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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


Advertising Richard Mair Tel 01342 824073 Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES October 2017 - Issue 128

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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

Network Health Digest Oct 2017 - SAMPLE  
Network Health Digest Oct 2017 - SAMPLE  

The Magazine for Dietitians, Nutritionists and Healthcare Professionals