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

April 2018: Issue 133


Non-IgE-mediated allergy: home introduction guides


Contact your local Nutricia Representative to learn more about the upcoming addition to the Neocate range Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, Multiple Food Protein Allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision. This information is intended for Healthcare Professionals only. For more information, please contact your local Nutricia representative, call 01225 751 098 or email Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ




WELCOME Emma Coates Editor Emma has been a registered dietitian for 12 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 We would love to hear from you.

"O, how this issue of NHD resembleth The uncertain glory of an April day; Which now shows all the beauty of nutrition and dietetics, And by and by another month takes all away." Proteus: The Two Gentlemen of Verona (I, iii, 84-87) Ok, so perhaps that isn’t completely true to the word of Shakespeare, but it signifies our arrival into the month of April. And whilst we have the time now to enjoy this issue, another month will soon fly by . . . Nutrition management in older people is a key theme for us this month, with malnutrition being an important topic in care of the elderly. The management of malnutrition rests at the core of much of the day-to-day working of the dietitian or nutritionist, regardless of specialism. Katherine Sykes from the BSNA brings us an insightful article which focuses on the unrecognised burden of malnutrition and outlines a new report that launched in March. The risk of malnutrition increases as patients grow older, particularly if patients are diagnosed with dementia. Kirsty Robinson RD, Older People’s Dietitian and committee member for the BDA’s Older People’s Specialist Group, provides an overview of clinically assisted nutrition and dementia. Oral nutritional supplements (ONS) are often appropriate in the nutrition management of undernourished patients, but what about for obese patients who have undergone surgery? Acute Dietitian, Jess Coates, takes us through the use of ONS in overweight or obese patients in order for nutritional requirements to be met. With the first of our paediatric articles this month, we welcome Mary Feeney, Paediatric Allergy Dietitian, who shares her knowledge and expertise in home

introduction of egg, soya and wheat when managing non-IgE-mediated allergy with the introduction of new guides for healthcare professionals. We are also pleased to publish an article from Judy More, Paediatric Dietitian and Member of the Infant & Toddler Forum (ITF) which discusses current advice on how to support parents to understand portion sizes. In clinical dietetics, we are pleased to introduce two new contributors, Leona Courtney, Specialist Diabetes Dietitian, who gives us an overview of enteral feeding; and Gastroenterology Dietitian, Rebecca Gasche, who focuses on bile acid malabsorption, talking us through current approaches and information. In our IMD Watch, we introduce Metabolic Dietitian, Justin Ward, who tells us how British cycling inspired a new emergency regimen, a vital protocol used as treatment for a number of inherited errors of metabolism (IEM). Nikki Brierley returns with an article which explores the need for increased general awareness and understanding of eating disorders within the care setting, with a view to improved compassion in this area and Lucy Aphramor offers us a fascinating and insightful discussion around addressing trauma in public health. Our April issue also brings you our regular columnist Priya Tew’s advice on raising the profile of dietetics. ‘When April showers . . .,’simply read NHD! Emma. April 2018 - Issue 133



IN THIS ISSUE: Focus on care of

the elderly 6



Portion sizes for children

Latest industry and product updates

Available support for parents

11 MALNUTRITION The growing cost to England's NHS

29 ENTERAL FEEDING Feeding routes & delivery 33 IMD watch Standard emergency regimens 37 Trauma In public health and dietetics

41 EATING DISORDERS Understanding and compassion

16 ONS Nutritional support in obese inpatients 19 Dementia Clinically assisted nutrition

22 BILE ACID MALABSORPTION Raising awareness

44 Raising the profile of dietetics Realise your potential 46 Events & courses Dates for your diary

25 Non-IgE-mediated allergy New home introduction guides

47 Dietitian's life By Louise Robertson

Copyright 2018. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD Publishing Director Julieanne Murray Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Special Features Ursula Arens News Dr Emma Derbyshire Design Heather Dewhurst


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Discover more at Or for more information call our free Healthcare Professional Helpline on 0800 996 1234 REFERENCES: 1. Mabin DC, Sykes AE, David TJ. Arch Dis Child, 1995;73(3):208-10. 2. Pedrosa M, Pascual CY, Larco JI, et al. J Investig Allergol Clin Immunol, 2006;16(6):351-6. 3. Miraglia Del Guidice M, D’Auria E, Peroni D, et al. Ital J Pediatr, 2015;41(1):42 4. Keohane PP, Grimble GK, Brown B, et al. Gut, 1985;26(9):907-13. 5. Ammoury RF, Croffie JM. Pediatr Rev 2010;31(10):407-16. 6. Bach AC, Babayan VK. Am J Clin Nut, 1982;36(5):950-62. 7. Shaw V (ed). Clinical Paediatric Dietetics. 4th ed. Oxford: Wiley Blackwell, 2015.

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Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.

Each serving (150g) contains DIABETES UK - FOOD UPFRONT CAMPAIGN Diabetes UK are asking the UK government for clearer food labelling. Food Upfront has been launched to bring about improved food labelling and access to nutritional information which could help people with diabetes make better informed dietary choices. Understanding more about the calorie, sugar and carbohydrate content of foods from various routes will mean that people with diabetes can more accurately gauge what they are consuming - something which is particularly important in carb counting and insulin adjustment. The campaign sets out the following requests: 1 On all prepacked foods, traffic light style front-of-pack labelling should be made compulsory. Currently one in three food products don’t have front of pack labels at all. 2 On the back of packs, the carbohydrate content per portion and as prepared should be included on labels. 3 The campaign also calls for clear nutritional information regarding calories on key high street restaurant, café and takeaway menus. The carbohydrate content should be available on request in store or online. To support this campaign, healthcare professionals, patients and their families can sign a petition, which is accessible via the website: involved/campaigning/food-upfront-campaign

NEW TOOLKIT FOR PHYSICAL ACTIVITY, HEALTHY EATING AND HEALTHIER WEIGHT Public Health England inactive, doing less than 30 (PHE) and Business minutes of moderate physical in the Community activity each week. (BITC) have teamed • The cost of an unhealthy workforce up to produce a to the UK taxpayer has been number of toolkits estimated at over £60 billion per to be used in the workplace to promote year. healthy lifestyles and outcomes. • Employees who are in good health Many people on average spend are less likely to need time off anything between four and 12 hours work and are likely to be more a day in the workplace, therefore, productive. promoting healthier lifestyle and diet This toolkit joins a range of PHE and choices whilst we are there is vital in BITC toolkits which take ‘an innovative To book your order to chip away at the national co-production approach to the weight management challenge we development of interconnected toolkits company's all face. There are some startling by consolidating the best evidence, product news statistics which the toolkit aims to practical actions and employer case address if embraced by employers and studies.’ Other toolkits include the for the next employees: mental health toolkit for employers issue of • Around a third of adults in England and musculoskeletal health in the are damaging their health through a workplace. NHD call lack of physical activity. For further information about the PHE and BITC 01342 824073 • One in four women and one in five toolkit visit men in England are defined as toolkits 6 April 2018 - Issue 133

NEW KING’S FUND REPORT: TACKLING MULTIPLE UNHEALTHY RISK FACTORS A new report published by the King’s Fund shares the insights and learning points from the services that have been using innovative ways to address the problem of multiple unhealthy risk factors, such as tobacco use, unhealthy diet choices, excessive alcohol consumption and low physical activity levels. The new report takes insights from eight case studies in local authorities and the NHS, along with the outcomes of interviews with those who were designing or delivering interventions. It updates the evidence base that supports strategies for tackling multiple unhealthy risk factors. Key findings include the following: • Most services are local authority led and they are integrating health and wellbeing services, which provide behavioural advice and support across the various unhealthy behaviours. • Multiple unhealthy behaviours were also being addressed by the NHS. The report uses learnings from two hospital-based initiatives. • The evidence for behaviour change services to rely on, when considering multiple unhealthy risk factors, was limited. However, these services are in a position to generate the evidence base on best practice when addressing multiple unhealthy behaviours. The report makes recommendations on how the services can develop and how research can be shared. Also, how the Public Health England and the Department of Health and Social Care

can support the innovation of these services further. The report lays out five key steps: 1 Invite the case study sites used in the report (and others offering similar services) to join a network where learnings and best practice can be shared, local authority success can be built upon and implemented within the health service and better assess the impact of their actions on unhealthy behaviours in their populations. 2 Create a policy network to consider how unhealthy behaviours are relevant to other linked policy areas. 3 Fund research into interventions to tackle multiple unhealthy risk factors. 4 Promote the life expectancy risks of multiple unhealthy behaviours in government health campaigns such as One You. 5 Develop a strategy for tackling multiple unhealthy risk factors within the population.

For further information and to download the full report visit:

NICE GUIDANCE - PANCREATIC CANCER IN ADULTS: DIAGNOSIS AND MANAGEMENT (NG85) NICE has recently set out its guidance on the diagnosis and management of pancreatic cancer in adults. It covers adults aged 18 and over and aims to improve care by ensuring quicker and more accurate diagnosis. It also aims to specify the most effective treatments for people depending on how advanced their cancer is. The guidance includes recommendations on diagnosis, the monitoring of people with an inherited high risk of pancreatic cancer, staging, psychological support, pain and nutrition management, the management of resectable, borderline resectable and unresectable cancer The nutritional aspects of the guidance focus on the use of enteric-coated pancreatin for people with unresectable pancreatic cancer and its use before and after pancreatic cancer resection. It advises against the use of fish oils as a nutritional intervention to manage weight loss in people with unresectable pancreatic cancer. For people who have had pancreatoduodenectomy and who have a functioning gut, it recommends offering early enteral nutrition (including oral and tube feeding) rather than parenteral nutrition and signposts readers to Clinical guideline [CG32] Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition for further information. To read the full guidance visit: April 2018 - Issue 133



Judy More Paediatric Dietitian and Member of the Infant & Toddler Forum (ITF) Judy has specialised in Paediatric nutrition for over 25 years. She has worked in both Australia and the UK in NHS teaching hospitals and community trusts, as well as in private clinics. Judy is a lecturer and accomplished food and nutrition writer.

REFERENCES Please visit the Subscriber zone at


SUPPORTING PARENTS TO UNDERSTAND PORTION SIZES It can be difficult for parents to determine how much food to offer young children. Recently, Public Health England (PHE) has warned that children are eating three times more sugar in a day than their recommended allowance, with half of this coming from unhealthy snacks and sugary drinks. Research from the Infant & Toddler Forum (ITF) has shown that parents are unwittingly giving their toddlers too much food. The survey asked 1000 UK parents to look at images of portion sizes and decide which ones they felt would be appropriate to give to their one- to four-year-olds.1 The majority (79%) of respondents routinely offered portions bigger than the recommended size range for preschoolers and around 10% of parents usually served their child close to an adult-size portion when serving popular meals. With evidence linking larger portion sizes to excess weight gain2 and with one in five being overweight by the time they start school,3 parents need more practical advice.


The ITF has developed a user-friendly guide on how much food to offer children aged one to four years. The visual guide is presented as a factsheet at and shows how many portions from each of the food groups should be offered each day and the portion size range of each particular food to offer. Following this guidance will meet the nutritional needs for activity, growth and development. Portion size ranges are used due to the fact that precise, or fixed portion sizes are not useful for one- to fouryear-olds. This is because the amount of food they eat varies considerably from meal to meal and from day to day. The

Figure 1: Sample dayâ&#x20AC;&#x2122;s menu for a toddler with portion sizes


Y2~1slice wholemeal toast 2-4 Tbs scrambled egg


2-4 Tbs grated cheese Y2-1slice wholemeal bread 1-4 cherry tomatoes



'/4-1small fillet salmon 1-4 small florets broccoli 2-4 medium potato wedges

) Y2-lkiwifruit

'/2-1small pancake 3-10 small berries

8 April 2018 - Issue 133

1pot of yoghurt (125mil

3-10 cherries

Table1: Healthcare professionals can advise the following: Include foods from all food groups each day to provide all the nutrients. Have a routine and offer three meals and two to three nutritious snacks each day; don’t allow grazing on food. Offer two courses at each main meal. Limit high calorie low nutrient foods - crisps, packet snacks, pastries, cakes and biscuits to very small amounts. Avoiding them altogether may lead to unsocial behaviour when a toddler does encounter them. Avoid high-sugar drinks including fruit juices and smoothies. Toddlers need to be offered a drink of 3-4oz or 120mLs with each meal and snack. Water is the best choice. Limit milk drinks, as toddlers need much less milk than babies and an excess intake can lead to iron deficiency and anaemia.

ranges have been developed by comparing them with reported average amounts eaten by healthy young children in the ALSPAC studies and the 1995 UK National Diet and Nutrition Survey for children one and half to four and a half years of age4-8 and in other countries.8,9 They were published along with the scientific rationale in The Journal of Human Nutrition and Dietetics in 2015.10 The energy and nutrient content of daily combinations of a variety of the foods from the ranges were calculated using the midpoint of the portion size range. These daily combinations meet the UK estimated average energy requirements11 and Reference Nutrient Intakes (RNIs)12 for this age group for all nutrients except vitamin D which is not expected to be met by food alone. Practitioners can use these portion size ranges to help parents to understand when they may be overfeeding and to reassure parents who worry that their toddler is not eating enough. Other factsheeets for practitioners can be found on the ITF website (see below). These explain in more detail the aspects of the behavioural side of feeding toddlers well. ALLOWING CHILDREN TO EAT TO THEIR APPETITE

Over a week, most toddlers regulate their appetite to meet their energy and growth needs quite accurately and so can be allowed to eat to their appetite - to stop eating when they have had enough. Toddlers signal satiation by saying “no”, shutting their mouth, turning their heads

away or pushing the food away. When parents offer large portion sizes and coerce children to eat everything on their plate, they can inadvertently override children’s self-regulation systems. Larger portions can then begin to form acceptance about what is an appropriate amount to eat and this then becomes the ‘norm’. Most toddlers will overeat sweet foods; carefully observing portion sizes can prevent this. REWARDING WITH ATTENTION, NOT FOOD

Toddlers are best rewarded with attention such as hugging, playing, reading, or talking with them. If food or drinks are given as a reward, treat, or for comfort, this can encourage eating when not hungry and can develop comfort eating. It’s best to give fruit or a nutritious pudding as a second course, thereby providing a wider range of nutrients at the meal and not using this sweet course as a reward for eating the first savoury course, or for good behaviour. THE ITF: WHAT WE DO

The ITF promotes best practice in healthy habits from pregnancy to pre-school through reliable clear evidence-based advice and simple practical resources aimed at practitioners and healthcare professionals. ITF is supported by an unrestricted educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests.

More information and practical advice on supporting families: Portion sizes: For parents - and the range of ITF Fact sheets for healthcare professionals - For email more information on face-to-face training, contact @InfTodForum or - April 2018 - Issue 133



Supporting parents to understand portion sizes Table 2: Examples of portion sizes within each food group Bread, rice, potatoes, pasta and other starchy foods - offer a serving at each meal and some snacks. • ½-1 slice wholegrain or white bread or ¼-3/4 bread roll • 3-6 heaped tbs wholegrain or fortified breakfast cereal without a sugar coating Fruit and vegetables - offer at least one to two servings at each meal and also offer them with some snacks. • 3-10 small berries or grapes • 2-4 tbs raw, freshly cooked, stewed or mashed fruit Milk, cheese and yoghurt - serve three times each day. • 3-4oz (100-120ml) whole cow’s milk as a drink in a cup • 1 small pot (125ml) yoghurt or 2 x 60g pots of fromage frais • About 20g cheese Meat, fish, eggs, nuts and pulses - serve two to three times per day - twice for young children eating meat and fish and three times a day for vegetarians. • 2-4 tbs ground, chopped or cubed lean meats, fish or poultry • ½-1 whole egg Oils, butter and fat spreads - include small amounts twice a day, and choose high omega-3 oils, e.g. rapeseed, olive and soya oils. • 1 tsp oil • 1 tsp butter or fat spread Sugary foods and packet snacks: • Toddlers under two years of age have lower energy requirements and should not be offered any sweet puddings, cakes, biscuits, confectionery, chocolate or savoury snacks such as crisps. • Over two years of age offer small amounts of sweet foods and salty snack foods but these should be limited to: – once a day: ½ -1 digestive biscuit or 1-2 small biscuits or 1 small slice cake or pudding. – if given, limit to once a week only: 4-6 crisps, or 2-4 sweets, or 1 small fun-sized chocolate bar, 1 sweet drink.






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Katherine Sykes Health and Policy Consultant, BSNA Katherine is a strategic communications specialist, focusing on health and nutrition. Since 2005, she has worked both in-house and in consultancy. ~Spec~11s1


For more information on the malnutrition report, visit:

REFERENCES Please visit the Subscriber zone at

FORGOTTEN NOT FIXED: THE UNRECOGNISED BURDEN OF MALNUTRITION IN ENGLAND Malnutrition continues to be a serious problem in modern Britain, with more than three million people in the UK estimated to be either malnourished or at risk of malnutrition.1 The number of deaths from underlying malnutrition, or where malnutrition was named as a contributory factor, is also increasing, having risen by more than 30% from 2007 to 2016.1 This is unacceptable in any modern healthcare system. The increasing number of cases of malnutrition in hospital and associated deaths reflect a system-wide failure to consistently screen and manage patients who are either malnourished or at risk of malnutrition.2 Drawing upon malnutrition data broken down by NHS Trust for 2015/16,3 new research commissioned by the British Specialist Nutrition Association (BSNA)4 has found that more than half the hospital Trusts in England are significantly under-reporting malnutrition rates compared to accepted national estimates. This means that the overall incidence of malnutrition is likely to be significantly under-recorded, pointing to a much more significant problem than the available data suggests. Against this backdrop, the incidence of malnutrition continues to rise. IT COSTS MORE NOT TO TREAT MALNUTRITION THAN TO DO SO5

Malnutrition results in various adverse health outcomes for patients, including high numbers of non-elective admissions, greater dependency on hospital beds for longer and progression to long-term care sooner. Managing patients in a crisis situation results in high levels of inefficiency, which could be avoided or

minimised if more focus were placed on prevention and early intervention. The resulting cost to the public purse is significant. In England alone, the costs arising from malnutrition have been estimated at £19.6 billion. This represents approximately 15% of overall health and social care expenditure.5 On average it costs £7,408 per year to care for a malnourished patient, compared to £2,155 for a wellnourished patient.5 It is estimated that £5,000 could be saved per patient5 through better nutrition management. The provision of nutritional support to 85% of patients at medium to high risk of malnutrition would lead to a cost saving of £325,000 to £432,000 per 100,000 people.5 The impact on local areas is considerable, since 93% of malnutrition is estimated to occur in community settings. However, the largest cost comes from the management of malnourished people in hospitals, even though they only account for 2% of cases.1 Comprehensive effective screening, prevention and treatment and the introduction of incentives, are essential across all settings to protect those at risk of malnutrition and reduce costs to taxpayers. April 2018 - Issue 133




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Significant cost benefits can be gained from optimal management of nutritional care, not to mention the benefits for patients’ quality of life. Guidance exists that should be followed in all care settings. NICE Clinical Guideline 32 on Nutrition Support in Adults (CG32),6 and NICE Quality Standard 24 (QS24),7 set the standard for appropriate and timely nutritional care in this context. These are supported by the Managing Adult Malnutrition in the Community Pathway,8 an evidence-based tool that can be used across all care settings and which is endorsed by professional organisations such as the British Dietetic Association (BDA), British Association for Parenteral and Enteral Nutrition (BAPEN), Royal College of Nursing (RCN) and Royal College of General Practitioners (RCGP). The Malnutrition Universal Screening Tool (‘MUST’)9 is a recommended screening tool with five steps, which allows healthcare professionals to identify and manage nutritional issues, including both malnutrition and obesity. It includes the use of BMI calculation, consideration of unplanned weight loss and the effect of acute disease, as well as guidelines that can then be used to help establish a care plan for the individual based on their level of risk. Unfortunately, even though patients, care home residents and those receiving support in the community should - and can easily be - screened and assessed for malnutrition, this is not always the case. Even in situations where ‘MUST’ is being used, it can sometimes be viewed as a tick box exercise, meaning that patients do not always receive an appropriate management plan when they should. In order to be tackled effectively, malnutrition needs to be screened, identified and managed appropriately. However, it appears that there are fundamental inconsistencies in the implementation of CG32, QS24 and the other recommended strategies. Malnutrition remains a growing problem, yet is largely preventable and can be better managed if the right guidance is followed.


NICE Quality Standards are designed to measure and improve quality of care in specific areas. Estimates point to malnutrition as a sustained problem across the country, but the data is incomplete due to the non-mandatory nature of nutrition reporting and management. Were the Quality Standard and the full accompanying Clinical Guideline (CG32) implemented in full, comprehensive records would exist on the nutritional status of all inpatients, care home residents and people receiving care in the community. Malnutrition data broken down by NHS Trust is the only localised breakdown of such data publicly available. Although NHS Trusts cannot be mapped to a specific local footprint, because patients will not always attend their nearest hospital, data on them can be used to illustrate trends by region, or to identify local hospital activity. Grouping Trusts by region, the data shows that the upward trend for cases of malnutrition by finished admission episodes (FAE)10 is common across England. This data demonstrates that malnutrition remains a significant and growing problem despite significant efforts to improve clinical practice, including the existence of CG32. New research commissioned by BSNA explored the current reporting of malnutrition in hospitals in England, identifying Trusts where the recording of malnutrition is significantly below expectation. Analysis was undertaken using the latest publicly available malnutrition data from 221 NHS trusts, covering the period 2015/16. The recorded malnutrition data was then displayed as a percentage of overall admissions compared to the total admissions in each Trust. Official estimates indicate that around 2% of malnutrition cases appear in a hospital setting,1 yet, our research found that in half of the Trusts, fewer than 0.05% of admissions were classified as showing signs of malnutrition, equating to fewer than one in every 2,000 patients. Of these, roughly 50% (45) were large NHS Trusts with more than 100,000 admissions per year. These Trusts were split evenly across the regions of England, indicating a systemic April 2018 - Issue 133


PUBLIC HEALTH under-reporting of malnutrition. However, it is not possible to extrapolate from the available data whether this is because of full or partial adherence to the available guidance. Of the 221 Trusts analysed for the report, almost all reported fewer than one case of malnutrition for every 100 patients admitted. The statistics are at considerable variance with the generally accepted estimated prevalence of malnutrition in the UK, suggesting that they vastly under-represent the hospital population that could be expected to be affected by/at risk of malnutrition. It is, therefore, likely that many, if not all, Trusts need to improve the process by which malnutrition risk is identified and coded. Over and above the picture of varied reporting, the figures also illustrate an upward trend of incidence of malnutrition across all parts of England. The increasing number of cases of malnutrition in hospital and associated increase in deaths from malnutrition suggest a failure to consistently prevent, screen and manage the condition. THE PROVISION OF ORAL NUTRITIONAL SUPLEMENTS (ONS)

When CCGs are looking to reduce their overall expenditure on prescription costs, it is important to look at the burden of malnutrition in the local health economy, in terms of hospital admissions and readmissions, and to ensure that the nutritional needs of patients are being managed appropriately. Immediate savings from cutting ONS can lead to higher costs due to increased healthcare use in the longer term. The use of ONS as part of a dietary management strategy can produce significant cost savings. BAPEN estimates that the appropriate oral nutritional support in both prevention and management could: • save the NHS £101.8 million per year;5 • help to alleviate pressure on both primary and secondary care; • reduce GP visits, which alone could save the NHS £3.9 million in England.1 Implementing NICE CG32 and QS24 in 85% of patients at medium and high risk of malnutrition would lead to a net saving of £172.2-£229.2 million, which equates to £324,800£432,300 per 100,000 people.5 14 April 2018 - Issue 133

Dietitians have an important role to play in finding a solution to this challenge, as they are expertly trained to devise nutritional care plans for patients with medical conditions and help support patients’ health and wellbeing. Prevention and management of malnutrition requires early action to reduce the risk of longerterm complications. Prescribing ONS whenever there is a clinical need to do so, and in line with both NHS England guidance12 and NICE guidance,6,7 can ensure that patients’ nutritional needs are managed adequately and that further complications do not arise. ONS are an integral part of the management of long-term conditions that require nutritional support and should be accessible to all patients who need them. Healthcare professionals are best placed to evaluate whether patients need ONS and if so, for how long patients should be taking them. They can also provide patients with the most appropriate products for their individual clinical conditions and circumstances. Patients who take ONS should be regularly monitored and reviewed and ONS should be discontinued when the patient is no longer malnourished, has met their nutritional goal(s) and is able to meet their nutritional needs through food alone. Healthcare professionals, commissioners and policymakers across all settings must balance investment in ONS and dietetic services against consideration of unintended consequences and longer-term burdens, to both patients and the NHS that can be exacerbated without action. The provision of dietary advice and ONS to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40%.13 There is little evidence of efficacy of managing disease-related malnutrition with food-based strategies alone compared to the use of ONS.14 Yet, despite this, against a backdrop of increasing cost pressures on the NHS, a number of CCGs have started to restrict prescribing of ONS, which requires an initial outlay, but consistently brings savings arising from the prevention of later associated complications. Fortified food has been provided instead in some cases, but this approach is over-simplified and often does not account adequately for patients’ individual clinical requirements, or the clinical assessments made by healthcare professionals.15

Implementing NICE CG32 and QS24 in 85% of patients at medium and high risk of malnutrition would lead to a net saving of £172.2-£229.2 million, which equates to £324,800-£432,300 per 100,000 people.5 In summary, prevention and treatment of malnutrition requires initial outlay and early action to reduce the risk and cost of longerterm complications. Healthcare professionals, commissioners and policymakers across all settings must balance investment in ONS and dietetic services against consideration of longer term burdens to both patients and the NHS that can be exacerbated without action. CONCLUSION

The importance of good nutrition should not be understated. Whilst considerable focus has been given to obesity in recent times, including high profile policy interventions, All Party Parliamentary Group (APPG) enquiries and General Election manifesto pledges, malnutrition still remains the poor relation, notwithstanding the size and scale of the problem. Yet, obesity and malnutrition are both states on the nutritional spectrum and the goal of public health intervention should be to ensure good nutritional status for the population as a whole, particularly for those individuals at risk of malnutrition. Malnutrition is an avoidable cost to the NHS, but remains a significant and growing problem. Efforts to improve clinical practice have not resulted in adherence to clinical guidelines and there are fundamental inconsistencies in data collection, which means that the overall incidence of malnutrition is likely to be significantly under-recorded. Action is needed to ensure that Trusts are given all the support they need to accurately record malnutrition risk, thus reducing its incidence over time. In light of this, BSNA recommends the following actions be taken to promote improved health in the population and to reduce the burden of disease-related malnutrition on the NHS:

1 The introduction of a new, comprehensive jointly developed and delivered clinical care pathway for the frail elderly, across all systems. 2 CG32, QS24 and the Managing Adult Malnutrition in the Community Pathway should be implemented and followed in all healthcare settings. In particular, since guidelines are not being followed in reality, BSNA calls for CG32 to be made mandatory. 3 Incentives should be considered to transform clinical practice, including how malnutrition is identified, recorded and managed, perhaps by the introduction of a new Quality and Outcomes Framework (QOF) (or equivalent) on malnutrition, which could transform how malnutrition is identified, recorded and managed. 4 ONS should be recognised as an integral part of the management of long-term conditions that require nutritional support, alongside food. They should be accessible to all patients who need them and all care pathways should clearly identify how ONS should be used to help manage a patients’ conditions. Patients should be regularly monitored by a healthcare professional so that the nutrition intervention is reviewed accordingly. The introduction of a new comprehensive jointly developed and delivered clinical care pathway for the frail elderly, across all systems, would go a long way to addressing malnutrition risk. This could include incentives, such as a QOF (or equivalent) for malnutrition, and mandatory adherence to CG32 and QS24. April 2018 - Issue 133



ORAL NUTRITIONAL SUPPLEMENTS: NUTRITION SUPPORT IN THE OBESE HOSPITAL INPATIENT Jessica Coates Acute Dietitian, Wirral University Hospital NHS Foundation Trust Jess works as an Acute Dietitian in a large district general hospital. She sees patients with a variety of needs, often focusing on nutrition support. Gastroenterology is becoming one of her main interests. @JessCoatesRD

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As obesity continues to become a growing problem in the UK and across the world,1 an increasing emphasis is being placed on all aspects of hospital treatment for this patient group. This article will look into the screening and assessment of nutritional risk, as well as use of oral nutritional supplements (ONS), in the obese hospital inpatient. As an Acute Dietitian, I am only too aware of the consequences of malnutrition. Increased risk of infection, poor wound healing and increased length of hospital stays are just a number of the negative effects experienced by patients. Rapid weight loss in hospitalised patients is associated with increased complications and poor outcomes, regardless of original body mass index (BMI).2 So, what happens when an obese patient is malnourished? Are they screened in the same way as a ‘frail’ patient? Are they offered the same assessment and treatment as their neighbour on the ward? NUTRITIONAL SCREENING

Current NICE guidelines state that all hospital inpatients should be screened for malnutrition on their admission and weekly thereafter.2 NICE also suggests that unintentional weight loss and period of reduced intake should be considered, using validated tools such as BAPEN’s Malnutrition Universal Screening Tool (MUST). In those with a BMI of >20kg/m2, malnutrition risk is heightened by: • unintentional weight loss greater than 10% within the last three to six months; • having eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer; • a poor absorptive capacity and/ or have high nutrient losses and/ or have increased nutritional needs from causes such as catabolism.2 April 2018 - Issue 133

Early identification of this risk facilitates appropriate management to be instigated without delay and can avoid a patient’s nutritional status deteriorating further. The most recent data available from BAPEN’s Nutritional Screening Week project shows that 49% of patients with a MUST score of 2 or more (usually triggering referral to Dietetic departments), had a BMI of <20kg/m2.3 Could this be because those patients with a higher BMI are not being properly screened? We know that some healthcare professionals (HCPs) tasked with screening for malnutrition would prefer to use their own clinical judgement when assessing risk, rather than using valuable time to fully complete a screening tool.4 In a small study on a medical admission unit, it was found that many nurses were reluctant to weigh patients, feeling that it was ‘unnecessarily invasive’ and made them feel uncomfortable.5 This is despite the fact that research has shown high risk of malnutrition is a common finding in obese hospital inpatients, leading to similar negative outcomes to those patients who have a low BMI.6 Anecdotally, a further barrier can be lack of appropriate and available bariatric weighing equipment. Many hospital scales have a maximum weight of 200kg and some clinical areas can struggle to access chair, bed or hoist scales. Regardless that any hospital inpatient is at risk of protein wasting and muscle loss,7 obesity on admission

We know that rapid weight loss, intentional or unintentional, can be physically dangerous and psychologically damaging. The potential complications and amount of dietetic follow up required by those patients undergoing bariatric surgery emphasises this.

can cause recent weight loss to be missed. A patient might be less likely to highlight recent weight loss as a problem when in consultation with HCPs, due to society’s positive associations with obese people losing weight, whatever the method. Research has shown that obese people can experience stigma and prejudices in many aspects of their lives, including when accessing healthcare, sometimes leading to stereotypes of laziness and non-compliance with treatment.8 We know that rapid weight loss, intentional or unintentional, can be physically dangerous and psychologically damaging. The potential complications and amount of dietetic follow up required by those patients undergoing bariatric surgery emphasises this.9 Indeed, NICE only recommends very low calorie diets (<800kcals/ day) as part of a multicomponent weight management strategy, with extensive support and follow up, in order to restore a healthy, well-balanced diet in the long term.10 Current guidelines advise a steady weight loss of 0.5-1kg per week, brought about by reducing intake by 600-1000kcals, dependent on a patient’s current intake and response to treatment.11 This is because it has been indicated that the majority of people are more likely to sustain healthy lifestyle changes that are made in small steps, rather than radical diets that result in extreme weight loss in the short term.

Weight loss should never be a nutritional goal during an acute illness or hospital stay, whatever the patient’s weight on admission. Why then, is it sometimes seen as acceptable when an obese patient loses weight due to low appetite resulting from an acute illness? NUTRITIONAL REQUIREMENTS

If an assessment of nutritional risk is carried out, and a patient is referred to the dietitian, the next challenge is calculating nutritional requirements. It has been well-documented that standard, weight-based predictive equations are less accurate in those with a BMI of >25kg/m2.12 Indeed, ASPEN guidelines state that if indirect calorimetry and Penn State University equations cannot be used, energy requirements may be based on the Mifflin-St Jeor equation, using actual body weight.13 However, this is a weak recommendation, with only moderate evidence to support it in practice. Many dietitians in the UK choose to use the PENG recommendations to calculate nutritional requirements: using the Henry equation for energy, omitting stress and activity factors for those patients with a BMI of >30kg/m2 to avoid overfeeding.14 A disproportionate ratio of fat mass to fat free mass is seen in obesity, increasing the risk of overfeeding energy when calculating resting energy expenditure, using weightbased predictive equations. To calculate protein April 2018 - Issue 133


CLINICAL CASE STUDY Male, 55 years, background of T2DM and HTN, recently admitted due to influenza. Weight: 114kg, Height: 1.72m, BMI: 38.5kg/m2 ASPEN equation = wt (kg) x 14 = 114 x 14 = 1596kcals and 1.2g x wt (kg) = 1.2 x 114 = 136.8g protein per day PENG method = 14.2 x 114 + 593 = 2212kcals and (0.15-0.17) x 114 x 6.25 x 0.75 = 80-91g protein per day Mifflin St Jeor = 10 x weight (kg) + 6.25 x height (cm) â&#x20AC;&#x201C; 5 x age (y) + 5 = 10 x 114 + 6.25 x 1.72 - 5 x 55 + 5 = 871kcals per day These methods clearly give a wide range of potential calorie and protein goals. Anecdotally, it could be extremely difficult for a patient to meet the ASPEN requirements based on a hospital menu. Foods available which are high in protein tend to also be higher in calories. Most UK hospitals use the BDAâ&#x20AC;&#x2122;s Nutrition and Hydration Digest to provide targets for the calorie and protein capacity of their menus.16 This document suggests that the energy a hospital menu should provide (including all meals, snacks, puddings and drinks) would be a maximum of 2772kcals and 83g protein, to meet the needs of most patients. This would clearly make the ASPEN protein recommendation an impossible task, even if the patient had an excellent appetite. Therefore, it can be essential to involve a dietitian in order to consider additional nutrition. It is possible that ONS should focus on lower calorie, higher protein products in some obese patients. The availability of these products in many hospitals in the UK is variable, leading to further challenges of meeting estimated protein requirements, whilst aiming to avoid overfeeding calories.

requirements, PENG suggests using 75% of the value estimated using actual body weight, for those with a BMI of 30-50kg/m2. Needs may be higher, however, if patients have co-morbidities such as pressure damage or wounds, which can be more frequently seen in those with morbid obesity. The proposed new method to calculate these requirements for all adult patients is eagerly awaited by the dietetic profession, due in the next edition of the PENG Pocket Guide, available May/June 2018. WHAT SHOULD WE RECOMMEND?

Based on the difficulties in estimating requirements in this population group and the risks associated with overfeeding, an increasing body of evidence, particularly in intensive care, has become the topic of much debate. Research has suggested that hypocaloric, high protein feeding may achieve favourable outcomes.15 However, much research focuses on parenteral nutrition and a randomised controlled trial investigating hypocaloric, high protein feeding, compared to eucaloric feeding, has yet to be published. ASPEN published guidelines to be used with all obese hospitalised patients, stating that a hypocaloric regime of target calories of 50%-70% of estimated energy needs, or <14kcal/kg actual weight and protein of 1.2g/kg actual weight or 2-2.5g/kg ideal body weight, can be used in those patients who do not have severe renal 18 April 2018 - Issue 133

or hepatic dysfunction.13 ASPEN also advises clinical vigilance to ensure adequate protein provision, as underfeeding is associated with unfavourable outcomes. Although recent research has supported these guidelines, they are based on poor evidence and give a weak recommendation. CONCLUSION

There is a paucity of evidence relating to ONS use in the obese hospital patient, in regards to usage, outcomes and opinions of HCPs. Extrapolating from previously mentioned research and personal professional experience, many medical and nursing staff appear to believe that prescribable nutrition is inappropriate for obese patients, regardless of their current intake. Dietitians are well placed to both add to the evidence base and to use available evidence and guidelines to challenge these views, potentially leading to improvements in patient care and outcomes for this patient group. Despite limited research in the area, the dietitian must use the best available guidelines and evidence to ensure that patients receive adequate calorie and protein intakes whilst in hospital, to minimise negative effects of underfeeding. This care plan would most likely be monitored using body weight, with the aim of the intervention being to maintain current weight. This may involve the provision of prescriptive ONS.








The Association of UK Dietitians

Specialist Group

Kirsty Robinson Older People’s Dietitian, Bart’s Healthcare Trust, London

There are 850,000 people living with dementia in the UK today (1.3%) and this number is projected to exceed two million by 2050.1 There are also approximately 700,000 informal carers caring for their loved ones with dementia, a number also expected to rise to 1.7 million by 2050.1

Kirsty has worked as a specialist older people’s dietitian for the last three years within an acute hospital setting. She enjoys supporting and educating patients, relatives and staff on a holistic and practical approach to nutritional support. Kirsty is a committee member for the Older People’s Specialist Group (OPSG).

People who have dementia experience a number of stages in their condition, from early difficulties with complex tasks such as driving, to the terminal phase where people become immobile, experience incontinence, dysphagia and are dependent on others for all care. Malnutrition risk increases as dementia progresses.2-4 People who have dementia have been found to account for 10 times more admissions to hospitals when compared to age-matched controls.5 A recent meta-analysis found minimal evidence of successful dietary strategies for combating undernutrition for those who have dementia.6 An individualised patientcentred approach addressing people’s different needs appears to be the most beneficial way to manage the condition.6 Clinically assisted nutrition is usually deemed as administration of food and fluids via a nasogastric tube (a tube that is passed through the nose and into the stomach), or via a percutaneous endoscopic gastrostomy (PEG), where a feeding tube is inserted into the stomach and is accessed through a permanent incision in the abdominal wall. A Cochrane review of clinically assisted nutrition and dementia in 20097 and a recent systematic review in 20158 found no conclusive evidence that clinically assisted nutrition is effective in terms of: • prolonging survival • improving quality of life • leading to better nourishment • decreasing the risk of pressure sores

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Alzheimer’s International’s Nutrition and Dementia - a review of available research (2014) suggests that enteral nutrition

may be considered if ‘dysphagia in a patient with dementia is deemed to be transient, but should not generally be used for patients with advanced dementia who are disinclined to eat or have permanent dysphagia’.9 In 2015, the European Society of Parenteral and Enteral Nutrition (ESPEN) similarly recommended the use of enteral nutrition in patients with ‘mild or moderate dementia if malnutrition is predominantly the cause of a reversible condition and only for a limited time’.10 In the UK, clinically assisted nutrition and hydration is regarded in law as a medical treatment. The General Medical Council (GMC) guidance on treatment and care when reaching end of life recognises that some people see nutrition and hydration, whether oral or artificial, as part of basic human nurture which should almost always be provided. It, therefore, advises clinicians to listen to the views of patients and those close to them, especially regarding their cultural and religious views and beliefs. MEDICAL DECISION MAKING

Doctors in the UK are guided in medical decision making by medical ethics, including the four key bioethical principles (Beauchamp and Childress, 1979): • Autonomy: respect for an individual’s right to determine what is done to them. • Beneficence: a duty to do things that will help others. • Nonmaleficence: a duty to not do things which will harm others. April 2018 - Issue 133


MALNUTRITION MATTERS Table 1: Factors that might influence the use of feeding tubes in advanced dementia Patient and family factors • Unawareness of or difficulty accepting the terminal prognosis of dementia. • Unawareness of the lack of benefit and increased risk of harm with feeding tube use in advanced dementia. • Perception of patient ‘starvation’ or ‘dehydration’ without artificial nutrition and hydration that might be influenced by cultural or religious beliefs. • Extra time required to assist with oral feeding. • Complicated social dynamics (e.g. viewing interventions as a representation of high-quality care). • Lack of advance directives specifically addressing artificial nutrition and hydration (when people do not want artificial nutrition). Clinician factors • Unawareness of the lack of benefit and increased risk of harm with feeding tube use in advanced dementia. • Lack of familiarity with simple techniques to reduce thirst and hunger. • Avoidance of difficult discussions or belief that the discussion will be held by a different clinician (e.g. family physician, geriatrician, interventional radiologist). • Fear of litigation. • Administrative and systemic factors. • Extra time and staff needed to assist with oral feeding in patients who have advanced dementia. Adapted from; Ying, I (2015). Artificial nutrition and hydration in advanced dementia. Vol 61: Canadian Family Physician, Le Médecin de famille canadien

Table 2: Things to consider when completing a detailed dietetic assessment for someone who has dementia and is referred for clinically assisted nutrition • The patients’ views (current or past) on nutrition - do they have an advance directive? What are their next of kin’s views on what the patient would want? • The patient’s cultural or religious beliefs or values. • Type of dementia - number of years since diagnosis. • Number of hospital admissions the patient has had within the last 12 months and reasons for admissions. • Cognitive assessment completed recently or in the past (MOCA, AMT). • Social situation - does the patient live alone or with carers OD/ BD/ TDS/ QDS, or in a residential care or nursing home? • Does the patient have dysphagia usually or currently? • How good is their mobility usually and currently? • What is their skin integrity usually and currently? • Is the patient continent usually and currently? • What do the patients food record chart and +/- diet history in 24 hours show? • Estimate of current intake energy/ protein vs requirements - is it improving, decreasing, or consistently the same over the last five days? • What are the current barriers to eating and drinking? Usual eating at home over the last week and the last 12 months: • Likes/dislikes • Quantity of food eaten • Time of day preferred, or no preference • Level of assistance needed; none, verbal encouragement, ‘hand-over-hand’ support, or full assistance • Texture modified diet - Yes/No? If yes, what texture food and fluids? • Nutritional supplements - Yes/No? If yes, type and quantity Anthropometry • Weight/ BMI • Weight history over the last 12 months if available • Mid upper arm circumference (MUAC)

20 April 2018 - Issue 133

Each circumstance is individual to that person. A holistic person-centred approach to nutritional assessment and multidisciplinary team working is required. • Justice: respect for an individual’s right to equitable treatment with others. In England and Wales the Mental Capacity Act (2005) states that clinicians should assess capacity by ascertaining whether or not patients can understand and retain relevant information, weigh up the pros and cons and communicate decisions. Where patients do not have capacity to make a decision regarding treatment, clinicians must act in patients’ best interests ensuring that: 1 decisions concerning withdrawal of lifesustaining treatments are not motivated by a desire to bring about death; 2 consideration is given to a patient’s past and present wishes, beliefs and values that may influence such decision making - the presence of an Advanced Decision to Refuse Treatment can assist in this context; 3 consideration of views from individuals named by the patient as someone to be consulted in this respect, i.e. anyone with an interest in the patient’s welfare, anyone with a Lasting Power of Attorney for the patient and any deputy appointed by the court. WHAT IS THE DIETITIAN’S ROLE?

As dietitians working in the acute setting, occasionally we receive referrals for clinically assisted nutrition and hydration for those who have ‘advanced dementia’. Quite often these referrals are for patients who do not

have advanced dementia - these patients have previously been living at home, alone with minimal support and have been managing their activities of daily living adequately. In this situation, a short-term, time-limited trial (typically for two weeks) of nasogastric feeding is sometimes agreed with the patient (if able to consent), medical staff and family members, with clear goals set such as ‘to return to eating and drinking post-acute chest infection’. I view our role as dietitians working with older people as helping to ensure that a detailed nutritional assessment is completed taking into account a person’s nutritional and medical history over the preceding year. In order to do this, the dietitian must speak with the person, family members, other healthcare professionals and/or care providers (residential or nursing care homes). Referral to other team members such as geriatric psychiatry, dementia specialist nurses, speech and language therapy (if dysphagia is present or suspected), can be useful too, if things are unclear. This information can help aid medical decision making and help to establish the potential goals of clinically assisted nutrition as a medical treatment. CONCLUSION

Each circumstance is individual to that person. A holistic person-centred approach to nutritional assessment and multidisciplinary team working is required.

Further reading Oral feeding difficulties and dilemmas; A guide to practical care, particularly towards the end of life (2010), Royal College of physicians End of life care: Clinically assisted nutrition and hydration (2012). GMC April 2018 - Issue 133



BILE ACID MALABSORPTION 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.

This article will focus on a specific type of malabsorption - bile acid malabsorption (BAM) - with the aim of raising awareness of the signs and symptoms, to improve recognition and early diagnosis. Malabsorption is a word we often come across when working in a clinical setting. It can be defined as the poor absorption of nutrients in the small intestine and may be nutrient specific (i.e. affecting only the absorption of fats), or generalised (i.e. affecting the absorption of many nutrients).1 There are a number of causes for malabsorption, such as intestinal resections, mucosal damage, pancreatic insufficiency, inflammatory bowel disease or coeliac disease.1 WHAT IS BILE ACID MALABSORPTION?

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Bile contains bile acids, which are manufactured in the liver and stored in the gallbladder. The ingestion of dietary fat causes the gallbladder to contract and the bile acids are secreted into the upper small bowel to aid the breaking down and absorbing of fats and vitamins. They are then reabsorbed in the terminal ileum, and around 97% of bile acids are recycled for re-use back to the liver (the last 3% are excreted in faeces), a process called enterohepatic circulation.2 If the terminal ileum is diseased or has been resected, or if hepatic bile production is increased so much so that it overwhelms normal absorptive mechanisms, excess bile can enter the colon and cause erratic, chronic diarrhoea.3 BAM is best diagnosed by a SeHCAT test or by the 7ɑ-hydroxy-4-cholesten3-one blood test.3 The SeHCAT test involves the patient swallowing a capsule containing a synthetic bile salt with a small amount of ionising radiation, which tests the function of the bowel by measuring how well the compound is retained or lost in the April 2018 - Issue 133

body.2 The SeHCAT test involves two scans one week apart to assess the amount of the compound retained, and results will be as follows: • retention values of 10-15% (mild bile acid malabsorption) • retention values of 5-10% (moderate bile acid malabsorption) • retention values of 0-5% (severe bile acid malabsorption)2 The SeHCAT test is advised in the British Society of Gastroenterology (BSG) guidelines.4 BAM is thought to affect one in 100 people5 and, unfortunately, is often misdiagnosed, with physicians frequently misdiagnosing patients with irritable bowel syndrome.3 BAM can be effectively treated with medications and dietary changes. SYMPTOMS

The main symptom of BAM is diarrhoea,5 which can be classed as bile acid diarrhoea (BAD).6 BAD is caused as the excess bile acids are not absorbed from the ileum, but are passed into the large intestine. This excess of bile acids irritates the lining of the large intestine and stimulates electrolyte and water secretion, causing urgent diarrhoea.5 As well as inducing secretion of sodium and water, BAD is also caused by various mechanisms including, increasing colonic motility, stimulating defecation, inducing mucus secretion and damaging the mucosa, which increases mucosal permeability.2 BAD can often be described as chronic, watery diarrhoea. Diarrhoea is


. . . BAM patients can suffer from a wide range of other gastrointestinal symptoms, including abdominal bloating, incontinence, excess wind, lethargy and abdominal cramping.

defined as the abnormal passage of loose or liquid stools more than three times daily, or a volume of stool greater than 200g/day and to be classed as chronic diarrhoea, it must persist for more than four weeks.2 The diarrhoea may often be in the form of steatorrhea (pale, greasy and hard to flush away), and be frequent, with patients reporting up to 10 episodes of diarrhoea during the day and at times nocturnally. A recent study by Bannaga et al6 looked at patient-reported symptoms and outcomes of those suffering from BAM, in particular how BAD can affect a patient’s quality of life. A questionnaire was collected anonymously by BAM Support UK (a charity set up in 2015)7 and the Bile Salt Malabsorption Facebook group8 and concluded that 91% of patients with BAM reported symptoms of BAD. 44% of the participants reported that they had been experiencing symptoms of BAD for five years prior to diagnosis and, unfortunately, just over half of the cohort felt as though their symptoms had been dismissed during clinical consultations. 28% felt their GPs were unaware of BAD. As well as diarrhoea, BAM patients can suffer from a wide range of other gastrointestinal symptoms,9 including abdominal bloating, incontinence, excess wind, lethargy and abdominal cramping.5,6 CAUSES

BAM can be divided into three types depending on aetiology: Type 1: where the terminal ileum (where bile acids are absorbed) has been affected.

This could be due to removal, resection or inflammation of the ileum, as a result of surgery due to conditions such as Crohn’s disease (a condition which affects the whole digestive tract and causes inflammation), or cancer treatment. Type 2: primary idiopathic malabsorption - which has no known cause. In people with type 2 bile acid malabsorption, there is a history of diarrhoea that can be either continuous or intermittent. Type 3: associated with cholecystectomy, peptic ulcer surgery, chronic pancreatitis, coeliac disease, diabetes mellitus, radiotherapy or small bowel bacteria overgrowth.2,5 TREATMENT

The treatment for BAM usually involves medications and if the BAM is caused by an underlying condition, for example small bowel bacteria overgrowth, treatment of this can in turn improve symptoms. The medications used are called bile acid sequestrants, which bind to the bile in the small intestine, before they pass through to large intestine, therefore preventing the irritation of the large bowel which can lead to diarrhoea.5 The most common medications used to treat BAM are: • colestyramine and colestipol • colesevelam Colestyramine and colestipol are in powdered form and are often used as firstline medical treatment. However, the tolerance of these medications is fairly low, as they are not very palatable. The dose must be adjusted for each patient, as too high a dose may cause constipation.5 Colesevelam is a newer drug and is available in tablet form, so is, therefore, often used if the powdered alternatives are not tolerated. April 2018 - Issue 133


Table 1: Recommended fat intakes for BAM patients Recommended daily calorie intake

Recommended total fat (grams)

Total recommended fat intake as a % of RDI

Low fat (grams)

Total fat intake for a low fat diet as a% of RDI













BAM Support UK:

The NICE guidance for colesevelam and BAM concluded that colesevelam appears to be well tolerated, but does carry adverse effects in some patients, such as flatulence and constipation.10 The guidance also discusses a randomised controlled trial (RCT) which reported no improvement in outcomes with colesevelam in 24 women with diarrhoeapredominant irritable bowel syndrome, four of whom had evidence of BAM. However, the study may have been underpowered to detect any differences between the groups.10 Further evidence shows that the use of colesevelam for bile acid malabsorption reported in two small case series found that colesevelam improved diarrhoea and gastrointestinal symptoms in people with BAM.10 The study earlier mentioned by Bannaga et al reported that following treatment, usually with bile acid sequestrants, 60% of participants reported improvement of diarrhoea and most reported their mental health had been positively impacted.6 Patients have been known to report symptoms of embarrassment, depression, isolation and low self-esteem as a result of BAM,6 and guidance emphasises how BAM can have a considerable impact of lifestyle and quality of life.2 DIETARY INTERVENTION

Once BAM has been confirmed, the patient should be referred to a dietitian to discuss a low fat diet.5 The use of a low fat diet to improve symptoms of BAD is reported to be largely unknown,11 despite studies suggesting its importance.12,13 A recent study conducted by Watson et al concluded that the use of low fat dietary interventions in patients with BAM led to a clinically important improvement in GI symptoms and, therefore, should be widely used.11 In this particular study, dietary fat was 24 April 2018 - Issue 133

restricted by one third to a median of 39.1g per day.11 Generally, it is advised that a low fat diet is <40g per day5,7 for women (see Table 1). Further research, conducted in 2017 by Jackson et al, also supports the use of a low fat diet to treat BAM/BAD, demonstrating that there was a significant reduction in urgency, flatulence, abdominal pain, nocturnal defaecation, belching and borborygmi upon following a low fat diet, as well as improvement in stool consistency and frequency. The study goes onto say that the exact fat restriction for effectiveness requires further study.9 Other dietary measures which may be useful and were noted to have been used in patients in the research conducted by Bannaga et al, include elimination diets to identify specific food triggers, for example lactose-free, low-FODMAP and low-residue diets.9 BAM Support UK7 describes dietary intervention as not being a ‘one size fits all’ process, and highlights that dietary changes may be different for different people. It discusses the use of low fat diets and potential food triggers, such as gluten and dairy. It is emphasised that the advice on their page is not written by a dietitian or nutritionist. However, when looking at the current evidence, the advice it provides is accurate. CONCLUSION

BAM is a common form of malabsorption, with its symptoms of BAD having a severe impact on a patient’s quality of life. Early recognition and treatment needs to be improved, as patients are often misdiagnosed, and increasing awareness with all healthcare professionals can help. Treatment includes the use of bile acid sequestrants and dietary support to guide patients through a low fat diet and help to identify specific food triggers may also be used.


Mary Feeney Paediatric Allergy Dietitian, King’s College London Mary has worked as the FASG Project Dietitian funded by a joint grant from the BDA GET and Anaphylaxis Campaign to develop guidance and dietetic resources in three areas of food allergy management through evaluation of research literature, current practice and dietetic consensus. Mary is also a research dietitian and is currently working on the LEAP Trio Study.

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DEVELOPMENT OF HOME INTRODUCTION GUIDES FOR EGG, SOYA AND WHEAT IN NON-IgE-MEDIATED ALLERGY The need for consistent guidelines on the introduction of egg, soya and wheat in non-IgE-mediated allergy, has been much highlighted, so much so that a project has been supported by the BDA General and Education Trust Fund and the Anaphylaxis Campaign. Out of this has seen the development of home introduction guides specifically for non-IgE-mediated allergy in children. The diagnosis of food allergy can be difficult and is often delayed, particularly for non-IgE-mediated allergies where symptoms are gradual in onset and occur ≥2 hours after eating the causative food(s).1-2 This type of allergy often presents with symptoms that overlap with other common conditions of infancy and childhood, including colic, reflux, eczema, altered bowel habit or faltering growth, making the diagnosis of allergy more challenging.3 Delays with diagnosis can lead parents/caregivers who suspect food allergy to eliminate multiple foods from their child’s diet. Children can often continue on restricted diets for prolonged periods without a significant improvement in symptoms. Such restricted diets can be onerous to follow and may be of limited variety with consequences including risk of nutritional deficiencies, faltering growth and longer-term impacts on family life.4-6 In the absence of validated allergy tests, the diagnosis of non-IgE-mediated allergies relies on the use of an allergyfocused clinical history to identify the likelihood of an allergy and the food or foods which may be involved.7 The diagnosis is further refined through the strict avoidance of the suspected allergen(s) for a trial period followed by re-introduction. The dietitian facilitates diagnosis by educating parents/ caregivers about which foods to avoid and advising on suitable alternatives to expand the diet and achieve nutritional

needs. If symptoms clearly improve during the elimination period, this supports a diagnosis of likely non-IgEmediated allergy; however, this is only confirmed if symptoms reoccur following re-introduction of the allergen(s). If the re-introduction step does not occur, then there is a risk of continuing the elimination unnecessarily.3,8 The Milk Allergy in Primary Care Guideline (MAP), developed to support the diagnosis and management of mild to moderate non-IgE-mediated cow’s milk allergy, includes practical guidance for home re-introduction of cow’s milk. This guideline is now widely used across care settings and has recently been updated with an international group of collaborators.8,9 UK dietitians often advise on home introduction of other common allergens; such as egg, soya and wheat. However, there is currently no established guidance, which means that advice may be inconsistent. The Food Allergy Specialist Group (FASG) of the British Dietetic Association (BDA) has already published evidence-based diet sheets for use by BDA member dietitians to support patients with allergen avoidance.10 FASG members indicated that there was also a need for resources to support patients with allergen introduction/ re-introduction. The purpose of this project was to develop standardised home introduction guides for egg, soya and wheat based on current research literature and by dietetic-led consensus. April 2018 - Issue 133


FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies



Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to five years1–3


step st ep in the effective management of

cows’ milk allergy is extensively hydrolysed formula†




References: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the fi rst two years of life. J Nutr. 2008;138:1091-5. 2. Arslanoglu S et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the fi rst 5 years of life. J Biol Regul Homeost Agents. 2012;26:49-59. 3. Pampura AN et al. Ros Vestn Perinatol Paediat 2014;4:96-104

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. † For the management of mild to moderate IgE-moderated cows’ milk allergy the iMAP guideline recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.

18-044 (GOS/FOS)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018

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Members of the FASG (n=350) were invited to submit copies of the resources they currently use to advise on home introduction of egg, soya and wheat. Information was received from nine centres (one private, four secondary care, four tertiary care). The project dietitian collated the information and together with feedback from project supervisors and experienced colleagues, developed draft standardised home introduction guides. Allergy dietitians (n=8) from a variety of clinical settings were then invited to contribute to forming a consensus based on the ‘Delphi’ technique.11 Five agreed to participate. The Delphi technique comprises of questionnaires answered anonymously by a panel of participants with relevant expertise. An advantage of this approach is that a participant’s decision to maintain or change their opinion during the process is unaffected by a desire to be seen to agree with certain other group members, e.g. seniors. The consensus questionnaire for the home introduction guides included questions related to the following debated areas: • Overall layout and content • Recommended portion sizes • Duration at each introduction stage • Assigning allergen foods to specific re-introduction stages • Appropriateness of recipes included • Advice about immediate allergic reactions • The disclaimer statement The areas of agreement and disagreement were identified and the resources revised until full consensus agreement was achieved. Of the debated areas, ≥60% of the group agreed with the draft introduction guides in five of the seven areas for the egg resource, in three of the seven areas for the soya resource and with five of six areas for the wheat resource. The highest levels of agreement related to the overall layout and content of the wheat resource. The highest levels of disagreement related to recommended portion sizes for soya-containing foods (80% considered them too large). The greatest levels of discordance within the group related to the recommended duration at each portion size and introduction stage. Primary

and secondary care dietitians preferred a slower progression, indicating that they typically advised patients to spend between three days to a few weeks at each stage before progressing to the next. Tertiary care dietitians preferred faster progression, typically advising patients that they could progress to the next introduction stage within days if they were non-symptomatic. This may reflect local variations in practice, or differences in the patient groups attending clinic in the different settings. In order to develop a resource which was considered suitable across all settings, the final versions of the introduction guides allow the dietitian to specify the number of days they recommend the patient spend at each portion and stage. There was discussion about the possible benefit of very slow progression in order to establish low levels of tolerance and whether maintaining tolerated intakes might support the acquisition of tolerance. Whilst there is some limited evidence for this approach in IgEmediated allergy to cow’s milk and egg, this has not been established for other foods, nor is there published evidence of a role in non-IgE-mediated allergy.13-14 However, even if gradual introduction of tolerated foods containing the allergen does not hasten tolerance acquisition, it can still have important benefits for the child and their family.14 USING THE HOME INTRODUCTION GUIDES

The guides are designated for use only in nonIgE-mediated allergy. This is due to concerns about the risk that individuals with an IgEmediated allergy could have a severe allergic reaction during allergen introduction.12 If used in the designated patient group, an immediate allergic reaction on introduction of the allergen food is considered very unlikely; a low initial portion size (half a teaspoon-size) has been included as a further safety step. It is recommended that those with IgE-mediated allergy should have had a negative oral food challenge in a clinical setting prior to continuing to consume the allergen food at home. Allergen foods were categorised into introduction stages based on clinical/expert opinion. Allocation was based on the allergen protein content of the food, temperature and duration of heating, e.g. baking, pasteurisation, April 2018 - Issue 133



Development of home introduction guides for egg, soya and wheat in non-IgE-mediated allergy *Table 1: Egg-containing food categories included in the egg home introduction guide Baked/well-cooked Plain, shop-bought cakes (avoid royal or fondant icing)

Loosely/lightly cooked (yolk and white cooked solid) Homemade pancakes

Biscuits, e.g. Jaffa cake, sponge fingers, cookies, TUC crackers

Boiled, fried, scrambled or poached egg - choose British Lion stamped eggs

Homemade cakes, biscuits and sponge puddings

Quiche, flan, Spanish tortilla, omelette

Shop-bought pancakes

Egg fried rice, Egg Fu Yung

Undercooked or raw Royal or fondant icing (fresh and powdered), homemade marzipan Some chocolates and sweets contain egg, e.g. nougat, MarsTM bars, Milky WayTM, ChewitsTM, chocolates with fondant/cream fillings, Cadbury Creme EggTM

Egg glaze on pastry

Raw egg in cake mix, other Dried egg noodles, fresh egg pasta uncooked dishes

Gluten-free bread with egg, e.g. GeniusTM, LivwellTM, WarbutonsTM

Fish, meat or vegetables fried in egg-based batter or tempura

Brioche, Cholla, choux pastry, rich shortcrust pastry with egg

Egg in batter or bread crumbs, e.g. Scotch egg

Dried egg pasta, e.g. lasagne, cooked for at least 10 minutes

Yorkshire puddings with soft centres, e.g. sticky batter

Some gravy granules contain egg, e.g. chicken flavoured gravy

Crème Brulee, egg custard, fresh custard

Shop-bought Yorkshire puddings, must be pre-cooked, e.g. frozen

Meringues - well-cooked with no sticky centres

Sausages containing egg (vegetarian and meat varieties), other processed meats, e.g. burgers

Some marshmallows

QuornTM-based products

Lemon curd

Fresh mayonnaise, Horseradish sauce, Tartare sauce, Béarnaise, Hollandaise sauce, mayonnaise, salad cream Cheeses containing egg lysozyme (E1105), e.g. Grana Padano, Manchego Meringues with sticky centres, soft meringue, e.g. lemon meringue pie Some ice-creams and sorbets, especially fresh and luxury types, e.g. Ben and Jerry’sTM, HäagenDazsTM Some mousses (most shop-bought mousses do not contain egg)

Table adapted from BSACI guidelines on management of egg allergy 2010 and updated by dietitian consensus 2018.

*Table 2: Recipes containing baked soya included in the home introduction guide for soya Savoury muffins (makes 6) 250g flour or wheat free flour mix 2 ½ teaspoons baking powder 50ml vegetable oil 250ml soya milk 60g soya cheese, grated/sliced Handful spinach (optional)

Method Preheat the oven to 180°C/Gas Mark 4 and line a muffin tin with 6 cases. Mix the flour and baking powder. Mix the oil and soya milk together and add to the dry ingredients. Add the soya cheese and chopped spinach if desired. Loosen the mix with extra soya milk if needed. Bake for 15-20 minutes until golden. Cool on a wire rack. (~1.8g soya protein per muffin)

Veggie Bolognese (4 portions) ½ tablespoon vegetable oil 150g soya mince ½ a small onion, chopped 1 small carrot, diced ½ clove of garlic, crushed 75ml vegetable stock ½ tin chopped tomatoes 2 tsp soya sauce Seasoning

Method Heat the oil in a non-stick pan and cook the onion and carrot for 5 minutes. Add the garlic and cook for a further minute. Add the soya mince, stock, tinned tomatoes, soya sauce and season with salt and pepper. Bring to the boil, reduce the heat and simmer for 15 minutes. Serve with cooked pasta. (4.8g soya protein per portion)

PAEDIATRIC matrix effects of wheat (for egg and soya) and other manufacturing processes which may impact on allergenicity, such as fermentation of soy products. Although these factors have predominantly been investigated in the context of IgE-mediated allergy; clinical expertise suggests that this may also be a pragmatic and safe approach for use in non-IgE-mediated allergy. The egg ‘ladder’15 has been modified following changes in the egg content of products currently available, e.g. many brands of dried noodles no longer contain egg and from updated manufacturers’ information about product preparation and processing (see Table 1*). It was agreed by dietitian consensus to move some products to a different group where it was viewed that patients might be unable to safely judge differences in very similar products, e.g. commercial mayonnaises containing pasteurised egg, or fresh mayonnaise containing raw egg. There are some products for which there is limited information available as to their exact preparation due to manufacturers preferring not to disclose such details. A decision was taken to categorise such products in the same group as similar products for which manufacturing information is known, e.g. nougat is made by pouring hot sugar, honey, or liquid glucose (120-150oC) over raw egg white which is then mixed and left to cool. As the heating of the raw egg is for a short duration, it has been included in the group ‘undercooked or raw egg’. Confectionary items with similar ingredients have also been included in this group, e.g. Milky WayTM, MarsTM bar. The rationale for including baked egg or soya in a flour matrix relates to research which found that heating of cow’s milk or egg proteins in the presence of wheat results in decreased allergenicity, compared with heating alone.16-17 This may be due to these allergens forming complexes with wheat, such that the milk and egg proteins are less ‘available’ to the immune system. In vitro research supports that heating also reduces allergenicity of soy.18 Soya lecithin is widely used as an emulsifier in foods including crisps, chocolate, crackers and gravy granules. Although tolerated by most individuals with soya allergy, as the majority of the protein content is removed during the 28 April 2018 - Issue 133

manufacturing process, some families do report allergic symptoms. It is included as the first stage in the soya introduction guide; however, if the dietitian is able to establish that the child is already eating and tolerating foods containing soya lecithin, they can start the introduction process at stage 2: baked soya in a flour matrix. Fermented foods containing soya are included as stage 3 in the introduction guide. There is research which indicates that the various fermentation processes used in the making of soya sauce and other fermented foods, such as miso or natto, leads to the degradation of some soybean allergens.19-20 Since there is a wide variation in recipes and preparation methods, e.g. duration of fermentation, the recommended portion sizes are small for the foods with a higher soya protein content. It is acknowledged that introduction of fermented soya products may be unsuitable for some individuals because of unfamiliarity with these foods, food preferences, as well as concerns about the typically high salt content of these foods. The inclusion of this stage should be discussed with individual families. It was not possible to accurately calculate the allergen protein content of many foods due to manufacturers preferring not to disclose such details and the fact that some foods contain more than one ingredient which contributes to the total protein content. The recommended target portion sizes, therefore, try to achieve a balance between portions with a broadly similar allergen protein content and those considered close to age-appropriate portions for young children. The approximate allergen protein content has been indicated per portion in the recipes, as this is more easily estimated (see Table 2*). CONCLUSION

Standardised home introduction guides for egg, soya and wheat in non-IgE-mediated allergy have now been developed by dietitian-led consensus. These resources support the provision of consistent dietetic advice on allergen introduction and improved outcomes for allergy patients and their families. Login to the BDA website to view the diet sheets and guides: regionsgroups/groups/foodallergy/diet_sheets. They are available to all BDA members.


FOCUS ON ENTERAL FEEDING Leona Courtney Diabetes Specialist Dietitian, NHS Greater Glasgow and Clyde Leona has been working for the NHS for two and half years. She is currently working as a diabetes specialist dietitian for Greater Glasgow and Clyde which she thoroughly enjoys. She has a keen interest in running and enjoys cooking.

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Enteral feeding (EF) refers to the delivery of a nutritionally complete feed containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum. This article gives an overview of EF, looking at routes for feeding and administration of feeds. Much research has shown that malnutrition is common in UK adults - both in community and in hospital settings increasing morbidity and mortality.1,2,3 It is well known that patients who are undernourished are at a greater risk of impaired immunity and wound healing, along with an increased risk of infections.1 These individuals cope less well with surgical and medical interventions and as a result, their hospital stay is increased by as much as five days, compared to those well-nourished.2,3 This in turn results in greater costs for the NHS. Therefore, it is vital that all hospitals provide their patients with adequate nutrition. EF plays a fundamental role in the clinical management of patients who cannot meet their nutritional requirements via oral diet and are, therefore, at risk of being undernourished.4 There are various reasons why EF may be indicated, these include; lack of appetite and inability to tolerate oral nutritional supplements, poor swallow, anorexia, neurological conditions, disorders of the gut, surgery which has removed part of the gastrointestinal tract, hypermetabolic conditions such as burns and severe infections, which greatly increase a patients’ nutritional requirements,5 and those critically unwell. Before a decision is made to commence EF, it should be discussed with the patient, their family and the multidisciplinary team (MDT), where a dietitian should always be included. Patients must consent to EF before it

is commenced. For patients who are lacking capacity, their welfare power of attorney can make the decision on their behalf. If the incapacitated individual has not appointed a power of attorney, then the doctor involved in patient care is responsible for making any decision to start, stop, or withhold medical treatment, including EF once it is in the patient’s best interest. If an illness is regarded as being in a terminal phase and the medical plan is to provide only compassionate and palliative care, ethical considerations indicate that EF should only be given to alleviate symptoms.6 Therefore, it should not be used to prolong survival. In cases where there is an element of doubt; a ‘trial period’ should be agreed on. ROUTES FOR FEEDING

Nasogastric (NG) feeding Most EF is given via NG tubes which feed into the stomach. Feeding into the stomach should always be used unless there is indication to bypass the stomach. NG feeding permits hypertonic feeds, higher feed rates and bolus feeding. NG tubes can be placed on the wards by nursing or medical staff. The position of an NG tube should be confirmed every time before feeding or administering medications in order to reduce aspiration risk.7 This can be done by testing the pH of aspirate which should be <5.5. If an aspirate cannot be obtained of a pH >5.5, an x-ray should be undertaken to confirm positioning before feeding is commenced.7 April 2018 - Issue 133


CLINICAL Nasojejunal (NJ) feeding NJ feeding is appropriate for patients with recurrent vomiting and/or tube feedingrelated aspiration, gastric reflux, gastroparesis, gastric outlet obstruction, or total, or partial gastrectomy.8 It could also be used in unconscious patients who need to be nursed flat as it reduces aspiration risk, but not completely.9 Percutaneous gastrostomy (PEG) feeding PEG feeding involves directly inserting a gastrostomy tube through the abdominal wall. The most common procedures are either endoscopic or radiological, using sedation and local anaesthetic. PEG feeding should be considered for patients who are likely to require enteral nutrition for longer than four to six weeks and who have a functional gastrointestinal tract.6 Benefits of PEG feeding include the fact that it is discrete and can go unnoticed, it is better tolerated than NG feeding, it has a lower risk of aspiration in those with swallowing difficulties and patients generally receive more of their feed from this method, therefore aiding nutritional status.6 Before a PEG procedure takes place, a pre-PEG assessment should be completed by the hospital nutrition team. This assessment considers if the patient is able to withstand the invasive nature of PEG-placement, use of anaesthesia, possible procedure complications and if the patient will tolerate the PEG post-insertion. For example, some patients, such as those with neurological conditions, may find the PEG distressing and can pull at it, or even pull it out. If required, a PEG tube can have a jejunal extension added to it to feed directly into the jejunum for the same reasons as an NJ tube would be indicated. PEG placement has associated risks and complications, including formation of gastrocolic fistula, especially in IBD patients who are in the active stage of their disease.10 Gastric outlet obstruction, wound infections, peritonitis and leaking at the peristomal site, skin ulceration and tube degradation are also contraindications which can occur.11 There is also the risk of buried bumper syndrome (when the internal bumper of the PEG tube gets buried into the gastric or abdominal wall).12 30 April 2018 - Issue 133

If indicated, PEG tubes can be removed. This is a relatively easy procedure which can be carried out endoscopically, or by cutting off fixation devices and pushing the remaining device into the stomach which could be passed.10 PARENTERAL NUTRITION (PN)

Sometimes, EF is not appropriate and PN is indicated. PN bypasses normal digestion in the stomach and bowel. It is administered into the blood through an intravenous catheter. PN contains protein, carbohydrates fats, vitamins and minerals. PN can be given solely or supplementary to oral intake to meet nutritional requirements. Some diseases and conditions where PN is indicated include, but are not limited to, short bowel syndrome, high output fistulas, intestinal failure, bowel obstruction and severe acute pancreatitis.13 Some patients may require this therapy for a short time and there are other patients who have received PN at home for a lifetime. HOME ENTERAL FEEDING (HEF)

The number of people receiving HEF is on the rise, especially in the UK which has shown a 42% rise in the number of people receiving HEF in a 10-year period.18 This may be due to a combination of reasons, including the fact that people are living for longer and a shift in care provisions from acute to community settings.10 Much research has shown that HEF can improve clinical outcomes and decrease healthcare costs via weight gain, improved nutritional status, reduced infections and a lower number of hospital admissions.19,20,21 However, we must not forget that the thought of HEF can be frightening for the patient, their family and any carers involved and much consideration should be made before deciding on HEF. Prior to discharge, planning arrangements should be discussed between the acute dietitian and the HEF dietitian, nutrition nurse, carers, district nurses and family. Adequate training on the feeding pump should be given to anyone who may be involved in the delivery of HEF to ensure safe practice. The patient should always be included in any planning and they should be made aware of what HEF will involve on a

daily basis. Any concerns or questions that the patient or carers have ought be considered and answered by the MDT. ADMINISTERING MEDICATIONS

Another benefit of EF is the ability to administer medications via the tube. Drugs should always be changed to liquid form before administering, as tablets are known to get stuck in the tube and cause blockage. Various considerations must be made before giving medications via an EF tube. This includes the fact that not all drugs are suitable to be given via enteral tubes. In order for the drug to have bioavailability, it must be delivered to the correct location of the gastrointestinal tract. For example, if a drug designed for absorption in the stomach is placed directly into the jejunum, this may compromise its overall effect. As dietitians, we must also consider that enteral feeds may interact with some drugs and negatively impact on their absorption. For example, an enteral feed should be stopped for two hours before phenytoin is administered and for two hours afterwards.14 This may require the feed timing to be altered around the medication administration, e.g. overnight feeding may be more appropriate, or starting the feed later in the day after the drug has been given. TYPES OF FEEDS

Much consideration should be made by the dietitian and MDT when deciding on what type of feed to administer. This includes considering the patientâ&#x20AC;&#x2122;s nutritional requirements, diarrhoea, disorders of the gastrointestinal tract, motility issues and diseases such as kidney disease. Polymeric Polymeric feeds (what we call standard feeds) contain nitrogen as their protein source. These feeds vary in carbohydrates, protein, fat, vitamins, minerals and fibre. They are suitable for those with a normal functioning bowel. The complex carbohydrate source is partially hydrolysed starch and they contain long-chain triglycerides (LCTs). The energy provided in these feeds can range from 0.5kcal/ml to 2kcal/ ml, which are more suitable for those with high energy requirements.

Elemental Elemental feeds contain individual amino acids, or pre-digested protein and are low in fat, especially LCTs. Carbohydrate is the main energy source. As these feeds are low in LCTs, but have a higher concentration of medium chain triglycerides (MCTs), they are thought to require minimal effort from the digestive system and reduced stimulation from the pancreas. MCTs have the added benefit that they can be absorbed in the absence of lipase.15 These feeds are, therefore, beneficial to those who present with malabsorptive or maldigestive issues such as pancreatic disease or short bowel syndrome.15 However, it should be remembered that these feeds are more expensive than polymeric feeds and should only be used when indicated. Disease specific These feeds are generally used in patients who are acutely unwell, including those with organ failure, acute renal failure, respiratory failure, or multiple burns. Research has shown that enteral feeds supplemented with EPA and DHA were advantageous in preserving lean body mass (LBM) compared to standard feeds in those with head, neck and oesophageal cancer.16,17 Enteral feeds which have modified amounts of fluid, protein and electrolytes may be used in those with renal failure.10 MONITORING

As dietitians, part of our role is to monitor patients who are receiving enteral feed. Each patient will be individual as to how closely they require monitoring depending on their tolerance of the feed, changes in medications, ability to meet their nutritional requirements, weight and changes in their clinical condition. However, patients should be closely monitored until they are tolerating their enteral feed with nil issues, weight is steady and they are meeting their nutritional requirements as planned. When a dietitian is reviewing an EF patient, they will investigate how much nutrition the patient is receiving from their feed and what percentage of their requirements they are meeting. They will also determine fluid balance, any losses (e.g. diarrhoea, stoma output, vomiting), biochemistry markers including April 2018 - Issue 133


CLINICAL hydration status and refeeding markers, if the nutritional requirements or clinical picture has changed since feeding was commenced in addition to early discovery of any side-effects. Body weight should also be checked, at least weekly.

the patient or their family may request EF to be stopped. Regardless of the reason for stopping EF, it should always be discussed with the consultant looking after the patient and the wider MDT should be involved too.


Overall, EF and HEF can provide many benefits to the individual, including improved clinical outcomes, preservation of LBM, increased recovery and reduced hospital stay. However, EF should only be commenced when it is in the patient’s best interests and much consideration should take place around the patient’s and family’s opinion, possible contraindications, ethical considerations, what we are looking to achieve from feeding, the length of feeding time, most suitable feeding route and most appropriate type of feed to use. Close monitoring from the dietitian is necessary, particularly when feeding is first commenced. Patients who require HEF should be made aware of what is involved with feeding on a daily basis and the MDT should ensure all members of the family and carers receive adequate pump training prior to discharge to allow the continuation of safe care at home.

It may be decided that EF should be stopped as it is no longer indicated. This may be for various reasons, including that appetite/ oral intake has improved and the patient can now meet their nutritional requirements via diet alone. Other reasons include improved swallow, gastrointestinal function has reoccurred, or the patient’s overall clinical condition is much better. If patients are transferring from enteral feed to oral diet +/- oral nutritional supplements, this process should be closely monitored by the dietitian and MDT to reduce nutritional risk. Other circumstances where EF may be stopped include that it is showing no benefit to the patient, or the patient’s clinical condition may have deteriorated and they require palliative care. In this case, the continuation of EF would not be in the patient’s best interest. Alternatively,



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Make the most of your NHD Community! 32 April 2018 - Issue 133




How British cycling success inspired a new emergency regimen! Justin Ward Paediatric Metabolic Dietitian, Bradford Teaching Hospital Justin has been a clinical Paediatric Metabolic Dietitian for the last 18 months. He has a passion for research, biochemistry, teaching and is aiming to raise the profile of the Metabolic Dietitian. He is currently working on introducing the dietary management of metabolic diseases into higher education academic courses.

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As a relatively new dietitian without much in the way of a professional profile, I suspect many readers will puzzle at the title of this article, stare blankly at my name, look at my photo and ask themselves, “Who is this bloke and what on earth is he writing about?” To make sense of the title we must first understand the recent history of Britain’s cycling performances. Don’t worry if you aren’t a particularly big cycling fan, I’ll keep it brief . . . Prior to 2003, cycling was (sadly) just one in a long list of sports that Great Britain struggled to get to grips with. After years in the doldrums, a man by the name of Sir David Brailsford was appointed as British Cycling’s Performance Director. Fast forward to the present day and we Brits are now the dominant force in world cycling. Achieving any sort of success in British sport instantly catapults the athletes and their managers into the spotlight in an attempt to reveal their secret winning formula. In Sir Brailsford’s case, he believes success was achieved by applying his ‘Marginal Gains’ theory to every aspect of the team’s preparation. “The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike and then improve it by 1%, you will get a significant increase when you put them all together.” (Dave Brailsford, 2012). This logic struck a chord and had me thinking, “How can I apply this theory to my clinical practice as a Paediatric Metabolic Dietitian?” STANDARD EMERGENCY REGIMENS (SER)

An SER is a drink protocol primarily intended as treatment for a number of inherited errors of metabolism (IEM). The SER drink consists of glucose polymer and water, carefully formulated to achieve a specific glucose concentration dependent upon the age of the child. Its consumption is advised during times of

illness, pyrexia, hypoglycaemia and/ or reduced nutritional intake, with the aim of preventing catabolism and providing sufficient fluid.1 At times of acute metabolic decompensation, patients typically stop their usual diet and consume their SER drink at regular intervals throughout the day and night. Two conditions that require an SER are Medium Chain Acyl CoA Dehydrogenase Deficiency (MCADD) and Ketotic Hypoglycaemia (KH). It is beyond the remit of this article to differentiate the pathological features of these two conditions; nonetheless, their respective dietetic management have similar themes, notably preventing excessive fasting and treating episodes of illness with an SER. Typically, a patient and their family receive their SER protocol during their initial visit to the consultant-led multidisciplinary (MDT) clinic. They receive a two-sided, A4 paper document detailing when an emergency drink is indicated, how to make it, how much of the drink to take and what to do should their child not tolerate it. A protocol to aid dietitians in devising an SER is presented in Table 1 overleaf. It is worth noting that any SER given to parents only details how to make the drink appropriate to the current age of the child. Once a child enters the next age range whereby a renewal is indicated, a dietitian will construct an updated copy of the SER. This specifies April 2018 - Issue 133


CONDITIONS & DISORDERS Table 1: SER renewal guidance2 Glucose concentration of Emergency Regimen

Scoops (5g) of glucose polymer (0.96g CHO/g) per drink and amount of water required

24-hour volume of Emergency Regimen required

0-3 months


1½ scoops made up to 70ml


3-6 months


2 scoops made up to 100ml


6-12 months


2 scoops made up to 100ml


12-18 months


3 scoops made up to 100ml


18-24 months


4 scoops made up to 120ml


2-3 years


5 scoops made up to 120ml


3-5 years


6 scoops made up to 140ml


5-7 years


7 scoops made up to 160ml


7-9 years


7 scoops made up to 170ml


9-10 years


8 scoops made up to 180ml


10-11 years


9 scoops made up to 180ml


11-14 years


10 scoops made up to 200ml


14-16 years


11 scoops made up to 220ml


>16 years


12 scoops made up to 240ml


Age of child

Figure 1: SER updating process (1) Construct latest SER paperwork based on age of child and give to family. (3) Insert patient name on rolling spreadsheet to ensure timely renewal once next age range is reached as per Table 1.

the latest recipe and is sent to the parents, the local paediatrician and the other members of the metabolic MDT. Finally, the dietitian will place the patientâ&#x20AC;&#x2122;s name on a rolling spreadsheet to highlight when the patient has reached the next age range on Table 1 and the updating process begins again (Figure 1). At the time of writing, the Bradford Metabolic Service cares for 114 patients with KH and 66 patients with MCADD across most of Yorkshire and the Humber. The service receives more referrals per year for patients with KH and MCADD than any other IEM and subsequently these form the two largest patient groups managed. 34 April 2018 - Issue 133

(2) Update local paediatrician, Metabolic nurses and Metabolic secretary of latest SER by letter/email.

Patients with MCADD are typically referred to the service within days after birth following a positive newborn screening result. The majority of MCADD patients are cared for until they transition to the adult service in Salford at 16 years of age. The main exceptions are those who move outside the geographical boundary of the service prior to transition. KH is not an IEM but rather a descriptive term to highlight the symptoms that a patient presents with, i.e. hypoglycaemia with the presence of ketones. Whilst KH is not an IEM itself, it may be the result of an underlying IEM. However, the majority of children with KH managed within the Bradford service are thought not to fit this

Figure 2: New SER updating process (2) Update local paediatrician, Metabolic nurses and Metabolic secretary of New SER by letter/ email.

(1) Once patient >2yrs old, construct New SER and give to family once.

(3) Insert patient name on a non-rolling spreadsheet for our own reference.

Table 2: Six months following implementation of ‘New SER’ Number of existing SERs transferred to New SER

Number of prospective reviews avoided by transferring

Prospective time saved (hrs)

Saving (£s)



















Banding of staff undertaking update


category and many children are discharged following a significant period of time with no episodes of hypoglycaemia. In cases where an IEM is not detected, incidents of KH are thought to be as a result of the body’s immaturity and inability to manage an increase in physiological stress, such as during illness. This typically improves with age and by eight years of age, many are considered to have outgrown the condition.3 For these reasons, patients with KH managed in the Bradford service rarely require the same number of SER updates as MCADD patients because they are often referred into the service at an older age and are discharged before they reach transition. MARGINAL GAIN - FURTHER STANDARDISE THE SER

It was clear that a disproportionate amount of time was being spent on updating SERs and maintaining the rolling database. To ensure no errors were present on an SER, the dietitian updating it would typically have a colleague proof check the document prior to finalising the update, further increasing the time spent on each renewal. It was this process that I believed would benefit from a ‘Marginal Gain’. Rather than use SER renewal guidance (Table 1) as a tool for dietitians, why not incorporate this Table

into a new SER and send all the information the patient ever needs in one go (Figure 2)? From this point on, I will refer to this idea as the ‘New SER’ for clarification. It is worth noting here that, as a team, we agreed that a patient with either MCADD or KH would only receive the New SER once they had reached two years of age. Our rationale was that younger children who typically have their total fluid requirements based on their bodyweight thus require a tailored recipe. But once over two years old, total fluid requirements largely become standardised irrespective of weight or gender. The new SER offers a number of significant advantages over the previous version, but I would be lying if I said the main appeal wasn’t that it significantly reduces the number of manual renewals needed. That said, another distinct advantage of the New SER over the previous edition is an increase in patient safety. The more alterations a document or spreadsheet demands, the more likely an error will occur. The previous SER potentially required 14 stages as the paperwork and spreadsheet required physically amending; by comparison the New SER eliminates nine of those updates. Last but not least, there is a substantial time and cost saving attached to adopting the New SER (see Tables 2 and 3). April 2018 - Issue 133


CONDITIONS & DISORDERS Table 3: Time and cost comparisons of ‘Old’ vs ‘New’ SERs in future patients (based upon 14 prospective revisions) Old SER













Time (hrs) Cost (£)


Obtaining feedback from the patients who have switched from the traditional version of the SER to the New SER is now necessary to thoroughly evaluate its impact. Should positive feedback be attained, then other IEMs requiring an SER, such as Carnitine palmitoyltransferase I deficiency, Carnitine palmitoyltransferase II deficiency and Carnitine transporter defects, should also be considered to embrace the New SER. In our case, the time saved has enabled our Band 4 Dietetic Assistant Practitioner to adopt a small Galactosaemia caseload since the New SER was implemented. This allows the dietetic team to review these patients more frequently than had been feasible when these patients were solely managed by a dietitian. It is important to view any time saving intervention as an opportunity to re-invest that time in other, more demanding areas of the service as opposed to it being perceived as a direct threat to job security. This can only be


Coming in the next issue May 2018 DIGITAL-ONLY - View it online at

• Infant weaning and taste development • Cereals and wholegrains • Coeliac disease

• Adult food allergies

• Ketogenic diet therapy


achieved if all members of the team are open to new ways of working, which luckily in Bradford, they are. So, I hope after reading this that you may be inspired to think about a ‘Marginal Gain’ that could improve the way you work. Innovation doesn’t demand a wholesale change and needn’t be overwhelming. As we have seen, minor tweaks to existing practice are usually all that is required. I do not expect anyone reading this to be blown away by the New SER, it is simply an amalgamation of various pieces of information collated onto one sheet of paper. However, if everyone in your department did something similar in their respective areas of work, collectively we could rid our entire practice of unnecessary paperwork. I don’t suspect you would have a hard time selling ‘Marginal Gains’ theory to any of your colleagues as, after all, I can’t imagine there is a single dietitian working who entered the profession because of their love for paperwork!

PLUS: PKU SUPPLEMENT April 2018 - Issue 133


WHY WE NEED TO TALK ABOUT TRAUMA IN PUBLIC HEALTH NUTRITION Lucy Aphramor Dietitian, Self-employed Lucy Aphramor developed Well Now, an approach to nutrition that teaches compassion, fosters self-care and advances social justice. She is an awardwinning dietitian and a spoken word poet.

REFERENCES Please visit the Subscriber zone at

When you consider the word trauma in relation to food, health and eating what does it conjure up? In what ways is trauma relevant to dietetic practice? What does it even mean? In this article, I briefly introduce the concept of trauma as used in public health, social justice activism and counselling. UK DIETETICS TODAY

Public health, social justice activism and counselling are three overlapping arenas that are germane to dietetic discourse and practise. Here I talk about those arenas in relation to trauma, plus I explore irritable bowel syndrome to highlight why we need to talk about trauma. I’ve not written a step-by-step guide to consultation - in the space available, this would become a tick box activity and as such, it would miss the point that the topic, including its erstwhile absence from dietetic discourse, deserves lengthy consideration. Instead, I’ve written an overview that flags up why we need to integrate trauma physiology into our practice. I hope it conveys the urgent need for conversation and action.

I was shocked, including by my ignorance, and by the fact that the ramifications of knowing that it was only by stepping outside of my professional conditioning on knowledge creation that I learnt pathways linking racism, classism and abuse with ‘lifestyle’ disease. I began to think of health in terms of both self-care and social justice. As part of this awakening, I came to realise that understanding the concept of trauma was crucial to my work as a dietitian with individuals and groups, and for addressing health inequalities. TRAUMA - DEFINITION AND PROCESS

In everyday conversation, we may refer to distressing or extremely trying events as traumatic. In a therapeutic context, trauma refers to extreme stress Shortly after starting work as a exposure resulting in a body response community dietitian, I began to suspect that prioritises immediate survival that I was missing something important over longevity. Common causes and about health, something that couldn’t categories of trauma are recognised. be pinned down to eating or exercise. One way of grouping the causes of Take prejudice: surely racism harmed trauma is given in Table 1 overleaf. health. I had no vocabulary for this, no A key point is that trauma is defined biochemistry of discrimination to draw by somatic experience and not by the on from my dietetic education. So I event itself. Not everything that is searched a clinical database for ‘racism’ highly stressful is traumatic. That said, and ‘heart disease’. The results made some events are irrevocably traumatic such an impact on me that I can still - rape, child abuse and neglect, for recall the first papers I read. One instance. investigated racism and waist circ- In other cases, two people may share umference;1 another asked, ‘Does racism an experience that traumatises one and harm health? Did child abuse exist before not the other. Thus, two children may 1962?’;2 a third introduced me to Michael undergo the same series of invasive Marmot’s work on status syndrome and interventions for an illness, leaving the social determinants of health.3 only one of the children traumatised. April 2018 - Issue 133


PUBLIC HEALTH Table 1: Categories of trauma (examples are not exhaustive and may overlap) Violation of body integrity: accident, disaster, sexual and physical abuse, medical intervention, violence, assault, diagnosis, torture, war Threat to sense of self and/or relational safety: sexual and physical abuse, shaming, coercion, diagnosis, group oppression, household substance misuse, refugee camps Loss: bereavement, relationship breakdown, incarceration, adoption, moving Neglect: developmental, emotional and physical needs unmet Trauma can be experienced in different ways, for example, directly, indirectly, vicariously, acutely, chronically and insidiously. Table 2: Hallmarks of trauma Core features of traumatic experience in adulthood are that it often involves a disrupted sense of self, in tandem with the experience of a lack of control and overwhelm, i.e. powerlessness. Horror and terror are often hallmarks. In childhood, primary carer relationships strongly impact neuronal growth, such that lack of safety and nurture have a neurophysiological impact causing developmental trauma. Left untreated, this can have life-long detrimental consequences. A traumatic experience is one that overwhelms a person’s physiological/ psychological capacity to process the event in a health-prolonging manner.

Another example is witnessing a disaster: one person shakes violently as they watch; the second person stands nearby and does not shake and, in fact, seems oddly numb. Why the different responses? In essence, trauma involves a lack of integration. The child who was not traumatised had reliable, nurturing caretakers and - in somatic terms - the stress they experienced was tolerable and could be integrated. The experiences did not have a deleterious effect on the child’s physiology or sense of self. In terms of physiological regulation, they did not tip over homeostatically to ‘a point of no return.’ The traumatised child did not have this support and, somatically speaking, stress became toxic. They exceeded what their body could handle within the parameters of homeostasis.4 What about the adults? The person who shook is processing the stress-emotion fall-out on the spot. They still need time to fully absorb what just happened, but their physiological sense-making system stayed connected and they remained present to events in real time. The memory is stored as a coherent narrative. The person who stood beside them was unable to process the somatic impact in a healthprolonging way and, instead, their body dealt with the stress-emotions complex in a survivalsustaining way. 38 April 2018 - Issue 133

We are less likely to be traumatised by adverse events when we have been brought up to believe ourselves worthy of love and respect and we view the world as a safe place. Hand in hand with these criteria, we are likely to have had our basic material and relational needs met, such as the need for food and secure attachment. As a result, our nervous systems, memories, endocrine and immune systems developed along particular health-promoting pathways. As adults we have a strong sense of coherence. In other words, we have an abiding sense of confidence that we will be able to cope with things, predicated on a core sense of self-worth and expectations of a safe world. Our biology is influenced by our biography. When we are traumatised, we are more likely to experience disaster as traumatic than if our biology is not shaped by trauma. TRAUMA AND ADVERSE CHILDHOOD EVENTS (ACES)

There is a growing awareness of the association between adverse childhood events, orACEs, and adult health. The strong link between ACEs and lifelong risk for adverse life events and poor health coutcomes testifies to the huge significance of early - developmental - trauma. This is relvant because high ACE scores are strongly linked with many conditions that bring patients to our

clinics, such as diabetes, heart disease, eating disorders, IBS and mental health problems. It is important to acknowledge that trauma impacts metabolic health regardless of eating and exercise habits. This means that public health campaigns which emphasise lifestyle change as a route to significant population health improvement are way off the mark. They rely on cherry-picked science to promote a neoliberal political agenda that embeds health inequalities. In other words, lifestyle does not explain the link between ACEs/trauma and poorer health. This is not the same as saying behaviours makes no difference. It is saying that current dietetic discourse misrepresents the role of lifestyle in determining health outcomes. Trauma impacts body responses and behaviours through interlinked pathways. The use of food for emotional regulation may be seen in comfort eating, comfort dieting and eating disorders. There may also be substance abuse, extreme exercise and other trauma-wrought behaviours. These behaviours are symptoms of distress and dysregulation and are also resourceful coping strategies, so that a mechanistic approach to behaviour change is likely to be counter-productive. The single most effective thing we can do to ameliorate and prevent trauma as a profession is to refuse to be complicit any longer in the cultural silence. Ignoring trauma leads to shame, stigma, isolation and pseudo-science. By educating ourselves on trauma and speaking up about its impact we contribute to social and scientific change. As practitioners, it is imperative that we adopt a trauma-informed approach. This means practising in a way that recognises the impact of trauma on people’s bodies, behaviours, beliefs and capacity for learning, planning and change. The traumatised child lives through a body and belief system shaped to respond to events as if the world and the people in it are unsafe. Without intervention, these deep-rooted feelings and habitual responses persist even when external circumstances change. A TRAUMA-INFORMED APPROACH TO IRRITABLE BOWEL SYNDROME

Can you list a few causes of IBS? We’ll come back to this later.

At a FODMAPs training day I attended, run by dietetic specialists, we were given case studies to work through. For one patient, let’s call her Sally, IBS symptoms returned after childbirth. We were given a formula for working through anthropometry, biochemistry, diet and so on, to help us in our response. Perhaps you know it. I volunteered to share my answer in the feedback session. I’d not said much, when a nearby colleague helpfully interjected to steer me in the right direction: it’s not so much that she thought I was answering the question wrongly, rather that my answer was so far removed from what we’d been told was right that she thought I was answering the wrong question. You see, I didn’t think the answer lay in a sweep of Sally’s diet history to change eating frequency and food type. It seemed hugely significant that Sally’s symptoms had returned after birth because there is a strong and consistent relationship between IBS and childhood abuse - and also between IBS and domestic (intimate partner) violence - and it is known that childbirth itself can trigger flashbacks and other symptoms of PTSD. The case study of eating patterns suggested that Sally was spiralling towards chaos. Now was really not the time to jump in with wholemeal bread. A more humane trauma-informed - response would involve listening and bearing witness, building trust and helping someone make sense of what was going on. The dietetic intervention would use a body-aware and compassion-centred approach to demystify experiences and give a context for dietary change. Focusing on nutrient profile at the expense of exploring Sally’s relationship with food and self-care, the meaning of her IBS and the context of her distress, inhibits body-mind healing and exacerbates symptoms. The global healthcare impact of IBS is huge. It accounts for more doctor visits than diabetes or hypertension (in the US).5 What do you think causes IBS? A USA study asked internal medicine physicians, family practice physicians and gastroenterology physicians this question. Gastroenterology physicians were most likely to state that prior infection April 2018 - Issue 133


PUBLIC HEALTH and a history of abuse were the causes of IBS.6 In a review of the field, one author considers the trauma-IBS link thus: ‘The pathophysiological features that explain this association relate to stress-mediated braingut dysfunction and can range from altered stress-induced mucosal immune function, to impaired ability of the central nervous system, to downregulate incoming visceral or somatic afferent signals. For gastroenterologists and other healthcare providers, it is important to understand when to inquire about an abuse history and what to do with that information.”4

To be clear, I am not suggesting that dietitians ask about abuse history. As things stand with our training and professional norms, this could be highly damaging. I am, however, suggesting that we need to educate ourselves about trauma and change our practice accordingly. In fact, the causal role of trauma in IBS had been mentioned in the morning session of the FODMAPs training. Yet, the information was not integrated into the treatment model, which, consequently, used a non-scientific methodology. Instead, foods were reduced to constituent nutrients and dietary change was framed as a mechanistic endeavour. This default ‘trauma-ignored’ model is harmful because it entrenches disconnect and because it disregards the relational dimensions of healthcare. It was a strange experience to be surrounded by experts talking about gut disorders, but ignoring trauma. It was as if no one else in the room had ever woken themselves screaming.


Professional narratives have real-life consequences. It is putting it mildly to say that doing what we have always done will not serve our patients or students well. For as long as it cements the cultural bias that silences trauma, dietetic practice contributes to systems of thought and practise that perpetuate personal and social trauma. This has implications for

human rights, health outcomes and suffering, ethical practice and professional reputation. Whether we intend it or not, the refusal to acknowledge trauma makes us adversaries in the struggle for social justice. Our adherence to positivism as a scientific paradigm ensures that we perpetuate the (neoliberal) belief that public health is largely a matter of lifestyle, education and willpower. The selective use of data to side-step the metabolic impact of racism, abuse, ACEs, poverty, other oppression and privilege, is post-truth ‘science’. How did we arrive here? Is there anything in the answer, about professional socialisation and leadership for example, which might improve future organisational knowledge-creation? The reality is that life is traumatic for many. We have a surfeit of evidence for this from Black Lives Matter and #MeToo, through to hate crimes, fat shaming, Grenfell Towers and welfare suicides. Either we continue to gate ourselves off from difficult truths and undertake research and CPD in a posttruth-science hermetic bubble, or we open our hearts to suffering - our own and others’ - and commit to develop an ethical, relevant, trauma-informed profession. If healthcare is not trauma-informed then it is trauma-ignored. Trauma-ignored practice is not evidence based: it is not science, but science fiction. WHAT NOW? STARTER IDEAS FOR CONVERSATION AND ACTION

Find out what any unfamiliar words mean, e.g. neoliberal, positivism, relational, reductionist. Are the concepts they describe useful to furthering your understanding and do you agree with the way they are used here? If not, why not? How would you paraphrase the text they appear in? Do a PubMed search for key words around childhood diabetes and trauma/emotions. Are there any surprises? What does this mean for your practice? How will you use the information? Are there any ethical issues raised for your team/profession?

Acknowledgements With thanks to Kimberly Dark for her work in raising awareness of the hidden stories of trauma and for her support and encouragement in helping me do the same. 40 April 2018 - Issue 133



Nikki has been a HCPC Registered Dietitian for eight years and more recently gained BABCP accreditation as a CBT Therapist. She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust. REFERENCES Please visit the Subscriber zone at

Eating disorders are complex mental health conditions that effect over 1.25 million people in the UK.1 They are often misunderstood, subject to stigmatisation and conversely sometimes praised/ promoted within the current diet culture. Increasing awareness, understanding and compassion in this area may be vital to help ensure improved access to treatment and to enhance overall outcomes. Eating disorders (ED) are defined by negative beliefs and behaviours concerning eating, body shape and weight and can result in restricted and/or binge eating and compensatory behaviours. The emotional and physical consequence of these beliefs and behaviours maintain the disorder and can make recovery difficult to achieve without appropriate support.1 ED can have devastating effects on those struggling with the conditions and can also greatly affect those around them. They are associated with poor quality of life, social isolation and can have a substantial negative impact on family and carers.1 Research suggests that early identification and treatment is associated with improved outcomes. It appears, however, that from the onset of symptoms, an average of three and a half years pass before specialist treatment is accessed. This is thought to be partly due to symptoms not being recognised, followed by a delay in patients asking for help once symptoms are apparent, then a further delay before services are made available.2

Identifying symptoms and assessing for ED can be extremely challenging. Commonly, individuals experiencing these disorders find it difficult and/ or distressing to discuss ED cognitions and behaviours.1 Possible reasons for this include the level of shame that can be experienced and the stigma attached to the potential diagnosis. As such, raising awareness of ED is needed to improve understanding and promote treatment. An event that aims to get more people talking about ED, reduce the stigma and misunderstanding and help individuals know they are not alone is Eating Disorders Awareness Weekâ&#x20AC;?. This is an annual event promoted by BEAT, a UK ED charity, and has previously focused on different areas of interest (i.e. self-esteem and ED in the workplace). In addition to national campaigns, it is vital that dietitians and other healthcare professions are aware of and promote awareness of the early signs and symptoms of ED.

Table 1. Spotting the first signs of an eating disorder Word/prompt

Question to consider


Are they obsessed with food?


Is their behaviour changing?


Do they have distorted beliefs about their size?


Are they often tired or struggling to concentrate?


Do they disappear to the toilet after meals?


Have they started exercising excessively?

Adapted from: April 2018 - Issue 133


COMMUNITY Table 2. Factors to consider when assessing for an eating disorder An unusually low or high BMI or weight for age. Rapid weight loss. Dieting or restrictive eating practices that are worrying them or others. Family or carers reporting a change in behaviour. Social withdrawal, particularly from situations that involve food. Other mental health problems. A disproportionate concern about weight or shape. Problems managing a chronic illness that affects diet (i.e. diabetes or coeliac disease). Menstrual or other endocrine disturbances or unexplained GI symptoms. Physical signs of malnutrition (i.e. poor circulation, dizziness, palpitations, fainting or pallor), or compensatory behaviours (laxatives, diet pills, vomiting or excessive exercise). Abdominal pain associated with vomiting or restrictive diet that is not explained by a medical condition. Unexplained electrolyte imbalances or hypoglycaemia. Atypical dental wear. High risk activities associated with increased risk of eating disorder (i.e. professional sports, fashion, dance or modelling). Adapted from: NICE (2017), Eating Disorder: Recognition and Treatment, Guideline 69

When assessing for a possible ED, there are a variety of factors to consider: Table 1 provides a simple list of easy-to-remember prompts that can be used to spot some of the first signs. This may be useful to encourage individuals to review their behaviour and/or assist family members, friends and colleagues to encourage further assessment/support. Table 2 provides a list of factors to consider when assessing for an ED and considering a referral to a specialist ED service. ENCOURAGING COMPASSION

Compassion can be defined as, ‘sympathetic pity and concern for the sufferings or misfortunes of others’,3 or a feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering‘.4 This can sadly be missing by those interacting with individuals with an ED, which can further increase the feelings of shame and self-judgement and reduce feelings of selfcompassion. Self-compassion can be described as the ability to extend compassion to oneself and is thought to comprise of self-kindness, common humanity and mindfulness. Research suggests that low self-compassion is associated with an 42 April 2018 - Issue 133

increased risk of negative mental health and that increasing self-compassion can have a positive effect on mental health and wellbeing.5 There are a variety of exercises that can encourage the development of self-compassion, two of which are summarised in Table 3. Additional information and activities to increase self-compassion are available at Demonstrating, modelling and encouraging compassion and self-compassion can, therefore, be imperative when raising awareness, developing a therapeutic relationship and promoting recovery. In order to achieve this, it is important to notice and acknowledge the suffering that is taking place; it is essential to recognise that behind the symptoms and a diagnosis is an individual who is struggling to cope and who has found some sort of comfort, safety and consistency from an ED. It is important to remember that the common myths about an ED are incorrect: it is not “a lifestyle choice”; it is not “extreme vanity”, neither is it just “attention seeking behaviour”, nor a phase that the individual will “grow out of”. Instead, it is essential to keep in mind that an ED is an expression of an anxiety disorder, a maladaptive coping strategy that can develop due to many different factors. In essence,

Table 3. Encouraging self-compassion Exercise


How would you treat a friend?

Consider how you would respond to a close friend who was struggling or suffering in some way. Compare the language used to how you might talk to yourself in a similar situation. Explore why there are differences. Try talking to yourself as you would a close friend and notice the differences in how you feel and behave.

Self-compassion break

Evoke the 3 aspects of self-compassion. Consider a situation that causes stress. 1 Acknowledge the suffering (mindfulness). 2 Accept suffering is part of life (humanity). 3 Express a kind statement to self (self-kindness).

Adapted from:

an ED communicates pain and if that pain and suffering is met with harsh judgements (which are often taking place internally for the individual experiencing the difficulty), then recovery can be problematic. However, if the pain is acknowledged, met with compassion, kindness, warmth and understanding, then the journey towards recovery can be improved. DISCUSSION

As dietitians and healthcare professionals, it is important that we consider our role in promoting understanding and compassion within ED. It appears highly relevant that despite our specialism or area of work, we ensure that our understanding and knowledge stays up to date about the signs and symptoms of ED. Also, that we know how best to raise and discuss any concerns with individuals, family members, or carers and that referrals to specialist services are completed when appropriate. It also seems important that we consider our own level of compassion towards ED and, indeed, our own self-compassion. It is essential that we consider how the health, eating and weight messages that are regularly promoted can contribute to increased risk of developing ED. We need to consider our interactions with individuals, groups or wider populations and how these can potentially impact on those who are struggling with, or at risk of developing, ED cognitions or behaviours.

If directly working within ED treatment, it is extremely important to reflect on our direct interactions and the importance of compassion. It is also vital to always remember that the disordered eating behaviours are only symptoms of the mental health condition and, therefore, recovery is not achieved by making changes to these behaviours alone. Indeed, focusing on such changes as diet and weight can have a further negative effect and greatly increase suffering and risk. SUMMARY

ED are multifaceted mental health conditions that are commonly misunderstood and stigmatised. An increase in general awareness and understanding is needed, as well as help to encourage prompt access to effective treatment. Compassion can sadly be missing and considering methods to increase this (including self-compassion) may prove to be very beneficial. As dietitians and healthcare professionals, it is important that we consider our interactions and the potential effect of the health messages that are regularly promoted. We need to recognise that those suffering with, or at risk of developing, an ED can be negatively impacted by the promoted ideals of health, weight and diet. It is also imperative that efforts are continued to be made to increase awareness, understanding and compassion in this complex area. April 2018 - Issue 133



RAISING THE PROFILE OF DIETETICS: REALISE YOUR POTENTIAL 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.

Times are a-changing and we as a profession need to change with them, which is not one of our strengths. However, it needs to fast become one and, as dietitians, we need to realise our potential and our worth. Dietitians are about more than just diets and yet our name and our reputation seems to be just that. Too many people have the stereotype of a stark white clinical environment where advice is given on restricting eating, on eating only healthy foods and stern finger wagging for eating the wrong things. People are constantly surprised when I tell them that I rarely prescribe an actual diet and that no one diet fits all. Part of the problem seems to come down to dietitians not actually realising their worth. This is possibly due to dietetics being a caring profession and the fact that we are not trained in marketing, PR and business skills - a side of things that may not come naturally to us. However, if we donâ&#x20AC;&#x2122;t shout about ourselves, then no one else will do it for us. There are plenty of weekend or short-term nutrition courses which include advice and tips on marketing and people taking these courses seem to instantly become nutritionists who then shout about their services. With more and more people stating that they can help with nutrition advice, our message gets diluted. SO WHAT MAKES US SPECIAL?

Dietetics training This teaches us how to be evidence based, but more than that, it teaches us how to read and interpret the research. Knowing the difference between a small scale study on rats and a long-term RCT on humans makes the difference. Appreciating the value of research and staying up to date is also key. Getting involved in doing research is also so valuable of course! 44 April 2018 - Issue 133

Clinical practice All dietitians, once qualified, already have a lot of clinical experience because of the education system in place. I still remember and value my clinical placements and my initial training years. Working on the wards as a newly qualified dietitian was a steep learning curve. Compare this to someone with a short-term nutrition course and there is a distinct difference. Dietitians have faceto-face clinical expertise from day one. Patient-centered care Every dietitian I have met really does care. We have valuable listening skills and CBT skills that are adaptable to whatever patient is in front of us. Taking the time to listen, help the patient understand and to appreciate how they are feeling, is part of our role. It is not just diagnosis and diet sheets. Interpreting the science into easy-tohandle advice The general public needs to know the evidence, but wants it in an accessible manner. As dietitians, this needs to be part of our role and whether this be in a clinical environment, on social media, or in written form, we have these skills. Get involved in doing this and sharing it around, whether that is in a newsletter at your place of work, via a blog, social media, media work, or in person. Working to a code of conduct There are so many unregulated professions out there. For example, when you have a kitchen fitted, you would look around and check the

“I think it’s crucial to get ourselves out there on social media and traditional media, share consistent evidence-based messages, support each other on social media, collaborate with other like-minded professionals and people in the media and to be entrepreneurs by embracing new technologies, learning about the business world and the media.” kitchen fitter’s qualifications and experience, see if they are recommended by others and under a trade body. We abide by the BDA and HCPC codes of conduct and this is a huge selling point. This makes us trustworthy and safe. don't know about ople “Ther e is so much that pe what dietitians do.” Denise Kennedy

Specialist areas of work Many of us work in specialist areas that are so niche that no one knows about them. We are largely a behind-the-scenes professional and need a PR company behind us! So how do we highlight the work that we do? We need to shout about it. It may not come naturally as, generally, we are not trained in business skills and perhaps this should form part of our ongoing professional development. As a Pilates studio owner, I go on many fitness courses and they all contain an element of marketing and business advice. Taking up a business course, or a social media course doesn’t have to be expensive; I’ve taken up many free ones in fact. They can give you the confidence you need to start shouting about your skills, knowledge and professionalism. We need more courses on these topics available to our profession. Social media, websites, other media, the local community, your workplace: these are all places in which to be active, where we can push the message

Maeve Hanan

about how awesome we are. It is largely unpaid work and it takes time to do, but personally, I do a lot of this as I am passionate about dietetics being seen in the right light. If you need advice on where to start, then reach out to those who already do it; we need to share and help each other out in order to move forward. Dietetics needs a shake up, wake up and a rebrand. How do we want the public to see us? As professionals who hide away and are out of date, or as caring, evidence-based, vibrant, entrepreneurs who are on the cutting edge of nutrition? It is up to us individually and as a group to up our game and realise that we can do more than we think. New technologies can be a huge learning curve, but we must embrace them and stay abreast of new developments in not only research, but in holistic therapies and counselling skills too. It may be that there are other areas that you can learn from too, and that can help you expand your role. to our successes rch in “Decen t, but effective, resea ing from the front.” lead s u will show Gillian Killiner I would love 2018 to be the year that dietitians take over social media, are seen all over the media and join forces together to highlight the amazing resources that we offer. I believe in us as a profession. Do you?

“We LISTEN to our clients. We provide a therapy that often helps reduce the need for drugs. By promoting hydration and nutrition in the community, we have the potential to keep our elderly patients out of hospital. We help get patients home faster. We have a huge range of specialisms. We have a professional code of conduct and duty to maintain CPD. We have a minimum qualification of undergraduate degree and registration.”

Ashleigh Macaskill April 2018 - Issue 133



Venue: multiple venues across the UK and Ireland Email:


Other dates for your diary Recipe Analysis: Maximising Accuracy 18th April and 20th April Nutrition and Wellbeing, one-day course at Kings College London Endorsed for CPD by the BDA and the AfN Tel: 07719 381949 recipe-analysis-training/. ECO2018, the 25th European Congress on Obesity 23rd to 26th May 2018 Vienna, Austria

STUDY DAYS 2018 AT THE ROYAL MARSDEN, LONDON Wednesday 9th May Targeted treatments for cancers of the digestive system - a bird’s eye view Thursday 12th July GI Study Day for Nurses Both events to be held at: The Royal Marsden Education and Conference Centre, London SW3 6JJ. For more information and to book your place please visit: BDA OPSG - Sarcopenia and Frailty: The Role of Protein and Exercise 25th May 2018 Join the group for an exciting day of reviewing the latest research, panel discussions, practical demonstrations and internationally acclaimed speakers. Kings College London, Strand Campus WC2R 2LS

More events listed on

• Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements

To place an ad or discuss your requirements please call (local rate) 46 April 2018 - Issue 133

01342 824073

WHAT’S IN A HEADLINE? Louise Robertson Specialist Dietitian Louise is an experienced NHS dietitian who has been specialising in the fascinating area of Inherited Metabolic Disorders in adults for the last 10 years. In her spare time she enjoys running her blog Dietitian's Life with her colleague and good friend Sarah, playing the cello and keeping up with her two little girls! www.

References 1 www.therooted 2 https://dietetically 3 Fiolet Thibault, Srour Bernard, Sellem Laury, Kesse-Guyot Emmanuelle, Allès Benjamin, Méjean Caroline et al. Consumption of ultra-processed foods and cancer risk: results from NutriNet-Santé prospective cohort BMJ 2018; 360 :k322

Nutrition stories have been getting plenty of airtime in the last few months, but not always for the right reasons. If we believe the newspaper headlines, then we all need to be on a diet (Britain needs to go on a diet - BBC news 6th March), but what diet should we be on? A low-carb or low-fat diet (Low carb diets no better than traditional focus on fat - The Telegraph 20th Feb 2018)? And we definitely shouldn’t be eating ANY processed foods, otherwise we will die of cancer (Processed foods are driving up rates of cancer - The Daily Mail 14th Feb 2018). Every time I see a sensational nutrition headline like those above, it makes me wince. I get it: the press want their stories to be read and more papers to be sold, but they are confusing the public. Wouldn’t it be great if nutritional professionals wrote these stories, getting the angle right and portraying the right messages? But this is unlikely to happen; so, we are trying to counteract these headlines with some myth busting on social media! Some great myth busters include dietitians Helen and Rosie from The Rooted Project1 and Maeve from Dietetically Speaking2 (follow them on Instagram and Facebook). Their skill is translating a scientific paper into easily understood information for the public on social media platforms. The Rooted Project’s graphics are eye-catching and recognisable. The Ultra-processed foods linked to cancer news story made great shocking headlines, the newspapers’ main messages being, ‘eating processed foods significantly raises the risk of cancer’ and ‘that sugary cereals and fizzy drinks are dangerous’. Scary stuff! They reported on the ‘processed’ foods that put you at risk, including breakfast cereals, bread, chocolate and biscuits.

Yes, fewer biscuits and chocolate may do you good, but cutting out bread and cereal could potentially reduce fibre intake which in turn could cause an increased risk of cancer and heart disease from inadequate fibre intake. The Rooted Project looked at the scientific paper3 from which the story came from. The link between processed foods and risk of cancer was actually only a weak one and the study couldn’t differentiate between other health behaviours which are known to be linked to cancer (smoking and physical activity). The main messages that The Rooted Project took from the paper were: 1 This study does not mean that eating ultra-processed foods will give you cancer. 2 The term processed does not always make it unhealthy. 3 The best way to reduce your risk of cancer is a varied diet, keeping active, avoiding smoking and keeping alcohol intake low. 4 Don’t panic if you consume some foods in your diet which are ultraprocessed. Two totally different messages taken from the same scientific paper - how did that happen? It makes me wonder if the health correspondents have any training in interpreting scientific papers at all. I know which message I will be listening to, but sadly most of the public will be taking what the papers say as read. As nutritional professionals, we need to keep on myth-busting on social media and getting involved with the media to try and bring some realism to these nutrition stories. April 2018 - Issue 133



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Nutramigen with LGG® reduces the incidence of future allergic manifestations2‡

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Versus an eHCF without LGG® or formulas based on rice hydrolysate, soy or amino acids. Return to milk means the normal physiological process in which the daily diet plays a role. When achieved it allows milk and dairy foods to be fully introduced without experiencing an allergic reaction. ‡ Versus Nutramigen without LGG®. References: 1. Canani RB et al. J Pediatr 2013;163:771–777. 2. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. †

Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding provides the best nutrition for babies. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: February 2018 UK/NUT/18/0026

Network Health Digest (NHD) - April 2018  

The Magazine for Dietitians, Nutritionists and Healthcare professionals Issue 133

Network Health Digest (NHD) - April 2018  

The Magazine for Dietitians, Nutritionists and Healthcare professionals Issue 133