: PKU basis simplified

Maternal PKU (MPKU) requires meticulous management, with stricter adherence to diet recommended prior to conception. Target blood Phe levels during pregnancy are lower than that advised in adulthood, due to the concentration gradient as blood Phe travels across the placenta. MPKU syndrome due to the teratogenicity of high Phe levels in combination with poor adherence to diet, is associated with an increased risk of foetal abnormalities: congenital heart defects, intrauterine growth retardation, microcephaly, development delay and miscarriage.3,4 Long-term outcomes reported include a higher prevalence of learning disability, attention deficit and hyperactivity disorder, anxiety and depression in children born to PKU mums.5 Figure 2: Baby in utero This case study reviews a lady who required gastrostomy feeding before, during and after pregnancy. Limited experience of gastrostomy feeding in MPKU has been reported.6 BACKGROUND This lady was 16 years off the PKU diet on referral with poor adherence in childhood. PKU was diagnosed via newborn screening (initial Phe level: 1,620 microMol/l; genetic mutation: 165T/F39L). She has a younger brother affected and three siblings not affected. Co-morbidities included: depression and anxiety; polycystic ovarian syndrome; hypothyroidism; B12 deficiency; a history of severe obesity (BMI 45.6kg/m2) and symptoms of malnutrition including hair loss. Socially there were many challenges including: being taken into care in childhood, history of homelessness, unemployment, heavy smoking and occasional alcohol intake. She had previously been assessed with poor literacy skills and a borderline learning disability. She had resided in sheltered housing with extensive community supports since the age of 19. October 2017 - Issue 128


IMD WATCH Achalasia was diagnosed post inpatient admission following a persistent pattern over 10 months of weight loss (40% of body wt.), gastritis, vomiting and nausea. Figure 3: Achalasia

Achalasia is a condition of unknown aetiology, where the lower oesophageal sphincter muscle fails to relax, leading to dysphagia and regurgitation of foods, often requiring surgery to alleviate symptoms. Medical treatment required the placement of a Radiologically Inserted Gastrostomy (RIG) for nutritional support prior to surgery. The PKU diet was being introduced prior to this and the discharge plan included a feeding regimen adapted for PKU in combination with a minimal oral liquid diet. Tube feeds using a bolus delivery method consisted of: Phe-free protein substitute; whole protein feed; and protein free energy supplement. Six weeks post discharge this lady presented in metabolic clinic with a positive pregnancy and therefore surgery was cancelled. Aims of treatment: • Aim for acceptable Phe levels during pregnancy to avoid toxicity associated with MPKU Syndrome: 150-250mmol/l (NCIMD, target range pre 2016). • Provide sufficient calories, protein and micronutrients to support growth of the developing baby, meet maternal requirements and replenish nutrient stores. • Provide a gastrostomy feeding regimen that patient is able to understand and implement. • Link in with community and hospital teams to provide the necessary support. MONITOR AND REVIEW Dietetic management during pregnancy • Patient sent microtube blood levels for analysis twice weekly with phone follow-up to advise on dietary changes. • Monthly outpatient review for nutritional assessment, intervention and ongoing education. • Minimal oral diet was tolerated intermittently providing additional fluids, energy and some natural protein (0-4ex) daily. • The composition of gastrostomy feeds was adjusted during the course of her pregnancy to meet changes in nutritional requirements. • Weight gain from 4/40-40/40wks gestation was within the acceptable range (IOM7).


Table 1: weight gain and nutritional intake from PKU adjusted Tube Feed + PO diet October 2017 - Issue 128

Gestation wks 2wks PreConception

Weight kg

Natural protein g

Synthetic protein g

Kcals via tube feed

Kcals via estimated oral intake






















































4wks Post Delivery






Figure 4: Graph of Phe levels and protein intake over time

NUTRITIONAL CONSIDERATIONS This lady has poor literacy skills, memory and concentration lapses. Dietary education and follow-up required intensive dietetic and MDT support. The supervised housing complex had limited facilities. Personal hygiene and care of the gastrostomy were also a challenge. Other issues during pregnancy included: • four maternity hospital admissions and linking in with hospital dietitian and staff; • poor compliance with the avoidance of certain solid foods to avoid reflux; • gastrostomy site infections and monthly fluid replacement to anchor feeding tube; • gastrostomy replacement @ 30/40wks gestation; • regular psychological support and community social work input; • liaison with community key workers, public health nurse and local pharmacy. Outcome A baby boy was born via normal delivery at full term with good centile measurements.8 Length: 50cm (9th-25th centile), Weight: 3.14kg (9th-25th centile), head circumference: 35cm (50th centile) Dietetic management postpartum Mum chose to bottle feed her baby and she continued to require gastrostomy feeding in combination with minimal oral diet prior to surgery. The gastrostomy tube was removed during the surgical procedure (Heller’s Myotomy), three months post-delivery and the patient struggled to maintain her PKU diet thereafter. She continues to require ongoing support from the metabolic multidisciplinary team (MDT) and is still engaged with the service. 4 EVALUATION There is limited literature on the dietary management and pregnancy outcomes for women with PKU requiring gastrostomy feeding during pregnancy. Close monitoring and regular communication between both the hospital and community MDT is needed to ensure optimal Phe levels, normal growth and improved outcomes for the developing baby. October 2017 - Issue 128


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Melanie Hill RD, Sheffield Teaching Hospitals NHS Foundation Trust Melanie works as a Specialist Dietitian for adults with inherited metabolic disorders at Sheffield Teaching Hospitals NHS Foundation Trust. She started her career in Dietetics in 1997 and has worked in a variety of specialities, more recently working in metabolic disorders and managing pregnancy in women with metabolic disorders.

PROPIONIC ACIDAEMIA AND A TWIN PREGNANCY: CASE STUDY Propionic acidaemia (PA) is an autosomal recessively inherited metabolic disease. It is a rare disorder of 1:50,000 to 1 in 100,000 births.1 It is caused by a deficiency in the enzyme Propionyl CoA Carboxylase. Propionyl CoA is produced in the metabolism of amino acids valine, isoleucine, threonine and methionine and odd chain fatty acids. Deficiency results in an accumulation of organic

acids including propionate which are toxic to tissues. Patients risk decompensation, severe acidosis and hyperammonaemia. In pregnancy, women need to be managed closely to prevent metabolic decompensation.

1 ASSESSMENT Patient: age 36 and six weeks pregnant The patient was diagnosed with PA at nine months old following investigations for hypotonia and slow motor development. She was treated with a low protein diet and protein supplement free of amino acids: valine, methionine, isoleucine and threonine. She also took Ketovite, calcium, Biotin and L-carnitine. Her past medical history included persistent ECG T wave inversions in anterolateral leads, fainting episodes, one episode of decompensation at the age of eight and hypothyroidism. She presented in our clinic at age 36 and six weeks pregnant after a third attempt of in vitro fertilisation (IVF). She had a decompensation two weeks after embryo implantation secondary to infection. Prior to pregnancy, her weight was 59.3kgs, BMI 21.7kg/m2. Dietary intake was 2,100 calories and 38g protein per day (0.65g/kg/day). She was taking folic acid 5mgs, magnesium sulphate 50mg bd, omega-3 supplement 1 gram/day, a pre-natal vitamin and mineral, vitamin D 25mcgs, thyroxine 137mcgs and carnitine 3g bd. 2 IDENTIFICATION OF NUTRITION AND DIETETIC DIAGNOSIS Aims of treatment • To reduce the production of propionate and other metabolites by using a low protein diet to restrict pre cursor amino acids. •

To avoid fasting, thereby limiting lipolysis and in turn oxidation of odd chain fats.

To provide sufficient calories, protein and micronutrients to support growth of foetuses.

To maintain metabolic control throughout pregnancy, peri- and postpartum period.

To provide an emergency regimen for illness and high risk situations, i.e. for two weeks postpartum. October 2017 - Issue 128


IMD WATCH 3 PLAN AND IMPLEMENT NUTRITION AND DIETETIC INTERVENTION The patient was commenced on: • 40Kcals/kg/day; • 1.1g/kg/day of protein made up of (40g from diet and 30g from a medical protein supplement for PA); • British Inherited Metabolic Disease Group (BIMDG) emergency regimen; IV dextrose and oral glucose polymer for illness and high risk times such as two weeks postpartum. She was advised to avoid fasting, eat every three hours and have a bedtime snack. Standard pregnancy food safety advice was also given, including limiting caffeine, and avoiding alcohol. Vitamin D, folic acid 5mg and omega-3 supplements were continued and a calcium supplement of 1,000mgs was added to meet the requirement for twin pregnancy.2 Dietary protein was increased by 15% at week gestation 6, 11 and 20 due to low branched chain amino acids. The protein intake from medical protein supplement was increased in the third trimester to provide a total protein intake of 1.2g/kg/day. Calories were increased in the second and third trimester and were extrapolated from single foetus requirements.3 Her total weight gain was within the recommended range for twin pregnancy 25.5kgs (17 to 25kgs).4 Twin girls were delivered via C section at 33 weeks due to a shortened cervix, signs of premature labour and breech of first infant. They weighed 1.55kg and 1.34kg. Breastfeeding was encouraged, but infant formula was used. 4 MONITOR AND REVIEW Dietetic management postpartum There is a risk of decompensation at birth and for the first two weeks postpartum.6 It is thought to relate to metabolic stress of changes to the puerperium and increased protein load for catabolism following involution of the uterus. For the first two weeks postpartum: • the patient restricted her dietary protein intake and continued her emergency regimen; • extra non protein calories were given in addition, which included prescribable low protein foods and glucose polymer; • IV dextrose was continued until she was eating well; • the medical protein supplement was weaned down and stopped; • energy intake was reduced after initial 14 days back to normal requirements of 35.3Kcals/kg5 and dietary protein was increased up to safe levels;3 • lower dose calcium, vitamin D, magnesium and omega-3 supplement and L carnitine were continued. 5 EVALUATION There is limited literature on the management and pregnancy outcomes for women with PA. Close monitoring by the multidisciplinary team is needed to ensure metabolic stability and normal growth and development of the foetus.

References 1 Schwoerer J et al (2016). Successful pregnancy and delivery in a women with propionic acidaemia from the Amish community. Molecular Genetics and Metabolism reports. Jun 2; 8: 4-7 2 Pen (2016). Dietitians of Canada Multi fetal practice guidance summary .Practice Evidence in Nutrition. KnowledgePathway.aspx?kpid=13491&pqcatid=146&pqid=13522. Last accessed 20.7.17 3 World Health Organisation, Food and Agriculture Organisation of the United Nations, United Nations University (2007). Report of a joint FAO/ WHO/UNU expert consultation (WHO Technical Report Series 935). Protein and amino acid requirements in human nutrition. World Health Organisation, Food and Agriculture Organisation of the United Nations, United Nations University 4 Rasmussen KM and Yaktine AL (2009). Weight gain during pregnancy: re-examining the guidelines. Institute of Medicine (US) and National Research Council (US) and Committee to Re-examine IOM pregnancy weight guidelines. Washington (DC): National Academies press (US) 5 Baumgartner et al (2014). Proposed guidelines for the diagnosis and management of methylmalonic and propionic academia. Orphanet J Rare Dis 2014; 9: 130 6 Murphy (2015). Pregnancy in women with Inherited Metabolic Disease. Obstet Med June; 8(2) 61-67

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NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD): NUTRITION AND LIFESTYLE ADVICE Dr Laura Wyness Registered Nutritionist Laura is a Nutrition Consultant providing research and communication services to a variety of sectors, including charities, commercial companies and local authorities. www.

For full article references please email info@ networkhealth

Until recently, NAFLD was considered to be quite rare and harmless. For most people, a fatty liver can remain free of inflammation and asymptomatic. However, there seems to be an increasing number of people with NAFLD due to the rising obesity figures. Individuals who have had a fatty liver for some time are more likely to develop inflammation causing scarring (or fibrosis). In these people, this can progress to potentially life-threatening liver cirrhosis. So, how prevalent is NAFLD? Who is at risk? What diet and lifestyle advice is appropriate? WHAT DOES THE LIVER DO?

The liver is involved in around 500 different reactions in the body. These include filtering and cleaning the blood; fighting infections; producing bile which helps digest fats; storing glycogen and some vitamins and minerals; producing and maintaining the balance of hormones, enzymes and proteins; and getting rid of waste substances from the body. It has the unique ability to repair itself, although it can sometimes be damaged beyond repair. WHAT IS FATTY LIVER?

Fatty liver occurs when too much fat builds up in liver cells. Although it is normal for liver cells to contain a small amount of fat, more than about 5% fat is considered too much. Liver disease is often associated with drinking too much alcohol. Excessive alcohol can result in a build-up of fat in the liver. However, fatty liver in people who drink within the alcohol guidelines is known as nonalcoholic fatty liver disease (NAFLD). This is a disease that is quietly becoming more prevalent and poses an increasing threat to public health. It is estimated that NAFLD affects 25% of people globally.1 The UK NICE

guidelines state that about two to three people in every 10 have NAFLD.2 Prevalence has doubled over the past 20 years due to the rise in obesity levels, mainly as a result of sedentary lifestyle and poor diet.3,4 NAFLD is now the commonest cause of abnormal liver function test results in the UK and the commonest cause of liver disease in western countries.3 NAFLD develops in four stages (see Table 1) with the first being simple fatty liver or steatosis. Too much fat in lever cells is caused by an accumulation of triglycerides. There are few, if any, symptoms in the early stages of NAFLD, so it often goes unnoticed. For many people, fatty liver does not develop further and can be reversed with a healthy diet and lifestyle. However, for some, fatty liver develops into nonalcoholic steatohepatitis (NASH) or fibrosis. The cause of progression from NAFLD to NASH remains unclear and researchers have estimated that approximately 20% of those with prolonged simple fatty liver will go on to develop NASH and fibrosis.5 NASH, which is thought to affect up to 5% of the UK population,6 occurs when the build-up of fat in the liver cells is accompanied with inflammation. Inflammation occurs as part of the process of repairing damaged tissue. If left unchecked, the liver may eventually not be able to regenerate fast enough and the inflammation tissue can remain as a scar. This is known as fibrosis and can take a variable amount of time, sometimes several years, to develop. October 2017 - Issue 128



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CONDITIONS AND DISORDERS Table 1: The four stages of NAFLD Stages


Steatosis or simple fatty liver

Fat accumulation in the liver cells, although there is no inflammation or scarring. As symptoms are often not present, fatty liver remains undetected in many people.

NASH (nonalcoholic steatohepatitis)

The liver becomes inflamed. Symptoms often do not occur, but if they do, they can include a dull ache or discomfort over the lower right side of the ribs, fatigue, unexplained weight loss and weakness.


Persistent inflammation causes scar tissue around the liver and nearby blood vessels. The liver still functions normally.


The liver shrinks and becomes scarred and lumpy. The damage is permanent and can lead to liver failure and liver cancer. Symptoms include yellowing of the skin and whites of the eyes, itchy skin and swelling in the legs, ankles, feet or stomach.

Table 2: Risk factors for NAFLD Overweight or obese Visceral adiposity (excess belly fat) Rapid weight loss (e.g. following gastric bypass surgery) Type 2 diabetes or family history of Type 2 diabetes Aged over 50 years High blood pressure High cholesterol Smoking Poor diet Sedentary lifestyle

Cirrhosis is the most severe stage of NAFLD. This occurs when the persistent inflammation and scaring causes permanent damage and reduced function of the liver. This can lead to liver failure and liver cancer. RICK FACTORS OF NAFLD

As NAFLD is often asymptomatic in the early stages, diagnosis is often a result of routine blood tests for liver function. Although NAFLD can be found in non-obese individuals, obesity is a major risk factor for developing NAFLD.7 Estimates suggest that 30-90% of obese adults have NAFLD.8 NAFLD is increasingly prevalent amongst children, with over a fifth of four- to five-year-olds and a third of 10- to 11-year-olds being overweight or obese.9 Visceral adiposity, or excess belly fat, is also a recognised risk factor.10 Some of the main risk factors for NAFLD are shown in Table 2. In terms of diet, a high intake of refined carbohydrates and sugar-sweetened drinks can contribute to

the development of fatty liver.11 Recent research also suggests that poor gut health may also contribute to the development of NAFLD.12,13 DIETARY ADVICE

As there is no effective drug therapy for NAFLD, diet and lifestyle modifications are the main prevention and treatment options. Dietary advice for NAFLD is generally similar to the advice for obesity and metabolic syndrome. For overweight and obese individuals, gradual weight loss along with increased physical activity can help reduce the amount of fat in the liver. A rapid weight loss, using a very low calorie diet, should be avoided due to the risk of worsening liver inflammation.3 The Mediterranean diet has shown to be particularly beneficial in NAFLD patients. The main beneficial factors of this diet includes plenty of plant-based foods and wholegrains, beneficial fatty acids and polyphenols.14 The classic Mediterranean diet consists of plenty of fruits, vegetables, grains, nuts, moderate October 2017 - Issue 128



There is a need for more awareness and understanding of NAFLD amongst both healthcare professionals and the general public.

amounts of dairy and fish, small amounts of meat, and predominantly unsaturated fats rather than saturated fats. Evidence shows that this dietary pattern can reduce fatty liver and improve insulin sensitivity in insulin-resistant individuals with NAFLD.15 A recent meta-analysis that examined the evidence on the optimal diet composition, reported that both moderate-carbohydrate (<45% of daily energy intake) and low/moderate fat (<30% of daily energy intake) diets can equally improve liver function.16

the body. Excess fructose is associated with hepatic steatosis, cellular stress and inflammation.19 Fructose syrups or sugar containing fructose and glucose is widely added to fizzy drinks, fruit juices, jams and sweets. A recent study of 271 obese children found that fructose consumption was independently associated with non-alcoholic steatohepatitis (NASH).20 Fructose also increases serum uric acid concentrations which is linked with the development of gout, coronary artery disease, Type 2 diabetes metabolic syndrome and NAFLD.21



In terms of fat, including foods high in monounsaturated fatty acids (such as olive oil, rapeseed oil, nuts and avocados) may be particularly beneficial in promoting liver fat loss.4 Long-chain omega-3 fatty acids are known for their beneficial effects in cardiovascular disease, stroke and diabetes and evidence has also shown reductions in lipid accumulation, improved insulin sensitivity and anti-inflammatory effects,17,18 which has increased interest in the benefits of omega-3 in treating NAFLD. The optimal dose of omega-3 supplementation or oily fish consumption for managing NAFLD is uncertain, as further high quality, and larger RCTs are required. Consuming the recommended two portions of fish a week, one of which is an oily fish, will help provide the beneficial long-chain omega-3 fatty acids. CARBOHYDRATE

Carbohydrates are an important part of a healthy diet as they provide energy, fibre and a range of nutrients essential for the body. There is good evidence to show that diets low in refined carbohydrates can help reverse NAFLD. Excess carbohydrates in the diet are converted into fat and accumulate in the liver. This occurs at a higher rate with high intakes of dietary fructose. The liver is the only organ that can metabolise fructose, whereas glucose is metabolised widely in 40 October 2017 - Issue 128

The impact of the amount and type of protein on the development and treatment of NAFLD is not clear. Some animal studies have suggested that supplementation with the amino acids tryptophan, glutamine or L-carnitine may have a protective effect against developing NAFLD, but further studies conducted in humans is required.22 VITAMIN E

The antioxidant activity of vitamin E is thought to be particularly beneficial in protecting against oxidative stress apparent in fatty liver disease progression. American Gastroenterological Association guidelines suggest the use of 800IU/ day of vitamin E in non-diabetic patients with NASH.6 However, the evidence is not strong enough to support the use of vitamin E to treat NASH in diabetic patients, NASH cirrhosis or in NAFLD. COFFEE

Coffee appears to confer a number of protective effects relating to liver disease. A meta-analysis of nine studies investigating coffee consumption and cirrhosis concluded that an increase in daily coffee consumption of two cups is associated with almost halving the risk of cirrhosis.23 A recent systematic review and meta-analysis investigating the effect of coffee on NAFLD found a significantly decreased risk of NAFLD among

The incidence of NAFLD has significantly increased in recent years with around one in four people in the UK currently living with NAFLD.

coffee drinkers and a significantly decreased risk of liver fibrosis among patients with NAFLD who drank coffee on a regular basis.24 It is unclear whether such benefits to the liver are due to the caffeine or the other constituents found in coffee, such as cafestol and kahweol, or the range of antioxidants. Consuming regular and moderate amounts (three to five cups a day) of filtered unsweetened coffee, along with following other recommended diet and lifestyle advice, appears to be beneficial for those with NAFLD. Measureable benefits to the liver were also recently found in frequent coffee drinkers in the general population in the large Rotterdam cohort study.25 POTENTIALLY BENEFICIAL DIETARY FACTORS

Current evidence suggests that gut microbiota plays an important role in fatty liver, fibrosis and insulin resistance. A systematic review of three randomised controlled trials investigating the effects of different probiotic and/or prebiotic formulations in adults with NAFLD, did not find sufficient evidence to support their use in treating NAFLD.26 Further research is needed to explore the links between gut microbiota and NAFLD. Several medicinal herbs may have potential benefits for the management of NAFLD. These include milk thistle and Tamarindus indica Linn. A Cochrane review of 77 RCTs with a total of 6,753 participants with fatty liver disease explored evidence relating to 75 different herbal products. The reviewers concluded that herbal medicines may have beneficial effects on fatty liver disease, but the evidence is insufficient to recommend them to individuals with NAFLD.27 GENERAL LIFESTYLE ADVICE

A recent meta-analysis of 20 RCTs found that exercise alone, or in combination with dietary intervention, improves serum levels of liver enzymes and liver fat.16 For the greatest benefit, a healthy diet needs to be coupled with regular physical activity. A combination of aerobic

activity and strength exercises as set out in the UK Government’s physical activity guidelines is likely to benefit liver health. The liver works hard to rid the body of toxins. Smoking is thought to have a detrimental effect on the liver through a variety of mechanistic pathways, including insulin resistance, cell death and oxygen deficiency. Evidence suggests that both active and passive smoking is likely to put extra stress on the liver and may aggravate and accelerate the progression of NAFLD.28,29 Although NAFLD is not caused by alcohol, drinking may make the condition worse. For example, alcohol can increase the progression of liver damage in individuals with NASH. Advice related to NAFLD from the NHS is to cut down or stop drinking alcohol.30 SUMMARY

There is a need for more awareness and understanding of NAFLD amongst both healthcare professionals and the general public. The incidence of NAFLD has significantly increased in recent years with around one in four people in the UK currently living with NAFLD. The main reason for this increase is the rise in obesity, which is mainly due to the population’s sedentary lifestyle and poor diet. There is currently no specific drug treatment for NAFLD. However, a combination of dietary modifications and increased physical activity can be effective in reducing the risk and slowing the development of NAFLD. NAFLD is largely preventable and in the early stages, it can be reversed. Therefore, it is important that the general public are more aware of the impact that diet and lifestyle has on their liver health. Relevant advice from healthcare professionals on healthy eating, as described in this article, along with advice on maintaining a healthy weight, exercising regularly, cutting down or not drinking alcohol and not smoking will help reduce the prevalence of NAFLD amongst the population. October 2017 - Issue 128




My name is Ruth and I have anosmia. It’s been 20 years since I became aware that I was losing my sense of smell, although I’m not sure when it actually started to disappear. I used to create elaborate explanations as to why I couldn’t smell things as strongly as before: hothouse flowers don't smell the same as flowers growing naturally in the garden; they must have changed the formula of Savlon cream; Christmas trees don't have that rich Christmassy scent because they are grown differently. You rationalise these things because the least likely reason for being unable to conjure up those scents anymore is that you’ve lost your sense of smell. How can that possibly be? But eventually, reluctantly, I arrived at the conclusion that I just couldn’t smell things as strongly as my friends could, and although that was sometimes a blessing (festival toilets became much more manageable!), it became increasingly obvious that something was very wrong. Fear and panic started to set in. Was I to blame for this? Had my slightly hedonistic student life contributed to it? In fact, I believe that several falls on my nose and coccyx were at least partially to blame, as well as a recurring bout of glandular fever. Of great comfort to me when I first realised what was happening, was the memory of a long conversation with a friend who was born with anosmia and who had in no way allowed it to impede her full and varied life. However, her case was very different to mine as she had never known what it was like to smell and, therefore, never knew what she was missing, while I, on the other hand, found the loss devastating. I reassured myself that I had a rich resource - a ‘memory bank’ of smells to remind me of what I was eating or

42 October 2017 - Issue 128

experiencing; but it wasn't the same. It still brings tears to my eyes when I try to recall the smell of a Sunday roast or freshly mown grass. A perverse aspect of anosmia is that you can walk through your day without noticing it… until someone says glibly, “Ooo, what’s that smell?” and once again, I have to explain that I can’t actually smell anything. So, whilst this condition is part of me, I am not defined by it; however, I can’t escape it. Sometimes I dream I’ve regained my sense of smell, but usually the smells are disgusting: sewage or ammonia related. Only once, I recall, did I dream of beautiful smells. I woke up and cried. FIFTH SENSE

Last year, I read an article about Kathy Clugston (from BBC Radio Four) and her project to discover why she had no sense of smell. At the end of the piece, I saw a reference to the Fifth Sense charity and website. It was a Eureka moment. I realised that there were many more of us out there! I signed up to the newsletter and volunteered to do whatever (anything) I could to reach out to other sufferers and spread the word to the smelling world. Recently, I had the privilege of sitting in a room with over 100 Fifth Sense members, their partners and friends, to share in an amazingly moving and affirming event at the Royal Society of Medicine. To crystallize into writing all the emotions that bubbled up would take far more space than this article allows, but suffice it to say, the warmth and solidarity I felt on the day will remain with me for a long time.

And I know I’m lucky in many ways. After all, as people take great pains to remind me, if you have to lose a sense it’s probably the best one to lose. (Thank you kind folk, but this is not - I repeat NOT - a comfort.) It is one of the most evocative of senses: a whiff of coffee, your favourite perfume or a certain shampoo can take you back to one of a million different memories. But if you’ve lost that…? And imagine what it’s like if you can’t smell your partner, your cooking, your baby. Smells can give you a subliminal awareness of the threat or danger too. Can you ever trust your emotions? ENHANCING TASTE THROUGH FLAVOURS

The scents of your environment give you an immediate sense of place. One of my strongest childhood memories is of returning every few weeks from boarding school and opening the front door to be hit by the delicious aroma of my mum’s sausage hotpot. It signified home to me. Hunger and appetite are very different concepts for those with anosmia; you sometimes have to remind yourself to eat, as you don’t respond to the triggers that smells give you. I've read that some people who have also lost their sense of taste have developed anorexia - they simply don't experience any physical incentives to eat and the eating process has lost all pleasure and fulfilment. I had a scare a few years ago when it seemed that the bitterness of everything I ate or drank was vastly augmented to the detriment of other tastes. It was most unpleasant and I worried that I would have had to force myself to eat from then on. Fortunately, things settled down and I'm lucky to have retained my sense of taste, although in a slightly diminished form. Smells contribute so much to our ability to taste, not only through the nose but via the back of the throat, as chewing releases flavours that travel directly up to the olfactory receptors. This means that those with anosmia miss out on a huge range of taste and over the years, I’ve found myself seeking stronger flavours, eating and drinking things I wouldn’t have touched before (such as liquorice and horseradish) and I add pepper, Worcestershire sauce and mustard to pretty much everything. But even so, I was getting bored with my food, so a few months

ago, in a concerted effort to improve my eating experience, I began experimenting. I’m now discovering a whole world of flavours out there. My personal new discoveries include adding lemon juice to green vegetables, which can vastly improve a meal, while miso paste and bouillon make an excellent addition to casseroles. Fresh herbs bring out flavours in salads and sauces, while adding colour and texture, and a spoonful of pesto sauce with some balsamic vinegar really adds to the flavours of roasted vegetables. Lemon juice and olive oil mixed with a little Dijon mustard makes a simple yet delicious salad dressing and, of course, sea salt and ground pepper liven up just about everything. None of these will come as a surprise to experienced cooks or nutritionists, but they are certainly making my culinary efforts much more enjoyable. I’m also learning the benefits of eating mindfully - trying to focus on the texture, heat, spice and flavour of each mouthful and ignoring all other distractions such as TV and social media. Eating out with friends is still a wonderful experience, but I think it's important to give extra attention to the food to ensure the tastes are fully appreciated. I’m always discovering new foods and taste sensations; the main thing is to keep seeking out new tastes and textures and try not to get sucked into the habit of grabbing a quick bite to eat when I’m between appointments. One of the most frustrating things about living without a sense of smell is how rarely ‘normal’ people - or normosmics - appreciate having the sense. People are far more likely to complain about a bad smell than point out a good one. But please, PLEASE, relish it. You will miss it if it’s gone. October 2017 - Issue 128



HOW FOOD WORKS The facts visually explained

Review by 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.


This is a stunning book which I recommend with great enthusiasm. Dorling Kindersley is a British publisher specialising in visual reference books, yet again showing a mastery in translating complex information into gorgeous pictures. And most importantly, retaining detail and accuracy of the subject, without drift and dilution. This book provides lots of great science about food and nutrition, presented beautifully. There are six sections, starting with nutrition basics, moving onto types of foods and drinks, discussing in detail different diets (pages 176-224) and finishing with current ethical and environmental issues of food supply. I was poised to find fault, but kept being delighted at great, up-to-date, top science. But, if forced to critique, I would note a few disappointments that on page 21, vitamin absorption is illustrated as occurring in the large intestine rather than the small. Or that on page 24, UK fibre targets are still presented as 18g, where these have been revised upwards by the Scientific Advisory Committee on Nutrition (SACN) to 30g. Or that on page 41, apples are shown as a source of vitamin A and E (they are not). Or that on page 187, damaging emissions are shown from the backend of a cow (methane is burped up orally). Or that on page 189, spinach is incorrectly described as a source of vitamin D. But these are all minor edits against an overall stunning and comprehensive feast of food and diet information. And yes, even expert dietitians will find enough solid science data to expand their foodie-quiz scores. Carbohydrate digestion and processing is described on page 22-23. The scientific categorisation of sugars

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and starches is crystal clear and current terminology is correct, i.e. ‘free’ sugars. The pictures showing the chain of intestinal breakdown of carbohydrates, channelling to the liver and then storage as glycogen or body distribution as glucose, makes detailed information appear simple. It is the clarity and accuracy of the information that is impressive, and shrinks many hours of lectures received by any student dietitian on the subject onto a single page. Energy and sports drinks struggle to back up their boasts, claim pages 162-163. Energy drinks are the devil most cloaked in misleading representation (energy = calories, not dynamic vigour). The critical description given about energy drinks, sports drinks, protein shakes and energy gels is welcome, and even promoters of these products would not be able to find fault with the evidence provided (although they would not like the conclusions). Do we need supplements? Pages 178-179 address this issue. There would be many ways to discuss this topic and this book presents a masterly balance of the facts. There are 10 reasons supporting the yes-or-no to the question. Natural products are not always better. Amazingly, 70% of patients who use supplements or other alternative

therapies do not tell their doctor. There is a wide range of dose levels in multivitamin products and label reading is advised. Stopping contraceptive pills and starting folic acid pills should be seamless; and the balance of vitamin D from sun and food and pills is clearly communicated. Religious diets are described on pages 186-187. Descriptions are detailed and at-a-glance, which sounds like a contradiction, but it just the strength of visual presentation. So, Jains exclude onions, garlic and root vegetables from their diets. Mormonism prohibits alcohol and caffeine. Judaism forbids wine or grape products from non-Jewish producers. Buddhism does not allow pungent foods with strong flavours such as garlic and ginger. Who would want to be the caterer for an inter-faith meeting? If you want a description of food intolerances, turn to pages 208-209. The main illustration is a description of lactose intolerance. The thousand words any dietitian needs to explain this condition to a sufferer could be turboboosted (in

terms of communication), with the help of this great graphic art. The use of art and illustration to more quickly and effectively communicate complex and important medical information is currently the theme of an excellent exhibition at the Wellcome Collection in London. (Can Graphic Design Save your Life? is open until January 2018.) The use of visuals is well proven as a short cut to understanding and perception and perhaps health professionals need to open doors to designers when planning information given to patients. This book is proof that you can have your cake and eat it; you can have complex scientific data presented in an attractive and accessible form. All dietitians will really enjoy this book - for themselves, to share with friends and family and to flip open in clinic when explaining concepts to patients. Well done Sarah Brewer and Dorling Kindersley.

We have five copies of How food works; the facts visually explained to give away in a free NHD prize draw. For your chance to win a copy, please email us at Closing date for entries is Friday 3rd November 2017.


Coming in the next issue November 2017 DIGITAL-ONLY - View it online at

• Premature infant feeding

• Low carbohydrate diets

• Food health claims • IBS and IBD

• PLUS: Nutritional support supplement October 2017 - Issue 128



UPLIFTED BY MAGGIE’S: AN ALTERNATIVE ‘DAY IN THE OFFICE’ Liz Waters RD Macmillan Dietitian and Nutrition Course Facilitator Having worked for 20 years with individuals being non-surgically treated for cancer in the NHS, Liz was flattered to be asked to facilitate nutrition sessions within Maggie’s Merseyside.

For full article references please email info@ networkhealth

The opening of Maggie’s Merseyside1 offered me a new challenge, as I was invited to provide the nutrition sessions within the centre, which has morphed into facilitating the Nutrition Course and providing nutritional input to the Psychological Support Course entitled ‘Where Now?’ Working within Maggie’s required a shift in my usual professional role as a clinical NHS dietitian - there are no case notes to view, no blood tests to check, and there is no institution to be restricted by. The ethos of Maggie’s is to provide free practical, emotional and social support to people with cancer and their family and friends, following the ideas about cancer care originally laid out by Maggie Keswick Jencks. Recognising that the individuals attending the course have potentially differing cancer diagnoses and treatment journeys, with their own experiences along the way, can mean that it’s challenging to get it right for everyone. The participants are usually made up of a number of ladies with a breast cancer diagnosis (with all the permutations that can bring: triple positive, ER negative, etc) and then those with other cancers, such as head and neck right through to anal, including blood and skin. The interactions between group members can result in firm friendships, or some disagreements in the sessions, so requires a recall of group management techniques on my behalf. Week One: A varied group - ladies with breast cancer, a gentleman who has successfully been treated for leukaemia and a lady struggling with the advice being given by her dietitian following gastroesophageal surgery: “All fatty and sugary foods I don’t usually eat…but

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my weight is still dropping.” I cover the evidence base for cancer survivors using the guidance from World Cancer Research Fund (WCRF),2 advising that although this is based on healthy eating, for some, it may suit better to think of it as ‘eating for health’ to fit their individual needs. I link this in with other guidance on healthy eating such as the NHS’s Change for Life website.3 I state that this guidance is for all, so perhaps family members or friends may change their habits too. To ensure all nutritional thoughts are captured, I hand out blank ‘thought bubbles’ asking that all queries or points for discussion are ‘captured’ when they are had, recognising the potential effects of ‘chemo brain’ on memory recall. At the end of the session the lady struggling after surgery turns to me and says, “I’m not ready for this yet. I need to follow the advice of my dietitian.” I advise that she does; she doesn’t return the following week. Week Two: Portion sizes, including red meat and alcohol. An eye opener for most and a bit of fun with it, as I include a practical session on comparing the calorie content of alcoholic drinks with food items. Alternative drinks are discussed and smoothies/juices only promoted within the 150ml recommendation.4 Portion sizes in relation to fruit and vegetables are debated, generally the portion of what we commonly call broccoli (green trees) compared to its correct name of calabrese. Most realise

the benefit of portion control and are pleased to be referred to the British Dietetic Association’s Food Fact sheets5 covering these topics. Week Three: A wider discussion about healthy living and the bigger picture with potential controversies cleared up, plus weight management and how individuals are tackling this. Some supportive words come from one of the ladies who has completed the same chemo regime as another, but a few weeks ahead, whose weight has started to reduce. The advice regarding physical activity can sometimes be a challenge for those struggling to get off the couch, but allows for signposting to health and wellbeing services such as ‘swim buddies’ or walking groups. The guidance around sun safety and the vitamin D debate results in a lively discussion, with brand names being swapped for ‘lighter’ high SPF creams being the result, ensuring that the UVA rating6 is considered as well. Last, but not least, bowel habits and the recommendations about increasing our wholegrain consumption and achieving the recommended 30g per day fibre intake.7 In previous groups, I’ve had those who continue with a low fibre diet to control symptoms, but yearn for “something brown”. A ‘no, no’ for some then, although another practical exercise about the difference in fibre content between various food items such a breakfast cereals, pasta and rice brings a few surprises. For those in need, I highlight the toilet card8 that can be used for urgent comfort stops and where to obtain them. Week Four: Generally, the session everyone attends - superfoods and antioxidants, busting the myths. One of my first group attenders reminds me regularly how she continues to advise that “there is no such thing as a superfood”, so an eye opener for all that this is simply a marketing term and has no scientific basis. The myth busting exercise utilises Cancer Research UK’s evidence9 and this time brought about an interesting discussion regarding the complementary/alternative diets that are promoted as ‘cancer cures’ with one member of the group. This was heightened by the guidance that additional vitamin and mineral supplements10 shouldn’t be taken unless specifically advised to do so, for example, the calcium and vitamin D supplements taken by some in the group.

Week Five: Sometimes an awkward week, as the participants are realising the bonds between them are growing stronger and their knowledge has increased, but the course is nearly over. This week I aim to widen the focus to encourage the participants to move on from simply ‘nutrition and cancer’ to thinking of diet, activity and overall health, as everyone should. Clearing up the complexity of food labelling11 starts off the session with the topic winding along to ‘best before/use by/sell by’ dates, common food allergens and how these are labelled. The session draws to a close after discussing the differences between food production and storage methods, fresh, tinned and frozen in relation to growing your own and the seasonable eating message.12 Week Six: The final week, when I have invited the participants to perhaps bring along some food or drink items to share, to celebrate the role of nourishing ourselves as a social activity. I encourage final thoughts to be submitted, perhaps drawing on those ‘thought bubbles’ from Week One and recipe swapping to occur. Often contact details are passed between participants and I request that the evaluation forms are completed on behalf of Maggie’s. Fortunately, these always reflect well on my delivery of the sessions, which have on occasion been referred to as ‘laughter therapy’ due to confessions regarding alcohol intake, or not knowing the difference between a garlic bulb and a garlic clove for a recipe! Each time, the participants depart with a great sense of thanks for enabling them to have grown in their nutritional knowledge, feel empowered in their food choices and able to enjoy it as part of their lives. For others, it can be more significant - they can eat without fear that what they are consuming will harm them, believing it will make their cancer come back. Personally, to be able to make such a difference by using my dietetic knowledge, a wide evidence base, my communication skills and years of experience to benefit others, is a real pleasure. Maggie’s has provided me with the challenging opportunity to have an uplifting ‘day in the office’. I would encourage others to feel challenged and do something different from ‘the day job’. October 2017 - Issue 128




For the British Dietetic Association (BDA), having a strong media presence both online and in the traditional press and broadcast media - is very important. Communicating with the public is a core part of our desire to educate the public, develop and influence policy and advance science and practice. Nutrition and diet are always popular news topics and rarely will a day go by without a story on a new piece of research or a feature on the latest fad diet. In 2016, Roxhill Media carried out analysis that showed that one in 10 health news stories related to diet - on a par with stories about new medicines and treatments. Unfortunately, reporting of science and health stories is often inaccurate and there are a great many people willing to offer opinions, whether or not they are qualified to do so. This makes it all the more important that the BDA is able to offer clear, evidencebased information to journalists. Of course, we aren’t just limited to commenting on nutrition and diet stories; we also work hard to ensure that the BDA voice is heard on wider health and policy issues, particularly those relating to the healthcare workforce. We also aim to be proactive in setting the news agenda as well as promoting dietitians and developing stories and news items based on our own policies and research, including the ever popular ‘Top Five Diets to Avoid’ each New Year. MEASURING OUR IMPACT

For a small organisation, the BDA punches well above its weight in terms of media presence and coverage, with our media spokespeople answering dozens of inquiries every month. In 2016, the BDA was mentioned over 2,300 times in UK print and broadcast media, with The Daily Mail, The 48 October 2017 - Issue 128

Guardian, BBC Radio and The Huffington Post being the most frequent sources. Our spokespeople have also seen a growing TV presence, on shows such as Food Unwrapped and Supershoppers. Figures for the first half of 2017 show a continuing growth, with over 1,250 UK media mentions already. Our reach isn’t limited to the UK either, with over 490 stories reaching a global audience in the US, India, China and Australia to name but a few. SOCIAL AND ONLINE

Nowadays, news is consumed in a variety of ways and particularly on social media. Younger audiences are increasingly getting their news and information from online sources. A survey carried out for us by Populus earlier this year showed the 18-25 age group are most likely to trust online sources, such as bloggers, for their diet and nutrition advice. Facebook and Twitter help us react quickly to news stories or trends and also allow us to more easily promote our own messages, stories and campaigns. The recent Dietitians Week 2017 campaign had a theme of ‘Evidence and Expertise’, and the posts and content shared throughout just that week had a potential combined audience in excess of one million people. These numbers are comparable with coverage in conventional news outlets, reflecting our need to remain up to date with the latest social media trends. We have most recently launched

an Instagram account, which is already seeing huge growth. ALWAYS MORE TO DO

Our aim is to be the ‘go to organisation’ for diet and nutrition comment and stories and we continue to make progress in that regard. For the first six months of this year, stories featuring the BDA have the potential to have been viewed over 80 million times. However, we know that we need to keep working hard to increase our impact and grow the profile of dietitians and dietetics. You can find examples of the BDA’s media coverage on the BDA website:

Be sure to follow us on Twitter and on Facebook.


HAVE YOU JOINED THE BDA YET? As the professional body and trade union for the dietetic profession, we work hard to ensure that the expert dietetic voice is heard in the media. We take our important relationships with journalists and media outlets very seriously to ensure that they utilise our expert media spokespeople first for trusted evidence-based advice and comment. With approximately 80% of all HCPC registered dietitians within our 9,000-strong BDA membership, there has never been a better time to consider joining your professional body and trade union. If you are keen to share your enthusiasm, knowledge and experience and get involved in programmes to help advance dietetics and the dietetic profession, then joining the BDA is a great place to start. Membership is open to Registered Dietitians, dietetic support workers, dietetic students and those with an occupational interest in diet or food, so the BDA invites you to take a look at the benefits of becoming a BDA member at membership and consider joining at: October 2017 - Issue 128



Coming up soon . . . NEW, FREE WEBINAR: SUSTAINABLE EATING - WHY, WHAT AND HOW Wednesday 25 October 2017, 8-9pm This BDA and AfN endorsed webinar with leading Consultant Nutritionist and Registered Dietitian, Lynne Garton BSc (Hons) RD will be of interest to any dietitian or nutritionist (or student) interested in sustainable eating. Register here if you wish to develop your knowledge and skills in this important topic

UNIVERSITY OF NOTTINGHAM SCHOOLOF BIOSCIENCES Modules for Dietitians and other Healthcare Professionals • Professional Practice 1 and 2 - Tutorials: 1st November 2017 (morning only) OR 8th November 2017. Presentations : tbc (spring 2018) • Public Health Nutrition Policy: 21st and 24th November 2017 and a date in January/ early Feb 2018 to be confirmed For further details please contact email or check out the University website at www.nottingham. and click on 'Study with us' and then 'short courses' which will take you to 'for practising dietitians'.

THE ROYAL MARSDEN NHS FOUNDATION TRUST - LONDON Nutrition and Cancer: what patients want to know 22 January 2018 A study day for dietitians, nurses, doctors and other healthcare professionals working with cancer patients. The event will aim to look at popular areas of nutrition and cancer and untangle the myths from the evidence. For further details please visit or contact the Conference Team on 020 7808 2924, email:

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HEALTH & WELLBEING SERVICES MANAGER HILS - £30,000PA The Hertfordshire Independent Living Service (HILS) is looking for a registered Dietitian to take on responsibility for the delivery and effective performance of operations across the County, ensuring the smooth running and high quality provision of all HILS health and wellbeing services. The post holder will maintain and develop business growth through the development and incorporation of new health and wellbeing services, in accordance with the overall HILS strategy and will help establish HILS as a preferred provider of preventative, community-based health and wellbeing services. You will be responsible for team members and will work closely with the Head of Operations and other managers on both internally and externally-facing projects to ensure that all HILS’ services achieve statutory/regulatory compliance (where required) as well as high levels of customer and stakeholder satisfaction. You will maintain clinical and operational excellence and will oversee advice given by HILS’ community health professionals across all health and wellbeing services. You will also manage own small clinical caseload of dietetic cases for elderly and vulnerable adults at risk of malnutrition and dehydration. This role is based at Letchworth, but covers all HILS’ sites including St Albans, Hemel Hempstead and Ware and the candidate will be expected to travel to all locations where HILS’ health and wellbeing services are operating, ensuring that each site is visited on a weekly or fortnightly basis. Visits may also be required to clients in their own homes, where most of HILS’ health and wellbeing services are delivered. Please send CV and covering letter to jobs@ or to: Unit 16, Green Lane One, Blackhorse Road, Letchworth, Hertfordshire SG6 1HB. For an informal discussion about the role, please contact Emma Hart, Team Leader - Human Resources on 01462 347026. Closing date: 23rd October 2017

To place a job ad here and on please call 01342 824073

Louise Robertson Specialist Dietitian Louise is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults. In her spare time she enjoys running her blog ‘Dietitian’s Life’ with her colleague and good friend Sarah Howe. www.

While working through my emails, I came across one from the BDA asking if I would be willing to hold the @NHS Twitter handle for Dietitians Week. How exciting, a chance to highlight the work of dietitians and the field of Inherited Metabolic Disorders (IMD). Each week, NHS England uses the Twitter account to spotlight a health professional or patient from the NHS. There have been paramedics, nurses, doctors, but this was the first time a dietitian would hold the account. The aim is to be on the Twitter account from Monday to Friday, tweeting about dayto-day life in the NHS. At first I was a bit worried, as I only work part time; what would I tweet about on my days off? NHS England reassured me that people like to see the personal side too. My first task was to write a plan for the week. I decided to include general dietetic issues, such as working in a hospital and malnutrition and then towards the end of the week talk more about my speciality of IMD and specifically Phenylketonuria (PKU). I then had a teleconference with NHS England, my hospital communications and the BDA. I went through my plan and had a safety briefing which included the importance of not tweeting out any clinical information and what to do if challenged. I was also given a list of ‘trolls’ to look out too. I had a few weeks to prepare, so I started to take useful photos around the hospital. I persuaded some of my colleagues to pose with supplements and diet sheets and found feeding tubes and bags of feeds to photograph. I was

all ready to go for Dietitians Week when we had to change the date due to the general election. A couple of weeks later, we were ready to go. NHS England set me up with some intro tweets and then I was in charge at 8.30am. IT had given me permission to use Twitter on my desktop and I started tweeting about the role of a dietitian. At lunch time I headed over to the dietetic department to persuade the dietitians to pose while eating their lunch and then one willing volunteer took me up to the wards to take photos. Taking pictures without any patient or clinical information in them was tricky. I had to use virtual stickers on the photos to cover information up. It was an enjoyable week, but scheduling and tweeting live stories and answering all the questions took time. I had to wade through all the @NHS mentions and answer everyone meant for me. It was fun taking photos and videos of what my fellow dietitians and I were up to and I am happy to say that I didn’t have any trolling! And I did get encouraging messages, including from people telling me how helpful their dietitians had been. Keep up the great work guys. Photos from my Twitter week are on our blog at: dietitians-life/a-dietitians-week/ October 2017 - Issue 128



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October 2017: Issue 128


Social media apps for nutrition by Emma Berry


LEARNING TO WRITE ARTICLES Michèle Sadler RNutr Rank Nutrition Ltd Michèle is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry. Michele has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

Writing skills are a valuable asset for dietitians and nutritionists. Published articles, book chapters and scientific papers will raise your profile and help to establish your expertise. All such contributions will make a useful addition to your CV, and if freelancing is in your future plans, writing skills will give more options for potential work. Whether you are writing for fellow health professionals, research scientists, or the public, honed skills will help to get your message across. If you are a newcomer to writing, or time has passed since you last wrote for a publication, deciding where to start can be quite daunting. If you have been invited to write a book chapter, or are looking to contribute an article to NHD for example, this article aims to give some basic approaches and tips to help you get going. GETTING STARTED

Identifying the main message of the paper or article that you want to write is a good starting point. Try to express this in a concise sentence, as this will help you to communicate a clear message. Then outline the title to give you a clear focus - it can be changed later on if required. Where a literature search is necessary, this needs to be undertaken at an early stage. Otherwise, it is advisable to capture details of all the references you want to cite as you are writing. This avoids a separate, time-consuming job at the end to hunt down missing citations. If available, a reference manager programme such as Endnote is a great help in organising references. STYLE

Before you get started, look at some examples of previous articles, chapters or papers in the publication you are writing for and familiarise

yourself with the ‘house style’. If you are writing for a magazine or publication, you will be given a word count, or at the very least a guide to how many words are required for a particular topic. Take a look at various publications so that you can visualise how many words fit a page and how many pages make up an article. Find out if there is a ‘style guide’ that you can follow for the particular publication. This will cover details such as how to deal with numbers or numeric terms and use of abbreviations. Common conventions include spelling out numbers from one to 9, and using numerals for 10 onwards, though this varies between publications. In NHD, for example, units are spelt out from one to nine, e.g. six children, and numerals for 10 onwards, e.g.12 patients. Numerals are used with standard units of measure, e.g. 35mg, and percentages, e.g. 8%, but, Sentences should not begin with numerals, but with numbers written as words. Abbreviations should only be used if the term appears more than once in the text, in which case the term is provided in full on first use followed by the abbreviation in brackets. Some publications have a list of permitted abbreviations that can be used without providing the term itself, as they are universally understood. How to insert references within the text can vary from publication to publication too. With NHD for example, references are numbered in a list at the August/September 2017 - Issue 127


NHD-EXTRA: SKILLS AND LEARNING end of the article and corresponding superscript numbering appears in the main text of the article. References for all NHD articles are features on the website too ( An important aspect of style is to be concise - and this takes time. It may seem illogical that it takes longer to write something short than to write something long, but this is generally the case, as acknowledged by Mark Twain in his well-known quotation: “I didn’t have time to write a short letter, so I wrote a long one instead.” Attention to other aspects of style will help your writing to flow more gracefully. For example, it is best to avoid over-use of intensifiers, such as ‘very’ much, or ‘extremely’ positive - ‘much’ or ‘positive’ is sufficient. If emphasis is necessary, it is better to be more explicit, e.g. ‘less than twice the value’ rather than ‘very much less’, depending on the particular details. It helps to explain terms that the reader may not be familiar with rather than using jargon. Adding a glossary may be useful, if it fits with the publication style. GRAMMAR

Clear concise language without ambiguity avoids the reader having to stop and think what you intended to say. To quote another famous writer, George Orwell: “Good prose should be transparent, like a window pane.” Correct use of grammar helps the text to flow, making it easier to read. If your knowledge of grammar is a bit rusty and you are stuck on any particular points, an internet search will pull up various websites with helpful information or facilities to check use of grammar. Make sure you are using an English UK site though! STRUCTURE

Like a novel, scientific writing needs a beginning, middle and end. Organising the material you want to communicate into a clear and logical sequence is essential for the flow of your article or chapter, in order to lead the reader through your arguments. The text will typically begin with an introduction that sets out the relevant background and informs the reader what you are writing about. Identifying at the outset the other sections you want to include will help to 54 August/September 2017 - Issue 127

structure the main body of your article. Setting the heading levels early on is also helpful. It is important to marry the particular points you want to make to the correct sections and to avoid repetition in different sections. The conclusion should give an overall summary of the main messages that you want to convey to the reader. Making use of tables, figures or other illustrations helps to express information more succinctly than writing the details as text. Refer to the table or figure to make the point, and avoid repeating information in the tables and figures as text. In view of increasing emphasis on conflicts of interest and funding sources, be prepared to declare these within your article or paper. ACADEMIC JOURNALS

If you are writing a scientific paper or review for an academic publication, choose the journal you want to submit to at the outset. Each journal has specific requirements and these should be identified before you start writing. The instructions to authors will give information about the required style and structure, referencing style, maximum word count and other relevant details such as any restrictions on the number of tables and figures. A lot of time can be saved if you follow these guidelines when writing your initial draft. Again, it is important to ensure your material is allocated to the correct section. The methods section should cover factual information such as details of subjects, dietary manipulation and procedures and should not include any results. The results section should only report the findings and not explain them, whereas the discussion section is the place to elaborate on the results and put them into context with other research in the area in order to explore their significance. Most journals require discussion of the limitations of the research and suggestions for further research. Where required, keywords and abstract are best written once you have a full draft, so you can draw on the main points you have written. The format of the abstract varies between different publications - some require

Table 1: Writing tips Check out and follow the house style of the publication you are writing for. Organise your material into a clear and logical sequence; think: beginning, middle and end. Keep your writing concise throughout. Marry your points to the correct section. Avoid repetition of the same point in different sections. Data in figures and tables does not need to be repeated in the text. Allow time to re-read and edit your draft; check your spelling, grammar and punctuation; also ask a colleague to read it.

a structured abstract with sub-headings and others require text without headings, so check this out beforehand. PEER REVIEW

This is the ‘quality control’ process used by scientific journals that helps to maintain standards. It is also used by other publications. For example, it is sometimes used by NHD to ensure that detailed facts have been correctly reported. It is more common today that peer review is a double-blind process where the identity of the authors is masked to the reviewer and the authors are unaware of the reviewer’s identity. In most cases peer review requires revisions to the manuscript, but this typically results in improvements to presentation and clarity, usually making it a positive process.


Allowing sufficient time to leave your finished manuscript for a couple of days and then come back to it is usually beneficial. This allows you to read it with fresh eyes, making it easier to spot edits and tweaks that will improve the text before it needs to be submitted. It is also worthwhile asking a colleague to read through your draft for any extra insight they can provide. MEETING DEADLINES

Finally, submitting in a timely manner is crucial, as publications work to tight schedules. Hence it is essential to bring time management and planning skills into the equation when writing articles. It generally takes longer than you think to write a polished piece of work that you can be proud of…but it is very rewarding.


A wealth of useful dietetic resources for all dietitians and nutritionists Login with your username and password to view the Subscriber zone. If you don’t have login details, you can check whether you are eligible for a FREE subscription to Network Health Digest at

www.NHD August/September 2017 - Issue 127



APPS AND SOCIAL MEDIA: FRIEND OR FOE IN NUTRITION? Emma Berry Student, University of Aberdeen

Emma is currently studying MSc Human Nutrition. She has an interest in Public Health nutrition and health promotion within the community. Emma hopes to work within the community setting to improve nutritional wellbeing and health.

For full article references please email info@ networkhealth

Young adults are the highest users of social media out of all generations, with over 90% shown to be active in a 2015 survey,1 with a variety of different applications (apps) used to communicate with friends, family or strangers, both in real life and in virtual reality. Although social media carries risks, it also presents a new way of engaging young adults with important issues regarding their health.2 Apps are most commonly found on transportable devices such as smart phones, allowing constant access to Facebook, Twitter, Snapchat, Whatsapp and many more virtual communication devices. These apps allow the posting of video, images, voice recordings as well as the written word, allowing the thoughts and opinions of young adults to be viewed by any number of interested parties. Adolescence and emerging adulthood presents an important stage of life where nutrition and weight can have effects in later life.3 Malnutrition, in the forms of both under- and overnutrition, can have serious implications in this age group. Ensuring that these young adults take an interest in their nutritional wellbeing and what they eat, is important to ensure their future health.3,4 Young adults also have the quickest rate of weight gain out of all the age groups and, therefore, could be targeted to try and reduce the risk of obesity in later life.5 The use of apps and social media could not only improve awareness of healthy eating from governmental bodies such as Change4Life,6 but also aid in improving dietary behaviours through increasing self-efficacy and supporting behaviour change techniques. APPS FOR IMPROVING SELF-EFFICACY

Changing health behaviours in a young adult population is a difficult task. Even though there are many efforts to 56 October 2016 - Issue 118

improve healthy eating behaviours in the school setting, young adults are still defined as a at risk for developing a poor diet.9 Recent healthy eating campaigns are often presented as images targeted for families and children, making young adults believe they are not intended for them.10 One factor which can influence behaviour and behaviour change is self-efficacy.9 Studies have shown that young adults are more likely to improve their healthy eating behaviours when self-efficacy is higher.11 However, attempts to improve self-efficacy should be targeted towards the population of interest. Studies have shown that young adults face unique barriers for adopting healthy eating behaviours, such as perceptions of cost, time, peer pressure and competing factors including alcohol consumption.10 Targeting these barriers and demonstrating how these can be overcome could improve self-efficacy of young adults to make a change in their eating habits. An individual’s self-efficacy can also be improved through demonstrating change in a relatable character.12 Individuals having access to such examples of change is increased through apps such as Instagram, where individuals can post pictures of healthy food or weight changes. This may increase individuals’ awareness and knowledge of healthy food preparation. Young adults have reported having access to more recipes through using

social media, including ones for specific diets such as vegan or paleo.7 These apps allow individuals to follow each other, so they can find people who inspire them or who they can relate too. However, these apps can also have a negative effective on young adults, as they may find some images damaging to their self-esteem.13 As app users have their own accounts, there is limited controls on what is posted and shared, therefore, unhealthy food pictures or advice can also be posted, and therefore may also have a negative impact on nutritional wellbeing. Individuals posting pictures of certain foods such as desserts or chocolate cake could cause an increased feeling of hunger despite not being hungry.7 APPLICATIONS FOR IMPROVING INTAKE

Although improving self-efficacy and encouraging healthy behaviour change can be targeted through apps and social media, they can also have a role for supporting individuals at times of change. There are various apps which encourage and support individuals when attempting to improve their nutritional intake. Improving intake and health through the use of apps and social media still follows the same principles of any healthy behaviour intervention.14 Although using apps and social media for nutritional purposes is fairly new, similar behaviour change techniques are employed, such as self-monitoring, goal setting and having a support network.15 There are apps which are purposely designed for this, such as MyFitnessPal, which encourages the use of self-monitoring, self-weighing, goal setting and sharing progress with other users. However, some individuals use social media accounts, such as Instagram or Facebook, for such purposes. Communities within these social media apps have risen to support individuals who are looking to lose weight, or improve their health. These are often formed through a shared interest in losing weight or getting healthier.16 There has been evidence that individuals who post online regarding weight loss receive more support than discussing weight loss in person with their social networks.16 Again, the principles of behaviour change are the same such as stating goals on their social media, updating regularly with achievements and failures to their online support network.15

In theory, the idea of using social media to support healthy behaviour changes is a great way to encourage and support a large number of individuals. The use of apps on their smartphones means that individuals have access to this network at any time. However, many of these social media accounts and apps are not monitored. Apps such as MyFitnessPal can have various foods and their content input by users – meaning that the foods added may not have the correct information.17 Social media account users can also post anything relating to food without having to verify that it is fact, or scientifically accurate.7 Many social media stars - who use the platform as a base for selfpromotion - have become well known for their food posts and restrictive diets without necessarily having scientific grounding.7 Although these accounts and apps may not cause a problem if individuals choose to listen to it for one meal, over a longer period of time this could have an impact on an individuals’ nutritional wellbeing. SOCIAL MEDIA AND APPS IN RESEARCH

In recent years, there has been a move towards using social media and apps to improve health behaviours in research.18 Studies which have discussed the use of social media in promoting healthy eating have discussed various aspects of their use, for example, as a form of recruitment, encouraging forms of engagement and as a form of intervention itself.19 However, relatively few studies have looked at platforms which already exist and their effects on behaviours themselves.19 There is evidence to suggest that the retention of studies which used platforms that already exist in everyday life (such as Facebook, Twitter) is quite high.18 This suggests that using social media platforms which already exist could be an exciting way to reach young adults and engage them for future research on nutrition. Although these small initial studies are important to determine how social media can be used to engage young adults, larger trials are needed. Evaluating the use of social media as a form of improving nutritional wellbeing in young adults could further current efforts such as the Change4Life campaign. This would allow governing bodies to better target this age group, improve their eating choices and long-term health outcomes. October 2016 - Issue 118



Social media and apps could have a role in improving nutritional wellbeing in young adults. They have the potential to improve self-efficacy through the sharing of pictures, recipes and tips from inspirational and relatable figures. There are apps which are specifically designed to support and encourage healthy behaviour change, and apps which develop their own social media communities around relatable behaviours. These communities provide invaluable support that may be more encouraging than an individual’s

family or friend network in-person. These platforms also have the potential to improve engagement with young adults in health research. However, apps and social media can have negative effects. There is the potential to damage an individual’s self-esteem, and expose followers to nutritional information which is incorrect or dangerous. It is important that individuals who offer nutrition-based advice should be able to verify their claims, and that consumers of these messages are trained to be wary of claims without scientific backing.


Coming in the next DIGITAL ONLY issue November 2017

• Premature infant feeding • IBS and IBD

• Low carbohydrate diets • Food health claims

• PLUS: Nutritional support supplement


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58 October 2016 - Issue 118

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