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

NHDmag.com

Dec 2017/Jan 2018: Issue 130

FREELANCE PRACTICE: ADVICE ON MOVING FORWARD

ERAS BREASTFEEDING UPDATE IMD WATCH IRRITABLE BOWEL SYNDROME

Saturated fat & heart disease pages 16-18


FROM THE EDITOR

WELCOME Emma Coates Editor

Emma has been a registered dietitian for nine years, with experience of adult and paediatric dietetics.

If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk We would love to hear from you.

Welcome to this final issue of 2017. Another year almost done and dusted… like watching Usain Bolt blasting his way down the 100m straight, it seems this year has passed us by in record-breaking speed, but we’ve had plenty of time to enjoy ourselves in the process. The team here at NHD are incredibly proud to have put together another fine set of issues throughout this year, uncovering many new contributors and continuing to work with valued regular writers, to record the ongoing development of nutrition and dietetics. And this kind of ‘happily ever after’ is one to finish the year on, rather than a cliffhanger and there’s no twist in the plot to confuse you! Our Cover Story focuses on freelance practice, a career path for dietitians to consider. It can be daunting and confusing with big questions as to how and where to start. However, we asked Priya Tew, a successful freelance dietitian, to share her advice for anyone stepping in to freelance working or existing freelancers who need a bit of an update. Perhaps a new direction for the new year starts here . . . Maeve Hanan provides an overview of breastfeeding, reviewing the current situation and the public health strategies in place to improve uptake and maintenance of this important start to infant feeding. Maeve also contributes an article on saturated fats and the debate around whether or not they are the culprits in the development of heart disease. We welcome Naomi Johnson from the BSNA who guides us through the importance of ERAS (Enhanced Recovery After Surgery), looking at the positive impact of optimising nutritional status both pre- and post-operatively. The FODMAP diet has become a regular dietary treatment option for IBS over the last (almost) 10 years, from its development at Monash University,

Melbourne in 2008, to its adaption for the UK and BDA recognition in 200910 and it is now widely available. Rebecca Gasche RD discusses the diet and its role in the management of IBS symptoms, with a review of current evidence for its use. We have a duo of metabolic articles this month as part of our IMD Watch feature. Lisa Gaff and Nicole Mills share their experience of following a low protein diet for seven days. A challenging diet, which is achievable with a great deal of effort and commitment. Anita MacDonald, Karen Van Wyk, Rachel Skeath and Pat Portnoi talk us through their collaborative work to develop a range of teaching materials for use with parents who have children living with an inherited metabolic disease. TEMPLE (Tools Enabling Metabolic Parents LEarning) is available via the BIMDG website (for details see page 34). Throughout 2017, there was no escaping the unfolding saga of Brexit in the media and there’ll be much more to come in 2018; it’s really not too far away now! Michele Sadler discusses the implication of this epic political shift on the UK’s food industry and regulation. Don’t’ forget we also have our regular features from Ursula Arens and Dietitian’s Life, alongside more from Professor Simon Langley-Evans, who tells us about the Future Dietitian 2025 programme. So, all that remains to say is, Goodbye 2017, Hello 2018. We wish you all a Merry Christmas and best wishes for a healthy New Year! Emma

www.NHDmag.com December 2017/January 2018 - Issue 130

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11 COVER STORY

CONTENTS

Freelance Practice: advice for moving forward 6

News

8

Face to face

Latest industry and product updates

With Farhat Hamid

16 Saturated fat and heart disease Are they linked?

19 ENHANCED RECOVERY AFTER SURGERY The role of nutrition

37 BREXIT & FOOD REGULATIONS The potential impact 41 Irritable bowel syndrome The low FODMAP diet 45 Energy foods How best to fuel the active 48 Prof Blog The future dietitian

23 Breastfeeding An update on public health strategies

49 Book review Hunger: A Memoir of

29 to 36 IMD WATCH

(My) Body

50 Events and courses Dates for your diary

- PKU diet challenge - The TEMPLE teaching project

51 Dietitian's life 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 info@networkhealthgroup.co.uk 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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Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com December 2017/January 2018 - Issue 130

@NHDmagazine ISSN 2398-8754


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NEWS

FOOD FOR THOUGHT

Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

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LATEST INSIGHTS: A FOCUS ON IRON The American Journal of Human Nutrition has recently published a special supplements and symposia edition focusing on iron and health. I read this with much interest, as I did some research in this area a few years ago. High rates of iron deficiency, particularly amongst women, poor compliance with iron supplements and the need to develop accurate but cost-effective biomarkers of iron status were the main areas that needed driving forward. So, let’s take a look and see how the field has come along . . . Iron Deficiency - who is most affected? Latest data from 15 European countries shows that more than half of women in their childbearing years have small or depleted iron stores.1 This, in turn, has a domino effect on pregnancy, infants and the very young. For example, it was calculated that only a third of women have enough iron ‘stocked up’ to complete a pregnancy without the need for an iron supplement.1 So, new research also showing that about half of all infants born in Europe (up to 48%) are also iron deficient, is really not that surprising.2 Iron intakes in children aged six to 36 months still tend to be below the recommended dietary allowance, which does not help the problem. Young children are also less able to regulate iron.3 Whilst a degree of iron homeostasis kicks in at around nine months into infancy, the question about how effective this is remains largely unanswered.3 Biomarker progressions When it comes to markers of iron status the science has moved forward a few steps, but much remains to be done. It is clear that aligned definitions of iron deficiency, anaemia, iron repletion and excess are still needed. Cut-offs for markers of iron stores, such as serum ferritin, also need to be re-evaluated. These are not particularly accurate, as they were derived around 30 years ago and do not take ethnic or genetic factors on board.4 One thing that we do now know is that ethnicity and genotype can influence iron status.5 The movement towards measuring ‘total body iron’ does, however, seem to be a promising way forward. This involves the application of an algorithm that uses serum transferrin receptor levels and serum ferritin, thus covering the full range of iron status. Roundup This was a really interesting edition and of great value for anyone interested in the field of iron and health. What is clear is that we need to keep going with the research. Ongoing interventions are needed to test the efficacy of ways in which iron status can be improved. Aligned definitions and revised cut-offs also need to pave their way into the field and be consistently engrained across new research. References 1 Milman N et al (2017). Iron status in pregnant women and women of reproductive age in Europe. Am J Clin Nutr doi:10.3945/ ajcn.117.156000 2 van der Merwe LF and Eussen SR (2017). Iron status of young children in Europe. Am J Clin Nutr. doi:10.3945/ajcn.117.156018 3 Lönnerdal B (2017). Development of iron homeostasis in infants and young children. Am J Clin Nutr doi:10.3945/ ajcn.117.155820 4 Daru J et al (2017). Serum ferritin as an indicator of iron status: what do we need to know? Am J Clin Nutr doi:10.3945/ ajcn.117.155960 5 Gordeuk VR and Brannon PM (2017). Ethnic and genetic factors of iron status in women of reproductive age. Am J Clin Nutr doi:10.3945/ajcn.117.155853

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www.NHDmag.com December 2017/January 2018 - Issue 130


NEWS COWS’ MILK ALLERGY: IMPROVEMENT IN DIAGNOSIS STILL NEEDED The largest online survey1 of parents of children with cows’ milk allergy (CMA) in the UK, conducted by Allergy UK, confirms that there has been little improvement in the time it takes to get a diagnosis in the last five years.1 Comparative parent data from 2017 and 2012 shows that despite healthcare professionals (HCPs) demonstrating improved awareness and confidence, there is still work to be done to identify CMA sooner. 15% of parents had visited their GP 10 times or more between presenting their child’s problem and diagnosis of CMA, and 43% of cases waited between three months and a year.1 Despite this, there are some positive signs of improvement, with GPs now diagnosing nearly a third of cases (32%),1 more than double the 2012 figure,2 with the remainder diagnosed in secondary care.1 New iMAP guidelines3 (International Milk Allergy in Primary Care) provide GPs with clear and definitive support to help identify and manage this complex and distressing condition. Combining the essential advice within the recent UK NICE guidance, it has been created to facilitate accurate diagnosis and treatment pathway for suspected or diagnosed CMA. For the new iMAP guidelines and to find out more about the

issues facing parents of children diagnosed with CMA, visit www. allergyuk.org/CMAparentfeedback References 1 Survey of 2,852 parents of children diagnosed with CMA conducted in July 2017. Data on file 2 Survey of 328 parents of children diagnosed with CMA conducted in May 2012. Data on file 3 Venter, C et al (2017). 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. August, Vol 7, no 26

INFANT & TODDLER FORUM (ITF) LAUNCHES CHAT CHAT is a new online educational programme from leading health and nutrition experts. Offering online and face-to-face training, CHAT aims to increase practitioner confidence in engaging and supporting families in order for them to make improvements to their lifestyles. Combining the ‘knowledge of healthy behaviours in early life’ with Healthy Conversation Skills (HCS), this unique, scalable and transferable intervention will help achieve current government targets to combat maternal and childhood obesity through the MECC mandate. CHAT has already delivered positive results in a recent pilot with the Pre-school Learning Alliance. Of the 70 respondents, the majority (80%) reported a significant increase in confidence when giving advice on nutrition and lifestyle post training. Dr Wendy Lawrence, Associate Professor of Health Psychology at the University of Southampton leads the development and delivery of HCS training. She explains the value of HCS: “This programme aids implementation of the MECC mandate by providing practitioners with the skills to initiate difficult conversations on sensitive health-related topics and more effectively support individuals to make meaningful and long-lasting changes.”

For more information on the face-to-face training: www.infantand toddlerforum.org/health-childcare-professionals/healthy-conversation

GUT FLORA FLOURISHES AT DIFFERENT TIMES OF DAY A new article published in The American Journal of Clinical Nutrition has found that the time of day and our eating behavior can affect how bacterial flora flourishes in our gut. The research analysed 77 samples of poop from 28 healthy men and women. Data on eating frequency, timing of meals and length of overnight fasting were also collected. It was found that gut microbiota is in fact highly variable throughout the day. The timing of eating and length of overnight fasting, in particular, determine how bacterial populations accumulate in the gut. So, it seems that we need to be looking at the ‘bigger picture’ when it comes to our gut flora and how our general lifestyle habits can affect this.

For more information, see: Kaczmarek JL et al (2017). Time of day and eating behaviors are associated with the composition and function of the human gastrointestinal microbiota. American Journal of Clinical Nutrition; 10.3945/ajcn.117.156380 www.NHDmag.com December 2017/January 2018 - Issue 130

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F2F

Ursula meets amazing people who influence nutrition policies and practices in the UK.

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.

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FARHAT HAMID Head of Nutrition and Dietetics, Brent Public Health Advocate

There are many reasons to eat cake: to share celebration; because it tastes wonderful; to self-comfort after exertion or stress; or, in my meeting with dietitian Farhat Hamid, because the café was deserted and we needed to push the order up beyond cups of tea, as a way of paying table rent. And it was delicious warm apple strudel with custard: just the thing to sweeten our discussions about dietetics. Farhat is the Head of Nutrition and Dietetics for Brent, at London North West Healthcare NHS Trust, and clearly enjoys grabbing every opportunity to promote the work of the dietetic profession. You could describe her as pushy, or you could choose other descriptions with the letter ‘P’: pro-active, persuasive and passionate. Getting things done is clearly what drives Farhat and she shares her long career of achievements with me. She came from Pakistan to the UK as a young teenager and had the dual challenges of learning a new culture and language. Her hard work led to four great A-levels and a careers teacher’s random suggestion led Farhat to choose to study Dietetics. She really enjoyed her student days at the University or Surrey. “I particularly loved my placement with the infant formula company Milupa. They not only gave me some opportunities to travel across the UK, but also to lead on various creative projects,” said Farhat. Her first job was at Sandwell Hospital in the Midlands, followed by a job in

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the London borough of Haringey. The latter was a community post, so involved health education, and support for diverse specialist services such as mental health, infant nutrition or the then early days of HIV care. “Public health projects have always excited me the most, and my interest was sparked then,” said Farhat. In 1989, Farhat became Chief Dietitian at Parkside Health NHS Trust. This remains her geographical patch, but, of course, much has changed, not least that the number of dietitians employed has grown from three to 46. She lists many additional managerial responsibilities, such as being General Manager for Long Term Conditions, Chair of a Practice Based Commissioning Cluster and Chair of the Professional Executive Committee: not being familiar with NHS decision structures, I try to clasp these many roles, but they all escape my mind like released birds. But the pattern is very clear: Farhat always seeks to step into challenging roles to seize greater influence and recognition for the dietetic profession. “Some of these roles were new and seemed scary. It was comforting to find that other Board members felt the same and we all faced a learning curve whilst working with multi-million pound budgets. However, you always come out stronger and ready to face even more difficult challenges,” said Farhat.


Had she had any time-out in her 28-year period at Brent? Aside from three maternity breaks, the answer is, “No. I did consider going part-time, but decided that I would just be doing the same work load in fewer days, so that did not seem sensible. I did have an 18-month secondment at the Department of Health, as part of The Top Talent NHS Leadership programme. I was particularly involved with projects supporting NHS-wide equality and diversity policies, and really enjoyed getting nationwide perspectives on difficult issues.” She is one of 13 national advocates under a scheme to increase the participation of allied health professionals in public health (captured as AHP4PH; no doubt someone will claim this as a car number plate). She applied by submitting a project describing a community-based course for black and minority ethnic participants diagnosed with prediabetes. Data of excellent attendance and improved health evaluations impressed the AHP4PH project team, and Farhat is keen to continue these lifestyle courses. Her only frustration is that many such projects are occasional events when small funding amounts become available, rather than becoming firm longer-term commitments built into core NHS services. In fact, she has declined some projects where there is an imbalance between settingup costs and recruitment efforts and small oneoff funds offered. But Farhat is not the first NHS manager facing high service demands with finite resources. Another achievement is her prize as ‘Innovator of the Year 2017’ at the Trust Excellence Awards. She constantly seeks diverse funding sources and has clearly mastered the arts of tendering and writing business plans. She won all of the four bids she submitted in recent years, which brought in sufficient funding to pay for 13 additional dietetic posts. Of course, this is a great success for northwest Londoners, who now have greater access to dietetic services. But the projects also led to a series

of publications resulting in a clinically effective intensive lifestyle programme that Farhat has mainstreamed in her local dietetic service. Farhat feels that the British Dietetic Association is currently better and stronger at supporting its members, and she is a member of the steering group of the Future Dietitian 2025 project (turn to our Prof Blog on page 48 for more on this project). This is an exciting opportunity to consider possibilities as well as threats to the profession and find ways to raise our visibility amongst medical colleagues and in the media. The issues she particularly supports are greater diversity within the profession: ethnically, culturally and in attracting more men into dietetics. “Dietitians can sometimes be a bit demure and passive and a greater mix of people would support the vigour of the whole profession,” said Fahrat. She is also keen to pull more dietetic services out of hospitals and into more accessible and familiar community settings supporting the national policy of the Five Year Forward View. This is especially important at providing care for hard-to-reach population groups. She supports better training for student dietitians: to think laterally and to think outside of boxes; to become more entrepreneurial and risk taking. She is all of these things, but I query whether these skills and attributes can be taught. She laughs because I am being obtuse and insists that she does much to push and support her students and staff into greater actions and participation. But she agrees that perhaps these are not solely curriculum items. She hints that two great role models in her life - her ever-supportive father and her husband - may have been her greatest teachers (but they are not available to other dietitians!). As I walked back to the underground, I noticed graffiti sprayed on the wall. It proclaimed, ‘carpe diem’. This was more likely to have been done by some teenager; had it been Farhat, it would have been, carpe diem dietetica.

If you would like to suggest a F2F date

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

info@networkhealthgroup.co.uk www.NHDmag.com December 2017/January 2018 - Issue 130

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YOUR ESSENTIAL RESOURCE


COVER STORY

FREELANCE PRACTICE: ADVICE FOR MOVING FORWARDS Priya Tew Freelance Dietitian and Specialist in Eating Disorders

Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and Chronic Fatigue. She works with NHS services, The Priory Hospital group and private clinics as well as providing Skype support to clients nationwide.

The numbers of dietitian’s moving into freelance practice seems to be everincreasing. As someone who has always done some freelance work, but also had an NHS role, I know the highs and lows of working for yourself. Here is my advice for making your freelance role a success. JOINT WORKING WITH OTHER DIETITIANS

When I started out, a lot of the work I cut my teeth on was for other dietitians. There were a few dietitians who would subcontract parts of projects out to me; in fact, I still do this type of work now. I actually love it, it is safe and just like working within a department. You can ask for advice and get your work checked afterwards to see if you have missed anything. This style of working also means that you yourself could take on a larger project and subcontract it out to others; for example, if a local student approaches you asking for work experience, could you offer them some tasks that would help you out? BUILD YOUR OWN VIRTUAL DEPARTMENT

One of the big low points of freelance work for me has been the lone working. If

you suddenly have a question to ask, you want to double-check something, need to borrow a diet sheet or pick someone’s brains, you just can’t nip into the next door office. I’m someone who loves working on my own, but I also thrive when connected with others who inspire me, encourage me and do what I do. Until recently it hasn’t been easy to have access to a supportive network. Bring on social media and this has been created for us overnight. Back in my early days on Twitter, I remember being so excited to suddenly find other dietitians, to chat to them and get a response, to meet GPs and physiotherapists. Now there is no end to this, there are groups on LinkedIn, Facebook, Instagram and a constant presence on Twitter. Join in Twitter chats to meet others; if you can’t make them at the right time, then

Table 1: Social media groups for dietitians Facebook

LinkedIn

Twitter chats

Freelance/Private Practice Dietitians Group: www.facebook. com/groups/freelancedietitianssup portandclinicalsupervision/?fref=nf Great for chatter, asking questions and sharing resources

British Dietetic Association: members only: www.linkedin.com/ groups/1968119

Look for your local hours, these can be good for connecting with local businesses, building your profile and meeting others who you could work with, e.g. #hampshirehour #dorsethour

Dietitians in Virtual Practice: www.facebook.com/groups/ virtualpracticenetworkdietitians/ Useful to connect with others and hear what other RDs are up to

Freelance Dietitians: www.linkedin. com/groups/4123162 Good for work opportunities, webinars and CPD ideas

#RDUK is now a well-known and well-attended Twitter chat that is fabulous for meeting other likeminded people and for learning from each other. It is usually on the first Monday of the month 7.30-8.30pm

Dietitian Entrepreneurs: www.facebook.com/groups/ dietitianentrepreneurs/ Useful to ask questions and get an international flavour

Dietitian Connection Group:www. linkedin.com/groups/4471878 For webinars, blogs and business tips.

The Rooted Project Book Club #TRPBookclub is hosted at times throughout the year and is a good way of discussing a subject, as well as a nice hour of chatter

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SKILLS & LEARNING Table 2: Ideas of what to tweet/share about on social media Professional

Personal

CPD

Media quotes

Recipes you are cooking

Share events that you are going to, or that others are running

Articles you have written and your blog posts

Pictures of your meals at home

RT the science or research from others in the field

Summary of your clinic and work for the day

How you plan your own eating and nutrition

When you read an article, share the main points as tweets or a blog post

Top tips on nutrition

Personal views on foods and new products

Search for hashtags on areas you are interested in and share the content

Campaigns that are happening

Nutrition books you are reading and cookery books

Join in twitter chats and webinars

Business

Dietetic/nutrition

Speciality

Perpetual Traffic (Social Media and Web tips)

Dietitian Connection

The Guru Performance Podcast (Sports Nutrition)

Soulful PR

Food Psych Podcast

Recovery Warriors (Eating Disorders)

Being Boss

Don’t Salt my Game

The Gut loving Podcast (IBS)

Research that you are involved with Talks you are giving Table 3: Dietetic podcasts of interest

Online Marketing Made Easy

you can always catch up later on by searching for the hashtag. The huge plus of these groups is that there are so many people in them, so instead of a department of 10 people, you could have access to 700 people! Obviously, not everyone will comment and reply to you, but you will soon find people who you connect with and build relationships with. Who knows where those connections could take you. If you are like me and you like to be connected, then here are some of those social media groups to try out (see Table 1). PUT YOURSELF OUT THERE ON SOCIAL MEDIA

Social media has been a career changer for me, but it can also be an ever-changing place and very exposed. I’ve certainly been stung a few times with negativity and trolls. However, the positives outweigh the negatives and there are negatives in all areas of life. More healthcare professionals are putting themselves onto social media which is fabulous - we need to get chatting in order to get our professions and the 12

right advice trending. See Table 2 for ideas on what to post on social media. DEFINE YOUR NICHE

When I started in the freelance world, I took all the work that came along. This was good because I got a wide range of experience and I’ve been able to find out exactly the types of work I like and the bits I’m less keen on. Yes, you sometimes may have to do pieces of work that are mundane and uninspiring, but if this is all you do, then why bother? I want these pieces of work to be stepping stones to something else, or I only take on work I am passionate about. Some great advice I was once given was, “Work out what you are good at and then do just that”. If we all focus on the same area of work, then, firstly, the market could be saturated and secondly, there will be large gaps in the nutrition world of work. I specialise in eating disorders because it was my NHS role; I have lots of experience in it and I love it. However, it is also very demanding work when

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As dietitians, we do not have to be subservient. If you look at the nutrition world, there are plenty of people out there who have an enterprising and entrepreneurial mindset.

done on a private basis and so I know I need a balance. Freelance work offers me this balance of having my fingers in many ‘pies’. Media work, article writing, PR campaigns, social media projects and recipes analysis are all things I can fit around my family life. IF YOU WANT SOMETHING, THEN CREATE THE OPPORTUNITY

As dietitians, we do not have to be subservient. If you look at the nutrition world, there are plenty of people out there who have an enterprising and entrepreneurial mindset. If you are a freelancer, then you need a touch of this. Look for the problems and be creative about how you could come up with a solution. Remember that you do not need to work alone on a project. Think about what could happen if a group of dietitians came together and worked on something that they were passionate about. The work will not necessarily come and fall into your inbox (although it often does!), but it comes through networking, through recommendations from other people and also through you creating it. I’ve run cooking projects because I had a passion to do so, applying for funding to pay myself and then working with charities and local groups offering ideas and resources. For tips, ideas and inspiration there are some wonderful podcasts out there (see Table 3). CHARGE WHAT YOU ARE WORTH

This is the hard part and an area I have struggled with and still do. Only this week I asked another dietitian for advice on a project fee. How much

should you charge? Charge too much and you may not get the work, charge too little and you are potentially devaluing the profession and not earning your worth. As someone who has definitely done some projects for too little, I want to encourage you to know your worth. If you are like me and this is an area that you find tricky, then here are my tips: • When you have a project to quote for, work out how much it will cost you to do per hour, then add a few hours on for the extras. • Have a minimum price that you will take for the project and dare I say double it? Being bold can be the key. As dietitian’s we seem to undervalue ourselves and our work. If we are the experts in our field then shouldn’t our expertise be worth paying for? • Always ask for an amount higher than you actually want/expect to get and then you can negotiate from there. I’ve certainly turned work down in the past because it was unpaid and then it been offered back to me with a fee. Having said this, I do still take on some work for free, but I use the stance of: “Am I doing it because it is something I am passionate about and want to be involved with, or is it something that could benefit me later on?” For example, media work can enhance your profile and blogging work can improve your Search Engine Optimisation (SEO) of your website. Value your time: if you take on too many free pieces of work, ask yourself whether you will have time to work on your business and complete other paid work?

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SKILLS & LEARING Table 4: What to include in your invoices Date, your name, address and logo The person’s name who you are invoicing, their address Date the work was carried out and a description Invoice Reference and/or a supplier code if you are given one Break the costing down. e.g. three days’ work at xxx amount Expenses, such as travel time, petrol, food, resources Total amount invoiced and when payment is due How to pay - bank details for BACS NETWORKING IS KEY

Those chance meetings with people, those chats at study days and connections on social media, can all be more powerful than you think. If you can’t get out to meetings and events too often, then build that presence online. Joining local Twitter chats and groups on Facebook for dietary-related areas can lead to referrals. Placing your business cards in local cafes, hairdressers and schools will slowly mean your name becomes known and recognised. Being part of groups like Self Employed Nutritionists Support and Enlightenment (SENSE) and the Freelance Dietitians Group (FDG) are also a useful place to meet others and learn from them. Personally, I do not find that paid advertising works well for me, so I would advise caution before you spend out lots of money. Utilise your local community first. Life in the freelance world is like an unexplored territory. There is so much you could be doing, so many exciting places it could take you. Staying true to your passions and staying connected to other healthcare professionals can help you navigate which route to take.

• •

BE MORE BUSINESSLIKE

As dietitians, we can be all about the clinical work, but not necessarily be as clued up on the business side. In fact, I would go as far as to say that some people are even a little scared of the business side. Now, I am no business expert and have had to learn a lot along the way, but here are some of my tips: • Have templates set up on your computer for documents that you use regularly. Firstly, it saves you time creating them each time and secondly, it makes you look 14

professional if documents are standardised. Documents like clinical notes, reports, letters, dietary analysis, compliment slips and invoices can all be set up and saved as a template in a folder, or in your actual word processing software. Invoicing does not have to be complicated, many word processing softwares will have a template you can adapt, or just create your own. Send out invoices promptly (note to self: I need to improve on this!). If you are seeing a 1-1 patient/client, it is best to invoice them before you meet and preferably ask for payment before they arrive. See Table 4 for items to include in your invoice. Send out terms and conditions with a clear statement on how much your patient/client must pay if they do not attend a 1-1. Accountancy software is also a great option and can be used for your invoices too. This is something you pay for, but it will make your bookkeeping simple and is a nontaxable expense. Take a look at software such as FreeAgent, QuickBooks, Waves, ClearBooks, Xero.

TAKE-HOME TIPS

Being a freelancer can feel like a lonely field, but there are now so many places and people to get help from. Don’t be afraid to ask for help and to ask people how they do things. As dietitians, we may not be trained in business, but we need to charge what we are worth and learn the business and financial side of things as we go along.

www.NHDmag.com December 2017/January 2018 - Issue 130


FROM JANUARY 2018, APTAMIL PEPTI-JUNIOR WILL BE THE NEW NAME IN THE DIETARY MANAGEMENT OF MALABSORPTION RELATED CONDITIONS

Cow & Gate Pepti-Junior Product Code: 56560 PIP Code: 049-0714 Bar Code: 8712400590167

Aptamil Pepti-Junior Product Code: 124560 PIP Code: 049-0714 Bar Code: 8718117606917

SAME FORMULATION, NEW BRAND

WHAT DO I NEED TO KNOW?

SPECIALLY FORMULATED TO:

– Aptamil Pepti-Junior will be available in 450g tins, exactly the same as Cow & Gate Pepti-Junior

 Enhance digestion and absorption1,2  Promote palatability3-5  Reduce osmotic load6

– From JANUARY 2018, Cow & Gate Pepti-Junior will be called Aptamil Pepti-Junior – Only the brand name, packaging and codes will change, the formulation will remain the same

WHAT DO I NEED TO DO? – Continue to prescribe Cow & Gate Pepti-Junior until Aptamil Pepti-Junior becomes available, then simply switch over – the formulation is unchanged

For more information, call our Healthcare Professional Helpline on 0800 996 1234, or visit www.eln.nutricia.co.uk 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.

IMPORTANT NOTICE: Aptamil Pepti-Junior is a food for special medical purposes for the dietary management of malabsorption related conditions. It should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6 months. FOR HEALTHCARE PROFESSIONAL USE ONLY. 17-075/September 2017


PUBLIC HEALTH

THE SATURATED FAT AND HEART DISEASE DEBATE Maeve Hanan Registered Dietitian (full time), City Hospitals Sunderland Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

For full article references please email info@ networkhealth group.co.uk

16

There has been a lot of recent debate surrounding saturated fat intake and heart disease. This article will examine some of the common arguments put forward by those who challenge the link between the two. Saturated fats contain single bonds between carbon atoms which causes the fat to be ‘saturated’, or to be linked to as many hydrogen atoms as possible. Sources of saturated fat include: butter, coconut oil, palm oil, lard, full-fat dairy products, pies, pastries, cakes and biscuits and the visible fat on meat.1 Due to the association between saturated fat and increased low density lipoprotein (LDL) cholesterol levels, most public health bodies recommend limiting saturated fat intake in order to reduce the risk of heart disease.1,2 ARGUMENT ONE

Studies have found that saturated fat intake is not associated with heart disease A large meta-analysis by Chowdhury et al (2014)3 is often quoted to support this argument, as this study did not find a significant association between saturated fat intake and cardiovascular disease (CVD). However, there have been several criticisms of this study, such as errors in some of the data, omitting relevant studies, a lack of consistency (e.g. whether saturated fat was substituted for refined carbohydrates) and the fact that data representing monounsaturated fats was taken from meat and dairy rather than more relevant sources such as nuts and olive oil.4 Furthermore, numerous other large meta-analyses have found that lowering saturated fat intake is associated with a reduced risk of heart disease.5-7

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These studies also found that neither a lower total fat intake nor replacing saturated fat with refined carbohydrates was associated with a lower risk of heart disease, but that replacing saturated fat with unsaturated versions or wholegrains was associated with a reduced risk of CVD.5-7 For example, a large systematic review by Hopper et al (2015) found that a reduced saturated fat intake was associated with a 17% reduced risk of CVD.7 A more recent large prospective cohort study, called the PURE study, found that there were no significant differences between the type of fat consumed and the risk of cardiovascular events and that lower intakes of saturated fat were associated with an increased risk of stroke.8 Although these are interesting results, it is important to remember that no causal relationship can be assumed due to the observational design of this study. Another limitation is the potential confounding effect of socio-economic status. Although education status was corrected, the PURE study was predominantly carried out in low and middle income countries and the researchers themselves state that, ‘high-carbohydrate and low-fat diets might be a proxy for poverty or access to healthcare’.8


In the UK, we currently consume more free sugars and less fibre than recommended levels. ARGUMENT TWO

The initial research about saturated fat intake and heart disease was flawed The Seven Countries Study (SCS) by Ancel Keys et al which started in 1958, was a landmark study which identified an association between saturated fat intake and heart disease. A recent white paper report which was issued by ‘The True Health Initiative’ addressed the numerous recent criticisms related to the SCS which mainly focus on reported issues with the methodology of the study.9 This paper concluded that, as with every scientific study, the SCS had limitations, especially as it was an observational study which should be viewed within the wider context of epidemiological evidence.9 However, the overall body of evidence which has emerged since the SCS was published, including the famous Framingham Heart Study and the studies discussed above, supports the link between saturated fat intake and heart disease risk.5-7,9,10 ARGUMENT THREE

The French eat high levels of saturated fat, yet have low levels of heart disease Shortly after this ‘French Paradox’ theory was suggested in the 1980s, it was proposed that this may have been caused by the under-classification of CVD in France and the time-lag between the increased consumption of saturated fat in France (which was relatively recent at the time) and the subsequent increase in CVD levels.11 Based on recent statistics, the average intake of saturated fat in France remains high at 14.6% of total energy intake. However, France does not have a low prevalence of heart disease anymore.12 The ageadjusted average prevalence of CVD in France in 2015 was 6,101 per 100,000 for males and 4,666 per 100,000 for females, which was close to the EU average and was also very similar to the UK average, despite the higher obesity levels found in the UK.13

There are currently many other countries with a lower prevalence of CVD in Europe, including countries which have a lower average saturated fat intake than France, such as Italy, Portugal, Switzerland, Ireland, Spain etc.13-14 ARGUMENT FOUR

Sugar and carbohydrates are the problem, not saturated fat There is a grain of truth to this argument, as recent studies have shown that replacing fats with refined carbohydrates does not have a cardio-protective effect (as discussed above).3,5-8 However, vilifying carbohydrates as a whole ignores the numerous health benefits of wholegrains and fibre, which include a reduced risk of: cardiovascular disease, diabetes and colorectal cancer.15 In the UK, we currently consume more free sugars and less fibre than recommended levels, therefore, current public health guidelines advise us to gain ‘a greater proportion of total dietary energy from foods that are lower in free sugars and higher in dietary fibre whilst continuing to derive approximately 50% of total dietary energy from carbohydrates”.15 As with argument number two, there can often be a conspiracy theory element to the ‘sugar vs fat’ argument which may blame certain governments and the sugar industry. Drastic claims such as these should be assessed critically as to how they could have occurred on such a large scale, considering the knock-on effect they have on healthcare systems and taxpaying workforces. Furthermore, sugar has never been promoted in public health guidelines and there has been a recent emphasis on reducing sugar intake worldwide.15-16 Overall, this argument creates a false dichotomy as it suggests that a diet which has a lower saturated fat intake will result in an increased intake of refined carbohydrates, which isn’t the case, as, ideally, some saturated

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17


PUBLIC HEALTH

. . . in the UK we currently exceed the recommended intake of saturated fat . . . fat should be replaced with heart healthy alternatives such as: wholegrains, unsaturated fats, fruit, vegetables and legumes. ARGUMENT FIVE

All saturated fats are not equal Saturated fats can be classified as odd-chain or even-chain depending on the number of carbon atoms attached to the molecule. There is some emerging research which has found that odd-chain saturated fatty acids (which are generally found in full-fat dairy products) may have a protective effect against cardiometabolic disorders.3,17-19 However, it has also been suggested that the ‘whole food effect’ of dairy and other nutrients which it contains may contribute to this association, such as CLA (a naturally occurring form of trans fat), protein, the numerous vitamins and minerals present and the fact that some sources also contain probiotics.20 Although this is a fascinating area, more randomised controlled trials are needed before it can be stated that there is a causal relationship between individual types of saturated fat and health outcomes. ARGUMENT SIX

Coconut oil is good for your heart Due to its high saturated fat content (82% compared to butter which is 63% and olive oil which is 14%), the UK department of health advises to consume only small amounts of coconut oil.21-22 Some argue that coconut oil is healthy because it contains medium chain triglycerides (MCTs). However, less than 16% of the fats present in coconut oil are MCT as the main fat present is lauric acid which is a long chain triglyceride (LCT).23 There are some studies which have found that a high intake of coconut was not associated with an increased risk of heart disease.23 However, no conclusions can be made about 18

coconut oil based on this, as these studies were observational and were also based on the consumption of coconut flesh and coconut milk rather than the extracted oil. There is a lack of human research in relation to coconut oil and health, but the best available evidence indicates that coconut oil consumption is associated with an increase in total and LDL cholesterol when compared to consumption of unsaturated vegetable oils.22,24 Overall, coconut oil is fine to have in small amounts as part of a balanced diet. Nevertheless, there is currently no good evidence that it adds any specific health benefits. THE BOTTOM LINE

Although moderate amounts of total fat in the diet should not be vilified, the current body of evidence in relation to heart disease risk supports limiting saturated fat intake and consuming the majority of fat from unsaturated sources.25 It is also important to remember that on average in the UK we currently exceed the recommended intake of saturated fat which is <11% of total dietary energy.25 Whilst there is some emerging research in relation to how individual types of saturated fat may affect the risk of heart disease in different ways, more high quality research is needed to investigate this. Although the saturated fat and heart disease debate is often an emotive one, it is crucial to be guided by the best available evidence and to be wary of the potential appeal of conspiracy theories. It is also important to acknowledge that, as with all areas of science, nutrition is a complex and constantly evolving area which rarely provides one black and white answer to a topic such as this. It will be interesting to see whether we gain more clarity about this debate when the Scientific Advisory Committee on Nutrition (SACN) publish its upcoming review of saturated fat.26

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CLINICAL

Naomi Johnson Scientific and Regulatory Manager, BSNA

Naomi has a First Class Honours degree in Nutritional Science and an MSc in Public Health Nutrition. She has worked in the nutrition industry for several years. www.bsna.co.uk

For full article references please email info@ networkhealth group.co.uk

ENHANCED RECOVERY AFTER SURGERY: THE ROLE OF NUTRITION

IN ASSOCIATION WITH THE BSNA

â&#x20AC;&#x2DC;Failing to prepare is preparing to failâ&#x20AC;&#x2122;, a statement which is all too true when considering patient outcomes post-surgery. For any patient undergoing surgery, recovery and avoidance of complications are key objectives. The pre-and post-operative health and diet of the patient is an integral part of this . . . While there are numerous factors which will influence recovery post-surgery (i.e. underlying disease, extent of surgery, age and psychological wellbeing), nutritional intervention can play an integral role, with the correct nutrition an essential part of the recovery process. Malnutrition can negatively affect wound healing by prolonging inflammatory pathways, and in patients with undernutrition who present for surgery, there is a higher risk of post-operative complications including morbidity and mortality.1,2 More than three million people in the UK are malnourished at any one time, with an estimated 30% of people admitted to acute hospitals and care homes at risk of malnourishment.3,4 A survey by BAPEN (British Association for Parenteral and Enteral Nutrition) of UK hospitals found that adults admitted to hospital were more underweight (<20kg/m2) when compared with the general population.5 The European Society for Clinical Nutrition and Metabolism (ESPEN) guidance recommends that nutrition support should be used in patients with severe nutritional risk 10-14 days prior to surgery; inadequate oral intake during this period is associated with a higher mortality rate.6 For those patients at severe nutritional risk, a delay to surgery and administration of tube feeding and/ or oral nutritional supplements (ONS) is advised (with exception to intestinal obstruction, severe shock and intestinal

ischemia). Use of tube feeding and/or ONS is also indicated in those patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days and those who will be unable to eat for more than seven days peri-operatively (even if undernutrition is not obvious). Parenteral nutrition (PN) is indicated in patients for whom enteral nutrition (EN) may not be appropriate, such as in intestinal obstruction or failure.6 PN can also be used to complement EN, in those patients consuming <60% of calorific requirements. In upper GI cancer patients at severe nutritional risk, use of PN, pre-operatively, has been shown to reduce complications.7 PRE-OPERATIVE NUTRITIONAL CONSIDERATIONS

The overall health and nutritional status of the patient prior to surgery will vary significantly. Underweight, malnutrition, sarcopenia, cachexia and atrophy may already be present pre-surgery due to factors such as aging, disease and inactivity.8 Surgical nutrition studies have identified weight loss (>10%) and low albumin (<30g/l) as risk factors for adverse outcomes.9 Skeletal muscle plays an essential role in health; loss of aerobic capacity, reduced strength, weakness, fatigue, insulin resistance, falls and fear of falling, frailty disability and mortality are all associated with skeletal muscle loss.10 An interruption in nutritional intake can be negatively implicated in

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19


Getting Nan back to her old tricks again!

is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut function when compared with fasting or supplementary water.1 Helping patients get back to doing the things that they enjoy sooner.

Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision. 1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.

A Nestlé Health Science Company

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CLINICAL health outcomes; increased metabolic stress, hyperglycaemia and insulin resistance are all indicated in pre-operative fasting.6,11 Therefore, whilst pre-operative fasting is still common practice, it is now considered unnecessary for most patients (although this is contraindicated in those at risk of aspiration). When an earlier return to gastrointestinal function is facilitated, patients’ tolerance to normal food and even enteral feeding can also be improved.12 In a systematic review of patients who had elective gastrointestinal surgery, septic complications and length of hospital stay were reduced in those who received early EN.13 It should be noted, however, that risks are associated with both enteral feeding and its early use. BAPEN guidelines provide advice on best practice for the administration of medication via enteral tubes.14 Surgery can have a huge impact on the body, resulting in a cascade of metabolic changes. When an injury occurs, afferent neuronal impulses activate an endocrine response.15 This stress response to surgery results in a rise in stress hormones and inflammatory markers, which present as immune system suppression and increased cortisol secretions which will impact both carbohydrate, fat and protein metabolism. Insulin resistance is a sign of surgical stress, with more extensive surgery associated with greater levels of insulin resistance - an independent risk factor that influences length of stay and poor wound healing.16 Hormonal changes will lead to increased catabolism (to mobilise energy sources). Once surgery has commenced, blood glucose concentrations will rise: the extent of this varies according to the type and degree of surgery. Potential risks linked to perioperative hyperglycaemia include increased wound infection and impaired wound healing. Postoperative control of blood sugar levels is, therefore, essential to recovery and overall outcomes. POST-OPERATIVE NUTRITIONAL CONSIDERATIONS

During periods of inactivity/immobility, such as post-surgery, a loss of lean body mass is implicated in a reduced ability to recover. This issue is further exacerbated with age. An older cohort subjected to 10 days of inactivity

experienced approximately a three-fold greater loss of lean leg muscle mass when compared to a younger cohort examining protein synthesis and muscle mass in healthy adults who were subjected to bed rest for 28 days.5,17 From age 40, muscles do not respond to protein from the diet as well as that of younger counterparts.18 The right nutrition for muscle health and recovery is, therefore, key. Post-operatively, for the majority of patients a standard whole protein formula is appropriate, which may include immune-modulating substrates (arginine, omega-3 fatty acids and nucleotides) in enteral form.6 Extensive research exists on the role of ONS in older populations, which has shown to increase both body weight and improve nutritional status.19 In those older individuals who are malnourished, an ONS high in protein and vitamin D in particular, can have a valuable role to play in improved recovery. Patients with whole-body protein depletion have been shown to have a marked increase in both major complications and duration of postoperative stay.20 For both young and elderly individuals it is well researched that moderate-tolarge servings of protein or amino acids increases muscle protein synthesis.21,22 In older adults, high doses of protein (>25g) or essential amino acids (10-15g) have a similar ability to synthesise muscle protein compared to younger ones; lower doses (protein <20g; EAAs <8g) do not achieve the same skeletal muscle response. However, single servings of >30g protein do not stimulate a greater anabolic response between younger and older adults.23 The American Society for Parenteral and Enteral Nutrition (ASPEN) has suggested 1.2-2.0g protein/kg for those in the critical care setting, including post-operative major surgery.24 In a prospective non-randomised study, significant reductions in nosocomial infections and overall complications were shown in highrisk surgery patients (NRS 2002 ≥5) who received sufficient pre-operative nutrition therapy (>10kcal/kg/d for seven days) when compared with patients who received insufficient therapy.25 For low risk patients, no differences were observed between sufficient and insufficient EN.25 ‘Immune modulating nutrition’ or ‘immunonutrition’ (a liquid nutritional supplement enriched with specific nutrients), given by

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CLINICAL

During periods of inactivity/immobility, such as post-surgery, a loss of lean body mass is implicated in a reduced ability to recover. the oral/enteral route during the peri-operative period has demonstrated a reduction in postoperative infective complications.26 Optimal rehabilitation and wound healing is dependent on the body being in an anabolic state. For the majority of patients undergoing surgery, a pre-operative carbohydrate drink the night before (800ml) and a 400ml drink two hours prior to anaesthesia is generally advised.6 Reduced post-operative insulin resistance and preservation of skeletal muscle mass has been demonstrated in colorectal patients and those with hip replacement who took a 12.5% hypo-osmolar carbohydrate rich drink preoperatively.27,28,29,30 Additionally, pre-operative carbohydrate loading reduces thirst, hunger and anxiety.29,30 The correct pre-operative preparation is essential to post-operative recovery; carbohydrate loading reduces insulin resistance and diminishes nitrogen and protein loss.31,32 Post-operatively it also helps to preserve skeletal muscle. ENHANCED RECOVERY AFTER SURGERY (ERAS) GUIDELINES

Adopted by a number of hospitals, enhanced recovery after surgery (ERAS) protocols have become a widely accepted toolkit.33 These guidelines provide evidence-based recommendations for ONS and EN in surgical patients. In a systematic review of six trials (3 RCTs and 2 CTs; n=512) use of ERAS resulted in reduced hospital stays and a lower morbidity rate (RR: 0.54 [CI 0.42-1.69]), although there was no difference in readmission and mortality rate.6 The ERAS guidelines seek to minimise 22

surgical stress, maintain nutritional status, reduce complications and optimise recovery rates. The ERAS programme considers key nutritional and metabolic aspects of pre and post-operative care, which integrate nutrition into the overall management of the patient, and include: • pre-operative nutrition;34 • avoidance of long periods of pre-operative fasting;34 • fluid intake and carbohydrate loading up to two hours pre-operatively;34 • re-establishment of oral feeding as early as possible after surgery (ideally the first postoperative day);34 • metabolic control, e.g. of blood glucose;34 • reduction of factors which exacerbate stressrelated catabolism or impair gastrointestinal function.6 Recently published (ESPEN) guidelines on nutrition in cancer patients strongly recommend that all cancer patients undergoing either curative or palliative surgery are managed using an ERAS programme.34 Successful adoption of an enhanced recovery approach also requires input from the multidisciplinary team; ‘enhanced recovery is about the whole team rather than an individual’ at a sustained level.35 Implementing the most appropriate pre-and post-surgery protocols ensures that patients have the best possible chance of a successful and speedy recovery. Nutritional screening and intervention can play a vital role in this, with ERAS programmes offering a measured clinical impact on overall patient outcomes.

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PAEDIATRIC

AN UPDATE ON BREASTFEEDING Maeve Hanan Registered Dietitian (full time), City Hospitals Sunderland Maeve works as a Paediatric Dietitian in City Hospitals Sunderland. She also runs a blog called Dietetically Speaking.com which promotes evidencebased nutrition and dispels misleading nutrition claims and fad diets.

Breastfeeding is a key health promotion issue in the UK and worldwide. Rates of breastfeeding in the UK remain low, despite the current advice ‘to breastfeed exclusively for around the first six months of the infant’s life and to continue breastfeeding (alongside complementary feeding) throughout the first year’.1 This article will examine the current situation and public health strategies related to breastfeeding in the UK. Only 40% of infants aged under six months are exclusively breastfed worldwide.2 Breastfeeding duration tends to be shorter in high income countries than in lower income countries, with South Asia, Sub-Saharan Africa and parts of Latin America having the highest prevalence of breastfeeding at 12 months old.2-3 Europe has the lowest breastfeeding rates out of all World Health Organisation (WHO) regions, with only 13% of infants being exclusively breastfed during the first six months, compared to other regions, such as South East Asia where this figure is 43%.4 Within Europe, rates of exclusive breastfeeding at six months are variable; for example 42% in Bulgaria, 33% in Sweden and 1% in the UK.5 Despite having very low exclusive breastfeeding levels at six months (see Table 1), overall breastfeeding

rates in the UK are steadily increasing (see Table 2 overleaf). For example, 81% of infants in the UK are now breastfed at birth, which has increased from 62% in 1990.6 There is also variability within the UK, with breastfeeding rates tending to be highest in England and lowest in Northern Ireland.6 In the UK, higher incidences of breastfeeding are associated with specific sociodemographic groups (see Table 3 overleaf) and also with mothers having their first baby (84% compared with 78% with a second or later baby) and with those who have previously breastfed a baby for at least six weeks (97% compared with 79% who have breastfed for less than six weeks and 35% who have not breastfed previously).6 CURRENT EVIDENCE

It is estimated that universal breastfeeding ‘could prevent 823,000 annual

Table 1: Exclusive breastfeeding rates in the UK6-7 Stage

2005

2010

At birth

65%

69%

1 week

45%

46%

6 weeks

21%

23%

3 months

13%

17%

4 months

7%

12%

6 months

<1%

1%

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Aptamil Pepti for the effective management of cows’ milk allergy

RELIEVE

cows’ milk allergy symptoms1 with 97% efficacy2

REDUCE

incidence of atopic dermatitis up to five years3 NOW PROVEN4

*

REASSURE

with the UK’s most palatable extensively hydrolysed formula4*

For further information contact our Healthcare Professional Helpline on 0800 996 1234 or visit www.eln.nutricia.co.uk/cma References: 1. Verwimp JJ et al. Eur J Clin Nutr. 1995;49 (Suppl1):S39-S48. 2. Giampietro PG et al. Pediatr Allergy Immunol. 2001;12:83-86. 3. Arslanoglu S et al. J Biol Regul Homeost Agents. 2012;26:49-59. 4. Campden BRI conducted a blind taste test using a home usage design with a sample of 100 Dieticians and General Practitioners from 16.11.2016 to 09.12.16. Participants rank ordered the extensively hydrolysed formula (EHF) milk samples (Danone Aptamil Pepti, Abbott Similac Alimentum, Nestle SMA Althera and Mead Johnson Nutramigen LGG) in term of overall liking and answered a series of attitudinal questions in relation to the impact of EHF’s palatability on infants with CMA and their families. The results from the ranking showed that the Danone Aptamil Pepti sample was liked signifi cantly more than all the other three samples tested. * A home usage test assessment was carried out between 16/11/16 and 9/12/16 on the 4 products indicated for cows’ milk allergy from birth and included 100 UK healthcare professionals.

IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. 17-026 / June 2017


PAEDIATRIC Table 2: Overall breastfeeding rates in the UK6-8 Stage

1995

2000

2005

2010

At birth

66%

69%

76%

81%

6 weeks

42%

42%

48%

55%

6 months

21%

21%

25%

34%

Table 3: Breastfeeding initiation rates based on sociodemographic6 Maternal Sociodemographic

Breastfeeding initiation incidence

Over 30 years

87%

Chinese ethnicity

97%

Black ethnicity

96%

Asian ethnicity

95%

Working in managerial or professional jobs

90%

Living in the least deprived areas

89%

deaths in children younger than five years and 20,000 annual deaths from breast cancer’ in mothers.3 Breastfeeding is associated with a reduced risk of hospital admissions due to lower rates of infant infections, such as gastroenteritis, lower respiratory infections and middle ear infections (otitis media).1 Breast milk also has a key role in supporting the development of an infant’s immune system by providing passive specific immune protection, and is promoted as a strategy for reducing childhood obesity levels.1,9 In terms of maternal health, each additional year of breastfeeding is associated with a 4% reduced risk of breast cancer.1 Exclusive breastfeeding during the first six months is also positively associated with postnatal weight loss and breastfeeding duration is inversely associated with maternal BMI, as breastfeeding is reported to burn up to 600 calories per day.1,10 Further infant and maternal benefits of breastfeeding are outlined in Table 4 overleaf. In terms of cost savings, an estimated £11 million per year could be saved in the UK if all mothers who breastfeed exclusively at one week continued breastfeeding until four months, due to a reduction in infant hospital admissions related to infections.12-13 It is also estimated that doubling the amount of women who breastfeed for seven to 18 months in the UK could save £2131 million during a lifetime, due to a reduction in the incidence of maternal breast cancer.13

Breastfeeding is contraindicated with some infant medical conditions, such as: galactosaemia, glucose-galactose malabsorption and long-chain fatty acid defects.14 Some maternal health issues can also hinder breastfeeding, such as: polycystic ovary syndrome (PCOS), hypoplastic breasts, tuberculosis, HIV, substance abuse, undergoing chemotherapy or radiotherapy and taking certain medications.14-15 However, breastfeeding is not contraindicated in all of these cases, for example, milk production is possible for some mothers with PCOS and hypoplastic breasts; and WHO now recommends that HIV positive mothers can continue to breastfeed if receiving appropriate medical treatment which includes the use of antiretroviral drugs.15-16 However, physiological barriers to breastfeeding are reported as being statistically rare overall, therefore, the main barriers appear to be social and cultural (as reflected in Table 3).16 PUBLIC HEALTH STRATEGY

In view of the steep reduction in the amount of women in the UK who continue to breastfeed past the first few weeks, the Scientific Advisory Committee on Nutrition's (SACN) 2017 draft report on infant nutrition recommends that more emphasis should be placed on ‘supporting women who make the informed choice to breastfeed for as long as possible’.1 This includes promoting continued breastfeeding beyond six months

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PAEDIATRIC Table 4: Benefits of breastfeeding1,10-11 Benefits of breastfeeding for baby • Breast milk adapts to the infant’s needs, e.g. colostrum is produced in the first few days to provide the necessary antibodies, proteins and minerals. • Improves immunological development. • Reduced risk of infant ear infections, lower respiratory infections and gastroenteritis (therefore, fewer hospital admissions). • Reduced risk of sudden infant death syndrome (SIDS). • Potential reduced later life risk of leukaemia, Type 2 diabetes and obesity. • It is associated with improved cognition in later life. • Breastmilk exposes an infant to different tastes which may improve later dietary variety, whereas formula has one taste. • Bonding.

Benefits of breastfeeding for mum • Reduced maternal risk of breast cancer. • Potential reduced maternal risk of: ovarian cancer, osteoporosis, cardiovascular disease, Type 2 diabetes and obesity. • It is associated with improved post-natal weight loss. • Breastfeeding releases maternal hormones which help with recovery from pregnancy and childbirth by contracting the uterus back to its previous size. • Breast milk can help to heal swollen or painful nipples after birth. • Breastfeeding can help with spacing out subsequent pregnancies. • Convenience - no need to buy formula or sterilise bottles. • Bonding.

Table 5: Breastfeeding help and support available in the UK20 Organisation

Description

NHS or private healthcare one-to-one support

• Midwives • Health visitors • Local trained volunteer mothers (peer support) • Lactation consultants

Local Children's Centres and Family Information Services

Provide information on local breastfeeding groups

The Breastfeeding Network

A charity which provide information and support in relation to breastfeeding.

La Leche League GB

A voluntary group which provides mother-to-mother support for breastfeeding.

Association of Breastfeeding Mothers (ABM)

A charity which provides information and counselling in relation to breastfeeding.

Baby Café

A network of breastfeeding drop-ins.

The National Childbirth Trust (NCT)

A charity which provides support on all aspects of early parenthood, including breastfeeding.

The Twins and Multiple Births Association (TAMBA)

Provides information about breastfeeding twins or triplets.

Bliss

A UK charity for premature or sick babies.

The UK Association for Milk Banking

Provides information about donating or using donated breast milk for premature or ill babies.

National Breastfeeding Helpline

Available to provide support over the phone from 9.30am to 9.30pm every day via: 0300 100 0212.

Start4Life Breastfeeding Friend

A chat-bot which uses Facebook messenger to provide 24-hour breastfeeding support for mothers.

26

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of age, due to the additional health benefits this provides. SACN also recommend that a national system for monitoring the incidence and prevalence of breastfeeding is reinstated.1 The United Nations International Children's Emergency Fund's (UNICEF) baby-friendly initiative has been run across the UK for the past 20 years and is now used in 91% of maternity units and 85% of health visitor services.17 This provides an evidence-based accreditation programme to train healthcare professionals in supporting mothers to breastfeed and in helping all parents to foster a loving relationship with their baby, regardless of the chosen feeding method.17-18 This initiative focuses on providing ‘sensitive and effective care and support for mothers, enabling them to make an informed choice about feeding, get breastfeeding off to a good start and overcome any challenges they may face’. Another initiative which is reported to have improved breastfeeding initiation levels is the Family Nurse Partnership Programme which provides support to first-time mothers who are under 19-years-old and their partners.19 A recent literature review concluded that although individual support is important, investment is needed to target the numerous societal barriers to breastfeeding which exist in the UK in order to normalise breastfeeding.15

This highlighted that physiological and medical contraindications for breastfeeding are low and that countries such as Brazil have had significant success in using a society-wide public health strategy to increase breastfeeding rates. The main areas for public health investment which emerged in this review were: health services, population level health promotion, supporting maternal legal rights, protection of maternal wellbeing and reducing the reach of the breast milk substitute industry.15 Partners, family and friends can provide crucial emotional and practical support to a mother who chooses to breastfeed. There are also numerous organisations in the UK which provide support for breastfeeding mothers (see Table 5 opposite). CONCLUSION

Overall, the evidence is clear that increasing breastfeeding rates would improve maternal and infant outcomes globally. An ongoing multifactorial approach which focuses on improving breastfeeding duration and tackling societal issues in relation to breastfeeding is needed in the UK. In the process of normalising breastfeeding, it is also important to avoid demonising mothers who cannot, or who choose not to, breastfeed, as this is understandably an individual and emotive issue.

References 1 SACN (2017) “Draft Feeding in the First Year of Life Report: www.gov.uk/government/uploads/system/uploads/attachment_data/file/629221/Feeding_ in_the_first_year_of_life_draft_report.pdf 2 WHO website. 10 Facts on Breastfeeding (accessed August 2017 via: www.who.int/features/factfiles/breastfeeding/en/ 3 Victora et al (2016). Breastfeeding in the 21st century: epidemiology, mechanisms and lifelong effect. http://sci-hub.cc/10.1016/s0140-6736(15)01024-7 4 WHO (2015). European Region has lowest global breastfeeding rates. www.euro.who.int/en/health-topics/Life-stages/maternal-and-newborn-health/ news/news/2015/08/who-european-region-has-lowest-global-breastfeeding-rates 5 Wolfe & McKee (2013). European Child Health Services and Systems: Lessons without borders. www.euro.who.int/__data/assets/pdf_ file/0003/254928/European-Child-Health-Services-and-Systems-Lessons-without-borders.pdf 6 McAndrew et al (2012). Infant Feeding Survey 2010. http://content.digital.nhs.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010-ConsolidatedReport.pdf 7 Bolling et al (2007). Infant Feeding Survey 2005. http://content.digital.nhs.uk/catalogue/PUB00619/infa-feed-serv-2005-chap1.pdf 8 Hamlyn et al (2002). Infant Feeding 2000. http://doc.ukdataservice.ac.uk/doc/4746/mrdoc/pdf/4746userguide.pdf 9 WHO (2016). Report in the Comission in Ending Childhood Obesity http://apps.who.int/iris/bitstream/10665/204176/1/9789241510066_eng. pdf?ua=1&ua=1 10 Women’sHealth.gov; website accessed August 2017 via: www.womenshealth.gov/itsonlynatural/addressing-myths/incredible-facts-about-babiesbreast-milk.html 11 NHS Choices (2017). Benefits of breastfeeding www.nhs.uk/Conditions/pregnancy-and-baby/Pages/benefits-breastfeeding.aspx 12 Renfrew et al (2012). Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK 13 Pokhrel et al (2014). Potential economic impacts from improving breastfeeding rates in the UK 14 Thomas and Bishop (2011). The Manual of Dietetic Practice (4th edition) 15 Brown (2017). Breastfeeding as a public health responsibility: a review of the evidence. http://onlinelibrary.wiley.com/doi/10.1111/jhn.12496/full 16 WHO website. HIV and infant feeding; accessed August 2017 via: www.who.int/maternal_child_adolescent/topics/child/nutrition/hivif/en// 17 UNICEF website. What is Baby Friendly; accessed August 2017 via: www.unicef.org.uk/babyfriendly/what-is-baby-friendly/ 18 Kramer et al (2001). Promotion of Breastfeeding Intervention Trial (PROBIT): a randomised trial in the Republic of Belarus 19 Barnes et al (2011). The Family- Nurse Partnership Programme in England: Wave 1 implementation in toddlerhood and a comparison between Waves 1 and 2a implementation in pregnancy and infancy 20 NHS Choices (2016). Breastfeeding help and support. www.nhs.uk/Conditions/pregnancy-and-baby/Pages/breastfeeding-help-support.aspx

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IMD WATCH

PKU DIET CHALLENGE Lisa Gaff Registered Dietitian, Addenbrookeâ&#x20AC;&#x2122;s Hospital, Cambridge

Lisa and Nicole are both fairly new to the area of Metabolics, so they decided that one of the best ways to truly appreciate what they ask of patients and their families would be to follow a PKU diet for a week. Here they report on how they fared by adapting meals, cooking with the low protein alternatives and attempting to take the required volume of protein substitute.

Lisa works with adult patients with diabetes, severe insulin resistance and metabolic conditions.

Phenylketonuria (PKU) is a rare inherited metabolic condition where patients are unable to metabolise phenylalanine, one of the 20 amino acids found in protein. Without strict dietary treatment, phenylalanine builds up in the blood stream which can lead to severe neurological impairment in children. People with PKU can usually tolerate small amounts of natural protein depending on their age, genotype and residual enzyme activity. This natural protein is prescribed as an exact number of 1g protein (50mg phenylalanine) exchanges which need to be evenly distributed throughout the day. This protein allowance is reviewed regularly, based on the monitoring of the phenylalanine levels. To replace the protein, a phenylalanine-free amino acid mix needs to be taken to provide enough of the remaining amino acids to meet their protein requirement. During childhood, while the brain is developing, the PKU diet needs to be followed strictly. Whilst, previously, adults have been given the option to come off the diet once brain development is complete, more recent evidence shows that concentration, emotional wellbeing and cognitive ability can be affected by high phenylalanine levels. It is now recommended that the diet is continued for life.1 Foods, such as meat, fish, eggs, cheese and nuts (high in protein and, therefore, high in phenylalanine)

Nicole Mills Registered Dietitian, Addenbrookeâ&#x20AC;&#x2122;s Hospital, Cambridge Nicole is a Paediatric Dietitian working with ketogenic, metabolic and surgical patients.

and foods containing the artificial sweetener aspartame (which contains phenylalanine), must be avoided. Some foods, such as potato, cereals and certain vegetables, contain enough protein to require counting as exchanges, whereas most fruits, vegetables and salads can be eaten in normal quantities. There is an expanding number of low protein alternatives available on prescription, such as bread, biscuits, flour, pasta and cake mixes. THE CHALLENGE

By taking the challenge through adapting meals, cooking with low protein alternatives and attempting to take the required volume of protein substitute for a week, we felt we would be better placed to support and advise patients with PKU and their families. Most of our patients have a daily natural protein restriction of between 5-12g, therefore, we set ourselves an 8g allowance (2g breakfast, 3g lunch and 3g dinner) with three protein substitutes a day to meet our protein requirements (~1g/kg/day). We started with a good selection of low protein products, protein substitutes and lots of recipes and ideas. After removing any temptations from our houses and stocking up with lots of low protein and unrestricted foods, we were ready to begin our PKU challenge. TAKING THE PROTEIN SUBSTITUTES

Taking sufficient amino acid substitute is something patients report as challenging

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IMD WATCH

. . . armed with a burger mix, low protein burger buns and a sausage mix, I was ready to embrace the PKU experience.

. . . vegan mozzarella, olives and roasted vegetables as protein-free foods and had a rocket and spinach salad, low protein burger bun and sausage and burger substitutes to provide the remaining protein. due to the distinct tastes and inconvenience. There are a broad variety of phenylalaninefree protein substitutes available in the UK which range from pre-made drinks, powdered supplements, dessert style supplements and the new GMP (glycomacropeptide) products, but often patients will choose one type and not deviate. Nicole: On day one, I selected a powderbased product as my first protein substitute and had the (not so) bright idea of making it a longer drink to dilute the taste, a choice I soon regretted having extended the drink to last a lengthy and somewhat gruelling 10 minutes. Throughout the week, I tried a range of different preparations and was able to settle on a liquid-based substitute which was much more palatable and by mid-week, the protein substitutes became less of a burden and more of an appetiser. Lisa: Similar to Nicoleâ&#x20AC;&#x2122;s experience, I initially found the amino acid substitutes quite challenging to take and it also took me a few tries to find options that I could tolerate, but again, towards the end of the week, I found that I was almost enjoying these. The variety of protein substitutes available now is far wider than previously and something patients returning to diet comment on. Unlike Nicole, I liked the taste of powders best (which demonstrates it is important to offer full choice of options to patients, as we all have different taste buds), but as these were not as convenient as pre-made, I was taking a combination of these through the week. 30

WHAT ABOUT OUR PROTEIN EXCHANGES?

We had both expected the trickiest part of the diet to be restricting the amount of protein in meals. In reality, it was much easier to choose protein-free options rather than keep to an exact amount of protein containing foods that suited the meal. On the first day, we both opted for low protein toast with butter (protein-free) for breakfast; this actually tasted quite similar to regular bread and was quite pleasant, although we hadnâ&#x20AC;&#x2122;t appreciated how tricky it would be to find breakfast-worthy items with exactly 2g of protein. After searching our respective fridges and cupboards, we settled on rice cakes (Nicole) and tinned sweetcorn (Lisa) - not your usual breakfast choices, but it was our first learning point. After re-thinking breakfast, we settled on a more sensible plan for a weighed amount of yoghurt to meet our 2g protein breakfast allowance. Throughout the week, meal preparation and planning became easier. Lunches were a mixture of roasted low protein vegetables with spinach and rocket as exchanges (25g spinach = 1g protein), or low protein baguettes (available on prescription) with protein-free cheese. Evening meals varied from low protein pasta with pesto and roasted vegetables, to butternut squash with ratatouille and low protein cheese. We were both impressed by the variety of exchange-free vegan cheeses available in the supermarkets (information that will become handy within the PKU patient group, but also when supporting families using milk-free diets). There were also some products that contained significantly less protein than expected: some jars of readymade

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On the menu was a roasted vegetable pasta dish which was listed as freshly made to order . . .

. . . I took a box of low protein pasta and asked the chefs whether they could use it with their sauce which they were happy to do so. white sauce contain ~1g protein per 100g, surprisingly little considering the homemade equivalent would usually be made with cows’ milk and cheese. We both found ourselves relying heavily on pre-portioned foods to top up our exchanges to the required amount at each mealtime. Rice cakes featured in most meals (conveniently providing 1g protein per rice cake), to the extent that we would both be happy not to see another rice cake in quite some time. HOW DID WE COPE WITH EATING OUT ON A LOW PROTEIN DIET?

Nicole: On the first day on the diet, I went to a family barbecue (not an easy event to start a low protein diet!), but armed with a burger mix, low protein burger buns and a sausage mix, I was ready to embrace the PKU experience. Mistake one was to completely under-season the burgers: as well as containing little protein, they also seemed to have very little flavour. Luckily, I could make a second attempt and they improved dramatically. I’d used vegan mozzarella, olives and roasted vegetables as protein-free foods and had a rocket and spinach salad, low protein burger bun and sausage and burger substitutes to provide the remaining protein. Overall the meal was great and everyone was keen to try the low protein alternatives (perhaps photographing the burgers next to the ‘real thing’ was slightly unfair!). Midweek, we had our annual summer work social: a pizza buffet followed by punting and games on the river. As one of the organisers, I was perfectly positioned to ensure that the buffet catered for our PKU diet. I had been

enjoying the challenge of rethinking regular food/snack choices to fit in with the diet, until I stood surrounded by 15 freshly cooked pizzas covered in normal protein-containing cheese what an exercise of self-control! We made our PKU-friendly pizzas from low protein pizza bases, tomato puree, free-from mozzarella, topped with roasted vegetables. The first attempt wasn’t particularly successful as the cooking time for the pizza bases transpired to be roughly half the time for the free-from cheese to melt, resulting in an eye-wateringly crunchy base, burnt tomato and undercooked cheese. By attempt three, the pizza was mastered and impressed the majority of the team. Finishing with Lisa’s handmade low protein lemon cupcakes for dessert, the buffet was a big success. Having forgotten to consider drinks, we quickly realised that the majority of the drinks were sugar-free, therefore, aspartamecontaining. Luckily, there was one bottle of sugary lemonade - so we were still able to enjoy a Pimms. Lisa: I had a couple of dinners out during the week and also enjoyed the summer social as Nicole has mentioned. My first dinner out on day one was a semi-successful experience. On the menu was a roasted vegetable pasta dish which was listed as freshly made to order and so I took a box of low protein pasta and asked the chefs whether they could use it with their sauce which they were happy to do so. They seemed interested in the diet and didn’t make this feel like an awkward request. Unfortunately, however, when the dish arrived, the top had

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IMD WATCH been sprinkled with cheese! I scraped this off, but it did demonstrate very well the pitfalls when people don’t understand the diet. As this pasta dish was yet another exchangefree option, I was able to treat myself to a small amount of chips for my exchanges. My other meal out was less successful, as there wasn’t anything on the menu (not even any salads) that seemed appropriate and so I ended up just eating sweet potato fries. WHAT HAVE WE LEARNT?

Nicole: During the week, my self-control was regularly exercised, particularly when colleagues brought in sweet treats from their holidays abroad or birthday cake. For me, this was a week on a tightly-controlled diet; for children with PKU, this is their everyday reality. It must take a huge amount of commitment and outstanding parenting skills to keep to exact protein exchanges every day. At times, I found devising and cooking meals based on my preferences quite challenging, but for parents, this must be so much harder, as children’s likes and dislikes can change frequently. For parents making meals for both unrestricted diets and PKU diets simultaneously, it must be particularly challenging to ensure that their children’s meals are appealing, palatable and also to ensure that their children don’t feel as though they are missing out on other foods that siblings without PKU can enjoy freely.

Lisa: I was interested as to whether I would be hungry on the diet as this is something patients can report. I didn’t find increased hunger, but I also think I took the term ‘free’ foods literally and found myself snacking a lot of the day on ‘free’ biscuits, crackers and cakes, which I wouldn’t normally do. While the low protein products tasted different to their counterparts, I feel that I would easily get used to these, especially if used to the diet from birth. I think the main difficulty if I were to have to follow this long term would be to not be able to share the diet with my family, as unlike some other diets such as gluten- and dairy-free, it would be unsafe for family members to share the low protein diet. We have both significantly improved our awareness of the PKU product base and naturally low protein options. This will particularly help us to support parents wanting to increase the variety in their children’s diets and adults considering returning to a PKU diet. We found a lot of useful options in the ‘free-from’ product ranges: wheat- and dairy-free products are often low in protein, therefore, the experience has improved our knowledge of the dairy- and wheat-free market which will help when giving parents and patients practical suggestions on different types of restricted diet. We both felt that the week was a really useful way to gain insight into the diet and practicalities of living with PKU and would encourage anyone working with metabolic patients to give it a go.

Thanks to Mevalia, Nutricia, Promin, Taranis and Vitaflo for supplying a generous selection of their amino acid substitute products and low protein food products for this PKU challenge. Reference 1 Wegburd et al (2017). The complete European guidelines on phenylketonuria: diagnosis and treatment. Online at: https://ojrd.biomedcentral.com/ articles/10.1186/s13023-017-0685-2

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NETWORK HEALTH DIGEST NHDmag.com

The Magazine for Dietitians, Nutritionists and Healthcare Professionals November 2017: Issue 129

KETOGENIC DIET THERAPY

ONS AND DEMENTIA PREMATURE INFANT FEEDING ‘TEATOXING’ IBS & LOW FODMAPS

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Coeliac disease & the GF diet pages 25-28

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

www.NHDmag.com.

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IMD WATCH

Anita MacDonald (Birmingham Children`s Hospital)

Karen Van Wyk (Royal Manchester Children`s Hospital)

Rachel Skeath (Great Ormond Street Hospital)

Pat Portnoi (Dietitian to the Galactosaemia Support Group).

DEVELOPMENT OF EDUCATIONAL TEACHING PACKAGES (TEMPLE) ON INHERITED METABOLIC DISEASES For parents and health professionals in the UK. There are many rare inherited metabolic disorders (IMD). These can be complex, may be managed with diet therapy with or without medications and some patients are at acute risk of acute metabolic decompensation. Increasing numbers of infants are being diagnosed by newborn screening in the first few weeks of life. However, as we still only test for a narrow range of conditions, some infants will present acutely unwell in the neonatal period. The diagnosis of a metabolic disorder is overwhelming for parents and families and they are unlikely to have previously heard of the condition. To a family, the name of the condition is complex and they may be unsure as to how to pronounce the condition or spell it correctly. Internet information may be sparse and alarmist and initial explanations of the condition may use terminology that sounds like biochemical gobbledygook. Families may feel isolated and the entire experience is very frightening with many concerns about the future. There is very little professional information available that is clear and accurate and not often written in a language that everyone understands. For disorders of protein metabolism, it is not uncommon for professionals to adapt information written for the most common disorder, phenylketonuria (PKU), but families rarely receive well produced information about their child’s specific condition unless it is via a patient society or commercial company. In 2012, a set of structured, modular teaching slides for parents/caregivers

following a positive newborn screening test was developed by Drs Wendel and Burgard from Heidelberg, Germany. This was a comprehensive package which helped to guide medical doctors to ensure that any teaching given to parents/caregivers was delivered in a consistent and standardised manner using materials produced by considered methodology. The educational package was titled TEMPLE (Tools Enabling Metabolic Parents LEarning) and the information was very structured, designed for use primarily in Germany. It covered a range of IMD and was organised so that the health professionals had a systematic plan for teaching about each disorder. It even gave health professionals guidance on the best seating plans for clinic rooms. Although this was a commendable endeavour, the information was complex and unsuitable for lay people if they lacked background knowledge or biochemical skills. In 2014, the British Inherited Metabolic Disorders Group (BIMDG)dietitians group examined the work by Wendel and Burgard and with permission from Nutricia (who had bought the rights to the teaching package) decided to adapt the original teaching package into ‘friendly’ and understandable teaching slide sets and booklets that could be used as a basis to explain different IMD to parents. In keeping with the philosophy of the creators of the first teaching package, it was important to approach the ‘content’ of the teaching package in a manner that would help standardise how complex IMD are explained to families in the UK. Even when working

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IMD WATCH Figure1: TEMPLE online and downloadable from www.bimdg.org.uk

TEMPLE in booklet form

in the field of IMD, it is not uncommon to manage a small number of patients with each condition, so the opportunity to practice and perfect teaching methods for an individual condition is limited. Some patients may also be managed by dietitians working in district general hospitals who may care for one or two patients only. In the autumn of 2014, the BIMDG-dietitians group formed a small working party to adapt the original teaching package and produce a set of standardised teaching materials for the most common disorders. The working group included Pat Portnoi, Rachel Skeath, Karen van Wyk and Anita MacDonald. We prioritised the IMD conditions which would particularly benefit from the production of TEMPLE teaching materials and where dietary management played an important part. • Conditions diagnosed by newborn screening: these are Phenylketonuria (PKU), 34

• • • • • •

Maple Syrup Urine Disease (MSUD), Homocystinuria (HCU), Isovaleric acidaemia (IVA) Glutaric aciduria type 1 (GA1) and Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) Other amino acid disorders: Tyrosinaemia type I (HTI), Tyrosinaemia type II Other organic acidaemias: Methylmalonic acidaemia and Propionic acidaemia Urea cycle disorders: Citrullinaemia, Arginosuccinic aciduria, OTC Deficiency, Arginase Deficiency Galactosaemia Other fatty acid oxidation disorders: VLCADD and VLCHAD Glycogen storage disease: Type 1a and 1b, 3, 6 and 9

The modules chosen focused on conditions where dietary treatment played an important role in management.

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Figure 2: Slides from the MCADD TEMPLE

TEACHING MATERIAL PRODUCTION

The teaching slides and booklets are developed as a series of modules that provide simple but core information. They are designed as a teaching resource for dietitians working with parents of a newly diagnosed infant or child with inherited metabolic disorders. These teaching materials can also be used to teach children about their disorder, as well as to extended family members, child minders, nursery workers and schools. The information is provided in a consistent way; it is informative, but easy for families to understand immediately after their infant or child has been diagnosed. It is not designed to replace dietary information that may be given by a dietitian, but the TEMPLE teaching material is ideal to use when the first explanation of the condition is given to families. It should then be followed by more detailed dietary information.

A rigorous process is undertaken in the production of each TEMPLE module. The wording and format is agreed by all the working group team members, they are checked for consistency with other modules and each one is reviewed by an IMD physician. The working group have one face-to-face meeting annually and the rest of the work is conducted by evening telephone conferences. TEMPLE teaching materials are available in two formats, online and downloadable via www.bimdg.org.uk and in booklet form for new families to take away (see Figure 1). The artwork was produced by Nutricia, although specific guidance about the graphics BIMDG working group of was given by the BDIMG dietitians. It was important that the TEMPLE tool was not used to advertise commercial products.

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IMD WATCH DEVELOPMENT FOR UK USE

Format of the teaching material The teaching slides include the following: 1. Explanation of the condition and its pathophysiology 2. The function and metabolism of the nutrient affected by the disorder, e.g. protein, fat or carbohydrate 3. Outcome with and without treatment 4. Method of diagnosis 5. Dietary management and other treatment 6. Illness management 7. Treatment monitoring 8. Genetics Each TEMPLE slide set is colour coded to help differentiate each condition (see Figure 2 on previous page). FUTURE PLANS

So far, 11 modules are completed and are available online via the BIMDG (education section) and most are already in booklet format. Some new editions will follow in early 2018). It is planned that for two of the rarer conditions (Arginase Deficiency and Tyrosinaemia type II), the TEMPLE teaching module will be online only. TEMPLE is a long-term project and already the original eight temple modules that were produced have been updated. Over the next two years, it is planned to develop the remaining TEMPLE modules. We plan to formally evaluate this work in 2018 and we always welcome feedback from all â&#x20AC;&#x2DC;usersâ&#x20AC;&#x2122;. We hope to have links with the NSPKU, CLIMB and Galactosaemia Support Group websites. Already this work is being adapted throughout the world. For example, teams in the USA have been able to extend this work by producing short teaching videos and have used much of the format chosen by the BIMDGdietitians group rather than the original Wendel/ Burgard work. It will be exciting to see how far this project will progress in the future.

TEMPLE TIMELINE 2012

Burgard and Wendel finish TEMPLE in Germany. It was developed over 12 years

2013

Nutricia bought exclusive rights to translate, adapt and distribute translate from German into English

2014

BIMDG-dietitians group set up; start on GA1 module

Sep 2015

SSIEM Poster presented on TEMPLE UK - 4 modules GA1, IVA, MSUD, HCU

Oct 2015

ISNS Poster presented on TEMPLE UK - 5 modules-GA1, IVA, MSUD, HCU, PKU

Nov 2016 First versions available on the BIMDG website

2016

Further modules developed MCADD, MMA, PA, HT1

Feb 2017

All Modules refined and standardised; Version 2 available

Aug 2017 New Versions available on the BIMDG website

Oct 2017

Citrullinaemia and Galactosaemia module available

International versions become available in slide and video form (USA)

Acknowledgements This project would not have been possible without the considerable support of the Nutricia team who provided artwork, financial and administrative support. We would particularly like to recognise the help and support of Diana Webster (involved for the initial part of the project), Rychelle Walker (involved for part of the project), Ewan Forbes (Nutricia, who has been a key member), Heidi Chan (Nutricia, who joined the group in 2016). 36

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PUBLIC HEALTH

THE POTENTIAL INFLUENCE OF BREXIT ON FOOD REGULATION Michèle Sadler RNutr Rank Nutrition Ltd Michèle is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry. Michèle has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

For full article references please email info@ networkhealth group.co.uk

As we are constantly reminded by the media, leaving the EU (Brexit) is not an easy task and it is taking time to extricate the UK from the EU. A key issue is the likely impact of Brexit on UK food regulation, such as labelling, claims and food safety. This article outlines some of the implications. For many years, the EU has been working towards harmonised laws and legislation because, in principle, this benefits trade between Member States. In preparation for Brexit, the government will transpose existing EU laws into UK laws (Withdrawal Bill). Initially, this will ensure minimal changes for consumers and industry so that the supply chain should continue to function seamlessly from the day we leave. However, as food supply is a heavily regulated area, transposing EU food law is legally complicated and a major challenge; this is being overseen by the Department for Environment, Food and Rural Affairs (DEFRA). Longer term, there is potential for regulatory divergence between the UK and the EU. The implications for food safety, health claims and food labelling will not be fully clear until the type of relationship that will exist between the UK and the EU post Brexit is decided, as this will determine the future scope for UK regulation to diverge from that in the EU.1 Divergence will have advantages and disadvantages for consumers and businesses. A down side for businesses which market products in both the UK and the EU will be additional costs and complexities of complying with two sets of regulations. However, the opportunity for the UK to make new, or revise existing laws will be an

advantage, particularly in controversial areas such as the regulation of health claims for example. REGULATORY FUNCTIONS

In addition to harmonisation of EU laws, the EU performs a number of regulatory functions on behalf of Member States. The European Food Safety Authority (EFSA) is an independent body that undertakes risk assessments (e.g. the safety assessment of food additives) and issues advice and opinions; for example, on the scientific substantiation of health claims. Functions of the EU Commission and Council include alerting Member States to food safety threats, authorising health claims and taking risk management decisions. Post-Brexit, the UK will need to bring these regulatory functions back within the UK and ensure that an effective, robust regime is in place from the date we leave. This requires early decisions as to how such regulatory functions should be managed - what arrangements should be put in place of EFSA, for example. FUTURE UK APPROACH TO FOOD REGULATION

The role of the Food Standards Agency (FSA) is to protect public health and other consumer interests in relation to foodstuffs. Post-Brexit, there is potential for the FSA to undertake a number of

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PUBLIC HEALTH tasks currently performed by EU institutions to ensure the delivery of safe food and to maintain consumer confidence.2 In relation to food safety, a significant increase in scientific and other capabilities will be required for risk assessment and risk communication. However, ministers and Parliament will need to decide how the government should take risk management decisions post-Brexit. Through its strategic plan for 2015-2020, the FSA is already on a path to modernise delivery and enforcement of its regulatory regime. The UK’s decision to leave the EU has put this into sharper focus and plans are being developed to allow for different outcomes of the negotiations.3 Leaving the EU is expected to change patterns of food production, trade and consumption, such that a flexible and responsive regulatory system needs to be in place.3 The FSA aims to deliver a new regulatory model for food by 2020 that ensures a sustainable approach to food safety regulation and that can flex and adapt to future circumstances. It is proposed to have a ‘Permit to Trade’ placed on all businesses, with a digitally-enabled approach that makes it easier for businesses to get the information and guidance they need to comply with standards and regulations.3 CONSUMER INSIGHT

To help with its planning, the FSA conducted a number of online surveys and consumer focus groups between October 2016 and January 2017 to understand how consumers perceive such issues.4 The results show that consumers are generally unaware of the extent of EU involvement in food law. Consumer concerns about the UK’s decision to leave the EU include price increases, availability and product shortages, lower quality of food and having different regulations to the EU. POTENTIAL FOR FUTURE REGULATORY DIVERGENCE

Once the UK has left the EU, there is potential to make improvements to certain regulations, in order to make them more workable.5 However, 38

divergence from EU regulations is for the long term and will depend on government priorities. Regulation of health claims In the area of health claims, it would be advantageous to consumers for claims to be expressed in more understandable language, with less scientific wording than is currently the case. For businesses, a different approach might create opportunities for the UK domestic market, as research suggests that the EU health claims regulation has stifled innovation.6,7 Nutrient profiles, that would restrict the use of claims on products high in saturated fat for example, have not yet been agreed in the EU, though they were due to be set by January 2009.8 Leaving the EU could potentially allow the UK to develop its own criteria and rules for the implementation of profiles for the benefit of consumers. A more immediate reason for divergence potentially, relates to the regulation of ‘botanicals’ (food supplement preparations derived from plants, algae, fungi and lichens). If as part of its regulatory review8 Europe agrees changes to the Nutrition and Health Claims Regulation5 before Brexit, these changes may be implemented in the UK. However, if Europe agrees changes after Brexit, this could result in early divergence between the regulation of health claims in the UK and the EU. Longer term is the issue of trademarks and brand names existing before 2005 that could be construed as health claims. These have a transition period until 19 January 2022 to comply with the regulation. As this is after the projected date for the UK to leave the EU, some form of resolution may be required. Prior to the Nutrition and Health Claims Regulation5 being adopted, the UK had set up the Joint Health Claims Initiative (JHCI), a tripartite agreement between consumers, industry and enforcement, with the aim of offering pre-market advice. A code of practice was agreed to ensure that health claims were legally acceptable and scientifically truthful. The code was applicable to any health claim made in advertising, marketing and product labelling, and worked on a voluntary basis alongside the food legislation current at that

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The UK has always been forward thinking on food labelling, adopting a number of proactive voluntary labelling schemes agreed between consumers, manufacturers, retailers and other stakeholders. time. The Expert Committee of independent scientific experts assessed the evidence submitted by companies and approved a number of health claims. JHCI also worked to develop well-established nutrient function statements at the request of the FSA.1 Some of the claims approved by JHCI were subsequently refused authorisation in the EU, e.g. for wholegrains and heart health and for soya protein and reduction of blood cholesterol. In the case of wholegrains, this arose because, unlike EFSA, JHCI accepted claims based on evidence from observational studies, provided this was reflected in the claim wording, whereas EFSA’s approach requires evidence of a ‘cause and effect’ relationship reflecting a more ‘pharmaceutical’-type model. This previous experience suggests scope for alternative approaches provided they remain rigorously scientific and acceptable to consumers, enforcement and industry,1 and this history can usefully inform any future divergence for health claim regulation in the UK. Regulation of food labelling The UK has always been forward thinking on food labelling, adopting a number of proactive voluntary labelling schemes agreed between consumers, manufacturers, retailers and other stakeholders. For example, guideline daily amounts (GDAs) were initially developed in the 1990s through such a process by the Institute of Grocery Distribution (IGD), and were the forerunner of Reference Intakes now enshrined in EU legislation.9 Other such initiatives included voluntary schemes to improve the labelling of allergens and

food safety advice. 10 A collaborative, voluntary approach ensures that industry adopts a consistent approach, is quick to respond to issues and can adapt quickly to further developments. Continuing to encompass such an approach in the UK would be expected to benefit consumers. During discussion of the Food Information to Consumers Regulation,9 the UK was instrumental in ensuring provision for ‘National Measures’ (Article 39) which allows for additional mandatory particulars for specific types or categories of foods, provided these can be justified by the protection of public health or protection of consumers, for example. This highlights that the UK has always desired the flexibility to ensure effective food labelling, and leaving the EU makes such flexibility more likely. This might encompass a mandatory requirement for front-of-pack labelling, for example, and the UK will require its own scheme for products with protected origin and geographical location. CONCLUSION

A consequence of Brexit is that certain regulatory functions will need to be brought back within the UK, so that from the date we leave an effective and robust regulatory regime is maintained. Brexit may provide a future opportunity for regulatory divergence in the area of food law, depending on the final relationship that is negotiated between the UK and the EU. In the longer term, changes could be made to health claims and food labelling regulations for example. A more flexible approach to health claims could enable more innovation and more understandable claims, provided consumer confidence is maintained.

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CONDITIONS & DISORDERS

IRRITABLE BOWEL SYNDROME: THE LOW FODMAP DIET Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust

Rebecca has a keen interest and specialises in Gastroenterology Dietetics. She currently works in the Community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

For full article references please email info@ networkhealth group.co.uk

Irritable bowel syndrome (IBS) is a long-term condition affecting the digestive tract, thought to affect one in five people in the UK.1 It is known that diet and lifestyle factors play a huge role in managing symptoms.2 This article looks at the low FODMAP diet in the management of IBS symptoms. IBS can most commonly cause symptoms such as abdominal discomfort, an altered bowel habit and bloating, and can have a huge impact on a patient’s quality of life. Part of the difficulty in managing IBS is the wide variety and severity of symptoms that patients may experience and how these symptoms are often triggered by different things. The low FODMAP diet was created in 2008 by a team at Monash University in Melbourne, Australia. In 2009, researchers at St Guys and St Thomas’ hospital NHS Foundation Trust and King’s College London also began investigating this diet, eventually adapting it to suit the UK population. In 2010, the low FODMAP diet first appeared in the UK British Dietetic Association’s IBS Guidelines.3 WHAT IS THE LOW FODMAP DIET?

FODMAP stands for: Fermentable Oligosaccharides Disaccharides Monosaccharaides and Polyols. A bit of a mouthful. These are short chain carbohydrates, or sugar alcohols that are components of, or added to, foods. Normally, when we digest foods, they are broken down and digested in the stomach and small intestine. However, as these FODMAPs are poorly absorbed in the small intestine, they pass through to the large intestine, where they feed the bacteria and are fermented. This release of gas causes the symptoms of bloating and abdominal pain in patients with IBS. The process can also have an osmotic affect, which can lead to an altered bowel habit in IBS patients.

A number of studies, including randomised controlled trials; blinded, randomised rechallenge studies; observational studies and meta-analyses, have been thoroughly reviewed, demonstrating the efficacy of the low FODMAP diet and how it can improve patient symptoms.4,5 The low FODMAP diet has been seen to improve up to 86% of patients symptoms, having a clinically significant response and overall improvement in gastrointestinal symptoms.5 TYPES OF FODMAPS

Fructans: these include foods such as wheat, rye, onions, garlic and leeks. Fructans are varying length chains of the sugar fructose. Galacto-oligosaccharides (GOS): these include foods such as beans and pulses. GOS are varying length chains of the sugar galactose. Polyols: these are most commonly found in sugar-free mints and gums (containing sorbitol, xylitol and mannitol), avocado, sweet potato, cauliflower and broccoli. Polyols are sugar alcohols. Fructose: these include foods such as honey, mango, sugar snaps and fruit juice/fruits in large portion sizes. Fructose is a single unit (monosaccharide) sugar. Lactose: the most common sources of lactose is in milk and dairy products. It is a double unit (disaccharide) sugar.

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CONDITIONS & DISORDERS Figure 1: Updated guidelines on the management of IBS6

GUIDANCE

In 2016, Mackenzie et al completed a systematic review and updated the guidelines on the management of IBS.6 The new guidelines saw the removal of the ‘third line’ treatment of IBS which used elimination/empirical diets. Instead, the focus is now on first line treatment, being healthy eating, investigating food intolerances and probiotics (if the patient wishes to trial; the guidance also discusses informing the patient group on the limited evidence for probiotics and the potential placebo effect, however, that would warrant a whole new discussion!) and second line treatment of the low FODMAP diet (Figure 1). The previous advice for third line management for IBS was based on limited evidence and with the emergence of the low FODMAP diet, strict elimination diets which are nonspecific are thought to be no longer relevant in its treatment. DELIVERING THE LOW FODMAP DIET

When looking at how patients should be educated and guided through the dietary advice for IBS, the current guidance from the National Institute for Health and Clinical Excellence (NICE) state that dietary management for IBS should ‘only be given by a healthcare professional with expertise 42

in dietary management.’2 When looking at the low FODMAP diet more specifically, further studies have supported dietitians as the healthcare professional to deliver the dietary guidance, stating the reasons for this being that dietitians have an extensive knowledge of nutrition, health and disease and are the leading experts in educating patients on disease-specific dietary management.7 The fact that dietitians directly contribute to research elucidating the mechanistic basis and clinical efficacy of the low FODMAP diet, and that they are governed by an ethical code for evidence-based practice, provides more reasons to support them delivering the low FODMAP diet. One paper also concluded that dietitianled implementation of the low FODMAP diet is an effective strategy for the management of IBS, and that the trend for non-dietitian-led implementation of the diet is of concern, as there is no evidence on the clinical effectiveness or risks associated with such practices. For this reason, the importance of dietitian-led management in IBS needs increased recognition in clinical practice.7 Traditionally, the low FODMAP diet has been taught to patients in a one-to-one clinical setting

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It is currently not advised to follow the low FODMAP diet longer than eight weeks, partly due to its restrictive nature and partly due to the effects it can have on our gut microbiota.

and more recently in group education sessions. A number of studies have been conducted to demonstrate the effectiveness of group sessions and the low FODMAP diet.7-10 The interest in delivering the low FODMAP diet in a group setting likely comes from the success of group education sessions for other conditions, such as diabetes, and evidence from a number of studies which demonstrate how group education has been shown to enhance patient acceptability of a treatment through a sharing of experiences with others with a similar condition.8,9 O’Keeffe and Lomer published a recent review which investigated the best delivery methods for the low FODMAP diet.7 They concluded that further research into group education is needed, as preliminary evidence suggests that it is a clinically effective and an economic model of service delivery. Overall, the review found that the group pathway was a more cost-effective model of service delivery, but demonstrated equal clinical effectiveness. It was also acceptable to patients.7 In addition to this, Joyce et al found group sessions to be an effective way of delivering the low FODMAP diet, also as effective as one-to-one sessions, and again highlighted the positives from group sessions, such as peer support and the discussion of similar experiences.10 Whigham et al concluded that group education is as clinically effective as

one-to-one education and highlighted that the cost of a QALY gain (quality-adjusted life year) for this group pathway is well below the £20,000 to £30,000 threshold for UK healthcare costs.11 LIMITATIONS/FURTHER RESEARCH

Despite the positive outcomes following the still relatively new revelation of the low FODMAP diet, it has of course generated concerns around the long-term effects of following the diet. It is currently not advised to follow the low FODMAP diet longer than eight weeks, partly due to its restrictive nature and partly due to the effects it can have on our gut microbiota. There are a number of studies that have compared the low FODMAP diet with a habitual diet which demonstrate that the low FODMAP diet reduces the concentration of bifidobacteria.12,13 One study also indicated that the reductions in several bacteria (F prausnitzii, Actinobacteria and Bifidobacterium) noted during the restrictive phase of the low FODMAP diet, returned once the diet was supplemented with fructo-oligosaccharides, suggesting that these reductions are only temporary and should return during the reintroduction phase.13 It is also not clear on how following the low FODMAP diet long term can affect overall health of the colon. Some studies have suggested that the low FODMAP diet can cause a decrease in short chain fatty acids (SCFA).12 This is due

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CONDITIONS & DISORDERS to SCFAs being produced in the fermentation process of digesting foods, which is reduced whilst on the low FODMAP diet. However, other studies have contradicted these findings, stating no changes in SCFAs were noted whilst following a low FODMAP diet.14 The ‘reducing FODMAPs’ phase of the low FODMAP diet is restrictive and, at a glance, can appear very complex and overwhelming. Patients may be put off by this and struggle to adhere to the diet. The nature of restrictive diets does not suit everyone, so, it is worth bearing in mind that despite good clinical outcomes for patients, others may lack interest, or perhaps even become too involved in thoughts surrounding food, risking disordered eating.15 Further to this, restricting low FODMAP foods may lead to nutrient deficiencies, as it has been seen that patients following a low FODMAP diet consume fewer carbohydrates.16 This is thought to be as a result of the diet’s exclusionary nature, rather than the low FODMAP diet itself. Potential further research has been identified in studies suggesting that gut microbiota might be used to predict responders to the low FODMAP diet.17 This thought that evaluating individual baseline microbiome could lead to personalised low FODMAP dietary advice is exciting, but is an area that requires exploring further. Contrary to the elimination phase of the low FODMAP diet, the reintroducing phase appears to have had less research, with only a few observational studies reported.18,19 This is, therefore, also a window of opportunity for

further research, to help us discover more about how the diet works. Lastly, S Eswaran conducted a mini-review on the research on the low FODMAP diet so far, concluding that although the research into the diet appears promising, further research is needed in the following areas: the mechanisms by which FODMAP restriction improves symptoms; long-term effects/safety in terms of gut microbiota and potential nutritional deficiencies; standardisation of a reintroduction protocol; whether or not complete exclusion of all FODMAPs is necessary for full clinical benefit; and improving patient selection to enrich symptom response.20 CONCLUSION

Using the low FODMAP diet as secondary advice for management of IBS has proved successful so far, with good outcomes noted for patients. However, with positives there comes limitations and further research into the areas of the effect on gut microbiota, long-term health effects and nutritional adequacy of the diet are required. The low FODMAP diet may be adapted and personalised for a more individualised treatment, if further research into using gut microbiota as response predictors is undertaken. The diet should be delivered by a qualified health professional and patients have responded equally to one-on-one advice and group education. Due to the effects known on the gut microbiota, it is also the responsibility of the healthcare professional to ensure that patients follow the diet within the correct timeframes.

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FOOD & DRINK

ENERGY FOODS: HOW BEST TO FUEL THE ACTIVE Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

For full article references please email info@ networkhealth group.co.uk

Alongside a healthy and balanced diet, being active is central to a person’s wellbeing. Unfortunately, energy slumps can act as a barrier to being active and productive. This article discusses how best to keep energy levels up and fuel busy and active lifestyles. To counteract tiredness and give our energy levels a boost, energy drinks and bars are typical ‘go to’ solutions. Now, the role of malt as a slow release energy food source is emerging which may help to provide a general pick-me-up as well as a being a fitting pre-exercise snack. Other less traditional snacks such as yoghurt and lean red meat can also provide a good source of fuel. Firstly, it is important to define what we mean by being active. The term ‘physical activity’ refers to activities that can raise heart rate or lead to the expenditure of calories.1 This can range from walking or cycling to getting from A to B, to taking part in structured competitive activities (Figure 1 overleaf).1 Chief Medical Officer guidelines2 advise that adults (aged 19 to 64 years) should aim for a minimum of 150 minutes of moderate intensity activity on at least five days of the week. So, 30 minutes of brisk walking over five days would count. Alternatively, 75 minutes of vigorous activity can be spread across the week with comparable benefits. So, running at a pace for 40 minutes on two days would count. Alongside this, some activities to improve muscle strength on two days of the week are also advised. Unfortunately, physical activity levels in the UK are inadequate. Data from the Health and Social Care Information Centre3 shows that only 66% of men and 56% of women meet the recommended physical activity targets. There is also a general tendency to overreport on certain health behaviours such

as physical activity, so, in reality, levels may be even lower than this.4 When looking into barriers preventing daily physical activity, these can range from ‘being too tired’ to ‘not having time’ or ‘having no one to do it with’.5 Statistics from the Royal College of Psychiatry6 also show that one in five adults feel unusually tired while one in 10 report having prolonged fatigue - with women tending to be most affected. Energy drinks and protein bars are often used to get back get up and go.7 However, there are other foods that we can also be eating to help give a natural energy lift. ENERGY FOODS

Research has shown that energy slumps tend to occur in the afternoon - typically triggered by low blood sugar levels and the body’s natural plunge in circadian rhythm.8 In fact, a number of factors including: long working days, skipping or delaying meals, exercise or activity that is unplanned or intense and eating less carbohydrate-containing food than usual can all lead to low blood sugar levels, also known as hypoglycaemia.9 Typical signs of this include feeling tired, irritable, shaky, hungry, dizzy and turning pale.9 To fuel busy and active lifestyles, it’s important not to skip breakfast and eat at regular intervals throughout the day. We should also aim to eat five portions of fruit and vegetables daily, including iron-rich foods such as lean red meat and fortified cereals within our diets and opt for slow-burning

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FOOD & DRINK Figure 1: What is Physical Activity?1

Physical activity (expenditure of calories, raised heart rate)

Everyday activity:

Active recreation:

Sport:

Active travel (cycling/ walking)

Active play Dance

Exercise & fitness training

DIY

Recreational cycling

Individual pursuits

Gardening

Recreational walking

Informal sport

Heavy housework

Regular cycling (â&#x2030;Ľ30 min/week)

Occupational activity (active/manual work)

Structured competitive activity Sport walking Swimming

starchy foods to help sustain energy levels.10 Starchy foods should comprise about one third of everything that we eat.10 When it comes to choosing energy foods, there are a range that can be eaten including things like almonds, malt loaf, yoghurt and boiled eggs. Table 1 compares the nutritional profile of different energy foods. It can be seen that a chocolate bar contains twice the calories of dried fruit or malt loaf. Some foods, such as malt loaf, also have a lower proportion of carbohydrate as sugars which means that they will release their energy more slowly. Boiled eggs, yoghurt and almonds provide higher amounts of protein whilst a handful of almonds provides an ample dose of mainly monounsaturated fats.

Malt is derived from barley and undergoes a series of six steps to form the loaves that we know so well.12 Malt is a rich source of B vitamins, including thiamine, riboflavin, niacin, folate and vitamin B-6. B vitamins are essential for converting carbohydrates, protein and fat contained in food into energy.12 It is also a source of amino acids and natural source of energy.12 Before the abundance of foods that we have today, people used to regularly consume malt for its health and energy boosting properties.12 Today, malt loaf is available in many different forms and flavours, from traditional loaves to healthy snack bars and mini loaves in apple, banana and orange flavours.13

THE POWER OF MALT

Fatigue and energy slumps come hand in hand with modern life. Whilst we may want to be more physically active, we may just not have the energy to partake. As dietitians and health professionals, we should be encouraging patients to achieve standard activity guidelines in order to offset the risk of chronic disease development.1 So helping them to find ways to integrate activity within their daily lives, or guiding them to ensure they have enough energy to do this, is important.

The Ancient Egyptians were the first to use malt in baking. Using adapted methods, malt loaves have now been produced in the UK for 80 years. These were first created in 1938 by Mr John Rahbek Sorensen from Denmark. A baker by trade, he made a Sorensen Malt Cake which proved to be highly popular. This business was eventually taken over by Imperial Bakeries Limited and has been made in Manchester ever since. 11 46

DISCUSSION

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Table 1: Nutritional Profile of Energy Foods (per portion) Energy (kcal)

Carbohydrate (g)

Of which sugars (g)

Protein (g)

Fat (g)

Fibre (g)

Almonds (28g)

174

2.0

1.2

6

16

2.1

Banana (1 medium)

81

20

18

1.2

0.1

0.8

Boiled egg (1 whole)

143

Tr

Tr

14

10

0.0

Milk chocolate bar (30g)

156

17

17

2

9

0.4

Dried fruit (28g)

75

19

19

0.6

0.1

0.6

Energy drink (250 ml)

105

28

28

Tr

0.0

0.0

Malt loaf (per 1 slice)

65

13

6

2

0.7

0.9

Yoghurt (125g)

99

10

10

7

4

0.0

Key: Tr, trace; Source: FSA (2014). CoFID (2015)

Firstly, to help sustain energy levels throughout the day, we should look to ensure that the diet contains the four main food groups in the right amounts: 1) fruit and vegetables, 2) potatoes, bread, rice, pasta and starchy foods, 3) milk and dairy foods and 4) beans pulses, fish, eggs, meat and other non-dairy sources of protein. These can be delivered via the integration within main meals, but also as snacks, which we may not typically associate some of these food groups with.10 Snacks eaten throughout the day should also be tailored to an individualâ&#x20AC;&#x2122;s needs. For example, if a young female with fatigue presents low-energy levels, it could be that she needs more iron in her diet, so a fortified cereal pot mid-morning, or one to two slices of roast beef could help her to get enough iron. If a working male is training for a marathon, but has low energy levels at the end of the day, a slice of malt loaf may help him to get through his training. Finally, busy lives can mean that meals are skipped or eaten irregularly throughout the day.

Popping snacks into handbags or gym bags is a good way to ensure that clients or patients have a portable supply of energy. The average female needs 2,000 and average male 2,500 calories per day.10 So, if these energy requirements are not being met that could be another reason why energy levels are low. CONCLUSIONS

Physical activity is central to our health and wellbeing. Unfortunately, around half of us are not meeting weekly physical activity targets. There are a host of reasons underpinning this, such as low energy levels. Alongside following basic healthy eating guidelines and eating regularly throughout the day, the type and timing of snacks also has a role to play. Energy snacks extend far beyond chocolate and energy drinks/bars. Foods such as malt loaf which releases its energy slowly and provides B vitamins, can also provide a natural energy boost. Slices of roast beef, nuts, yoghurts and boiled eggs can also provide a healthy energy and protein boost.

Acknowledgement This review was supported by Soreen. The views expressed are those of the authors alone and Soreen had no role in writing the review. www.NHDmag.com December 2017/January 2018 - Issue 130

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PROF BLOG

THE FUTURE DIETITIAN Simon LangleyEvans, Professor of Human Nutrition, University of Nottingham Simon has 25 yearsâ&#x20AC;&#x2122; experience in nutrition research, with expertise in maternal and infant nutrition. He is Chair in Human Nutrition and Head of School of Biosciences at the University of Nottingham and is the Editor-in-Chief of The Journal of Human Nutrition and Dietetics.

The role of the dietitian has never been more important within healthcare and needs to adapt to meet modern demand. Every aspect of healthcare is undergoing change at a rapid rate and in the UK, the system is creaking, as an NHS originally designed to care for a population with a life expectancy of around 70 years, has to adapt to the challenge of an increasingly elderly population suffering from long-term conditions. Many of those conditions have either a nutritional cause, or need to be managed through dietary modification. Professor Mary Hickson and colleagues at the University of Plymouth engaged in a research study to inform the British Dietetic Associationâ&#x20AC;&#x2122;s Future Dietitian 2025 programme. This research included an environmental scan (collected information about the scope of dietitians practice in the UK, how dietitians fit within the rest of the healthcare workforce, the roles of dietetic professionals in other countries); an appreciative enquiry (an interactive event to explore positive aspects of dietetic practice with dietitians); and an online conversation with dietitians in the UK, other healthcare professionals, international dietitians and service users. This research generated a set of 16 recommendations to aid in planning for how the dietetic workforce develops over the next five to 15 years. Those recommendations sat across five key themes (see box). For those of you who are currently in training, these recommendations are

very much going to be shaping your future career. Have a read of the full report in the paper referenced below.1 Professional identity There is a tension between dietitians and nutritionists. Dietitians need to lead; be bold, innovative and proactive in the health and social care agenda and assert their expertise against a challenging background of public perception.

Strong foundations A rigorous education and training that equips the workforce for their role at any given level. Training and education should reflect the diverse opportunities outside the NHS including industry, working abroad, private practice or higher education.

Amplifying visibility and influence Dietitians need to be heard if they are to influence health and social care.

Embracing advances in science and technology Computers and e-technology will offer new ways to engage with service users and influence behaviour change.

Career advancement and emerging opportunities Dietetic practice to be developed, so that roles can be developed to specialist consultant levels and where publication of professional findings is the norm. Influencing policy rather than responding to it should be a part of the dietetic role.

References 1 Hickson M, Child J and Collinson A (2017). Future Dietitian 2025: informing the development of a workforce strategy for dietetics. J Hum Nutr Diet. https://doi.org/10.1111/jhn.12509

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BOOK REVIEW

HUNGER; A MEMOIR OF (MY) BODY 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.

AUTHOR: ROXANE GAY PUBLISHER: CORSAIR (LITTLE BROWN BOOK GROUP), 2017 ISBN-13: 978-1472151117 (PAPERBACK) PRICE: £13.99

“No matter where I am, I wonder about where I stand and how I look. I think, I am the fattest person in this apartment building. I am the fattest person at this university. I am the fattest person in this airport. I am the fattest person in this city . . . This is a constant, destructive refrain and I cannot escape it.” Yes, Roxane Gay is fat (her choice of descriptor). Her heaviest weight was 577 pounds (262kg) and, at over six feet tall, she is a very big woman in every way. She does not reveal her current weight, but she is still fat, and this memoir of her life and her fatness is not a before-andafter description of changed weight. Yet so much in this book is about change. It is about the how and why a slim girl from a family and slim and healthy parents and siblings, became so obese. And how living with obesity changes you as a result of the constant reaction of others. And how as you become older and wiser, you come to understand that your very fat body reflects many things about your life, other than just being the visible marker of many years of excess food consumption. Roxane Gay’s book is stunning, written with astonishingly intimate revelation of what it is like to be so obese. There are many obese people who have described their lives, but perhaps few can match the brilliance of this very articulate and intelligent woman. As a writer, professor, columnist, author, speaker etc, she is someone who is paid to think about things and write about them. Having written many fiction and non-fiction articles and books, it was time to face this biggest issue in her life; her weight.

The trigger of trying to escape from her vulnerable body, was brutal gangrape at the age of 12. Committed by fellow school pupils from nice homes and from nice families. Becoming large and fat was the escape from having been abused as someone who was small and vulnerable. The top veneer of text is a description of her life. She did well in school and college, but escaped normality with a few years of reckless life including painful noncontact with her family. But she returned to education, qualified and became an academic and writer. Including many years as a mentor to engineering students on how to most clearly and correctly communicate highly technical engineering concepts to decision-makers and funders. This is where she is now: someone with a PhD who guides college students on creative writing and is a successful author and regular contributor of opinion to many national US publications. But the body of the book is about her body. It may be lumpen, but her descriptions about obesity are delicate, finely-woven text that share deep insights on her condition, and the reactions of the world to fatness. Of course, she knows all about diets and dieting and she has tried the A to Z of methods to eat less. Perhaps some of the

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BOOK REVIEW weight-loss methods are less dietitian-approved than others and all of them work for a while. But then deeper and stronger currents driving behaviour lead her to overeat (again)â&#x20AC;Ś and again she has to face her own disappointments and those of friends and family. Although there is no direct mention of any dietitian she has encountered, she does appear to have received much well-intended support from an amazingly kind and patient family and many friends. Her parents in particular seem to have been rock-steady in their attempts to help her to lose weight, with no end of willingness to fund weight-loss camps, or purchase particular food items and accommodate every attempt to eat less and exercise more. While putting dietitianspectacles over my actual ones, I could not really identify a time and a way to have supported Roxane further (beyond the many interventions she describes). Because ultimately, no one can be un-raped.

This book is a very beautiful description of the many daily challenges of being obese. The discomfort of sitting in too-small chairs. Trying to find clothes that fit. Trying to not hear catty comments, or how to respond to well-intentioned bad advice from others. Balancing being both the most visible and invisible person in the room. Edits to food consumption in public versus private occasion. All these are familiar issues to obese people, but Roxane has the unique skills of observation and description, that will allow others some insights to being obese. This is the most perfect book for dietitians to read, to balance out the tomes on epidemiology and satiety hormones and macro-nutrient ratios and many other aspects of obesity treatment. You cannot help but adore every inch and pound of Roxane Gay as the most articulate and thoughtful champion of being obese. It is not a condition she has chosen, or is proud of, or is happy with. But it is her reality, and dietitians have much to learn from her wise thoughts.

We have three copies of Hunger: A Memoir of (My) Body by Roxane Gay to give away in our FREE NHD prize draw. For your chance to win a copy, email us at info@networkhealthgroup.co.uk stating that you want to be included in the NHD Dec/Jan book giveaway. Closing date for entries is Friday 9th February 2018.

DATES FOR YOUR DIARY

Events and courses coming up soon . . .

Next steps for policy on high fat, sugar and salt foods - regulation, innovation and marketing Westminster Food and Nutrition Forum, London 12th December www.westminsterforumprojects.co.uk/conference/ HFSS-policy-2018/29228 Gastroenterology (D24GE1) University of Nottingham: School of Biosciences 12th to 13th December Email: Katherine.lawson@nottingham.ac.uk www.nottingham.ac.uk/biosciences

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Nutrition and cancer: what patients want to know The Royal Marsden, London 22nd January 2018 www.royalmarsden.nhs.uk/Nutritionjan Eating Disorders Awareness Week 26th February 2018 to 4th March 2018 www.beateatingdisorders.org.uk Allergy and Free From Show Scotland SEC Glasgow 3rd to 4th March 2018 www.allergyshow.co.uk/scotland

www.NHDmag.com December 2017/January 2018 - Issue 130


RISING ABOVE THE GOOP! Louise Robertson Specialist Dietitian Louise is a Specialist Dietitian working with adults with inherited metabolic disorders, with PKU being her biggest cohort of patients. www. dietitianslife.com

We live in a world with information at our fingertips. When we want information, we want it now. We often turn to the internet before seeking out professional advice, so we need to be where the public is looking. If we are not there, they will find the self-styled health gurus instead of qualified nutritional professionals. I was invited to attend a breakfast meeting by PR Company Porter Novelli, looking at effective ways of harnessing social media. As qualified nutritional professionals, we often get lost in the noise of big health influences with little or no health qualifications. The meeting had two social media stars who discussed how they managed to successfully build their brands on social media. The first was Dr Megan Rossi (The Gut Health Doctor) who is a research dietitian at Kings’ College London and works in private practice. Over the past nine months, she has managed to accrue 38,000 followers on Instagram with her amazing photos and her excellent way of engaging the public with the latest research about food and health. The second was a food blogger, Annabelle Randles, who runs the blog ‘The Flexitarian’. She does not have any formal nutritional qualifications, but is passionate about sustainability and the environment. Megan and Annabelle were also joined by social media expert Lauren and moderated by Ruby Quince in the panel discussion. Here are the top tips I took from the panel discussion for raising dietitian’s and registered nutritionist’s profiles on social media: 1. Be proud of who we are, we should be shouting out that we are the experts. 2. Don’t copy other accounts, but take best bits and put them together to make your own style. 3. Choose a social media name that is like a brand: The Gut Health Doctor/ The Flexitarian.

4. Engage with like-minded people on social media. If the public see you engaging with other experts, they will want to follow you too. 5. Your posts need to be engaging and fun, people don’t want to read cold science. They want practical advice. 6. Make your posts personable (include a few selfies – yes, I know, we all cringe doing them!) as followers like to see that you are engaging with them. 7. Engaging with the public is more important than spending a long time creating good content. 8. You don’t need to be on all social media channels. Find a platform you enjoy. Different platforms serve different purposes. 9. Use planning, scheduling and time blocking to keep up with your social media. This way you won’t get distracted and it keeps your mind focused. Megan discussed that times are changing and brands and other big social media influences are asking experts to write or speak on their channels. They don’t want to be caught out like the case of social media star Belle Gibson in Australia who was fined £240,000 after falsely claiming that she had beaten brain cancer using natural remedies and nutrition. Now is the time to make ourselves known on social media. We also need to be more accessible to big influencers and brands, so they can choose to partner with qualified nutritional professionals rather than those without nutritional qualifications! See you online . . .

www.NHDmag.com December 2017/January 2018 - Issue 130

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Meals for your patients that tick all the right boxes.

627 Fish in White Wine & Asparagus Sauce

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To request copies of our brochures or to arrange a FREE tasting session call

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Network Health Digest - Dec 17/Jan 18  

The Magazine for Dietitians, Nutritionists and Healthcare Professionals Issue 130

Network Health Digest - Dec 17/Jan 18  

The Magazine for Dietitians, Nutritionists and Healthcare Professionals Issue 130