Network Health Digest (NHD) - August/September 2018

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

NHDmag.com

August/September 2018: Issue 137

MALABSORPTION AFTER SURGERY SWEETENERS PAEDIATRIC FOOD ALLERGY EATING DISORDERS IN OLDER PEOPLE DYSPHAGIA

Preterm infant feeding pages 29-31

FROM THE EDITOR

WELCOME Emma Coates Editor

This bumper August/September issue of NHD includes our own carnival of dietetic and nutritional wonders. They flow between these pages like the parade at London’s Notting Hill. After each article you’ll be wondering what’s coming next!

Leading us in this month is Rebecca Gasche as she takes us through an overview of Malabsorption after surgery, looking at the types of surgery that can cause malabsorption and the current thinking behind managing the complication.

Following on closely behind is an article from Jacqui Lowdon updating us on events at the European Cystic Fibrosis Conference held in Belgrade in June. The latest CF research and hot topics discussed at the conference make interesting reading.

Our paediatric articles come from Mary Feeney, who discusses the BSACI/ BDA FASG guidance for UK healthcare professionals on preventing food allergy in higher risk infants. Martha Hughes takes a look at preterm infant feeding highlighting the important role that specialist dietitians play in providing the nutritional support and intervention required for these infants.

We welcome back Jenni Simmons too, Paediatric Speech and Language Therapist, with an article focusing on the management of paediatric dysphagia in the community.

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

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

It’s that time of year when the sun is shining, the sandals are on and there’s so much to do. It’s another summer of music festivals and seasonal events for making happy memories and for releasing some of those feel-good endorphins.

Maeve Hanan asks the question, Sweeteners: friend or foe? looking at the current evidence and clearing up some of the confusion around these much used sugar replacers. Looking further into the psychology of eating, Nikki Brierley sheds some light on the potentially hidden epidemic of eating disorders in the elderly population.

Another question from one of our contributors places the spotlight on Huel, a controversial meal replacement product with big ambitions. Alice Fletcher investigates whether Huel is the future of food for human health and sustainability of the planet.

Our second winner of the NHD British Lion eggs writing competition is Freelance Dietitian Cordelia Woodward. In a thoroughly researched article, Cordelia reports on the safety and benefits of eating eggs during pregnancy. A worthy winner!

And don’t forget, we have our regular feature Dietitian’s Life plus Ursula’s F2F this month with Prescribing Support Dietitian, Alison Smith.

Do you think these stripy socks go with these gladiator sandals? Or should I be daring and give my toes a proper airing under my festival kaftan? Enjoy the read! Emma

www.NHDmag.com August/September 2018 - Issue 137

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CONTENTS

13 COVER STORY Malabsorption after surgery

6

News

Latest industry and product updates

36 EATING DISORDERS

9

Face to face

The 'hidden' epidemic in older adults

With Alison Smith, Chair BDA OPSG

19 Cystic fibrosis

Research update

23 SWEETENERS Friend or foe?

40 Dysphagia in the community

A paediatric perspective

29 Feeding the preterm infant

Effective dietetic management

43 HUEL Is this the food of the future?

33 PAEDIATRIC FOOD ALLERGY Guidance for HCPs

48 Eating eggs in pregnancy

Competition winner 51 Dietitian's life

Happy 70th birthday NHS

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 info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

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

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Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 01342 825349 Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

www.NHDmag.com August/September 2018 - Issue 137

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NEWS

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

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ENERGY DRINKS AND KIDS: HOW HARMFUL ARE THEY? The first energy drink appeared on our shelves in 1994, with Red Bull being the forerunner for a new market of caffeinated soft drinks, designed to keep you going. The drinks have been a source of debate regarding how safe/ harmful they are and on the regulation around their sale and advertising, particularly to children and young people.

An energy drink is defined as a soft drink containing more than 150mg of caffeine per litre, often containing other stimulants such as guanine, taurine or ginseng. The high glucose content of energy drinks is also a concern and may be contributing to the obesity crisis. Brands such as Monster, Rockstar and Red Bull contain around 300mg caffeine per litre, less than filter coffee at 400mg per litre, but UK kids love them.

According to consumer usage data from Mintel, around 63% of boys and 58% of girls between 16-24 years of age regularly consume energy drinks. The European Food Safety Authority (EFSA) research suggests our younger kids are also regular consumers too, with two-thirds of 10- to16-year-olds, along with 18% of three- to 10-years-olds consuming these high caffeine beverages.

There are concerns from EFSA that just one can of energy drink can exceed the recommended caffeine limit for children, which is ≤2.5mg/kg per day in children and adolescents. For healthy adults, the recommended limit is ≤400mg/ day, but ≤200mg/day in healthy pregnant women, as recommended by the NHS. Health risks for children include abdominal discomfort, headaches, irritability, insomnia or sleep disturbances and raised blood pressure. There are also concerns regarding adolescent bone health, where energy drinks are consumed in place of calcium containing drinks, thus reducing calcium intake during a period in the lifespan where bone deposition is at its peak.

According to EU labelling guidelines (Regulation (EU) No 1169/2011), soft drinks with more than 150mg of caffeine per litre must carry a warning about the high caffeine content and state that they are not recommended for children.

However, this isn’t a particularly effective deterrent, with the UK having the highest energy drink consumption by children across Europe.

Earlier this year, UK supermarkets banned the sale of energy drinks to children under the age of 16, however, smaller shops, convenience stores and vending machines haven’t necessarily followed suit.

The marketing of energy drinks to children and young people has also been scrutinised, but regulating it has been a challenge. Energy drinks manufacturers use many platforms for sharing messages about their products. Social media, sporting events and online gaming are key routes of advertising, which are accessible to children and young people with or without parental controls.

While energy drinks are perceived to be trendy and their accessibility and marketing continue to be relatively unregulated, kids will continue to consume them. Legislation to regulate energy drinks and their consumption by children is required to make significant changes to the current situation.

For information on further reading please visit the Subscriber zone at NHDmag.com

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www.NHDmag.com August/September 2018 - Issue 137

NEWS TYPE 2 DIABETES AND FOOD CRAVINGS A recent study from Australia1 has investigated the effects of higher protein intakes compared with higher carbohydrate intake on food cravings in people with Type 2 diabetes. This study aimed to compare whether a high protein (HP) diet would provide greater reductions in cravings than an isocaloric higher-carbohydrate diet (HC). In the randomised controlled trial, a total of 61 adults with Type 2 diabetes consumed either a HP diet (consisting of approximately 29% protein, 34% carbohydrate, 31% fat) or an HC diet of 21%:48%:24% respectively.

The study took place over 24 weeks, with participants engaging in 12 weeks of weight loss (WL) and weight maintenance (WM). The average age of the participants was 55 years +/8 years with a BMI of 34.3 +/1 5.1kg/m2. A Food Craving Inventory (FCI), which measured the types of food craved as well as questionnaires to measure the food craving states and traits were used at 0, 12 and 24 weeks of the study.

Weight changes were similar between both the HP and HC groups. During the weight loss phase average loss was equal to -7.8 ± 0.6kg and during the weight management phase, the average weight fluctuation was -0.6 ± 0.4kg. All food cravings (except carbohydrates) decreased over the 24 weeks study and sweets and fast food craving, loss of control and emotional cravings reduced, particularly if the subject lost weight

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The study’s investigators have concluded that both the HP and HC diets provided significant reductions in food cravings after similar weight losses which were maintained when weight was stabilised.

Reference 1 Nerylee A et al (2018). Reductions in food cravings are similar with low-fat weight loss diets differing in protein and carbohydrate in overweight and obese adults with Type 2 diabetes: A randomised clinical trial. Nutrition Research. Volume 57, September 2018, Pages 56-66. www.sciencedirect. com/science/article/pii/S0271531717310837

dieteticJOBS.co.uk SPECIALISED DIETITIAN – STATES OF GUERNSEY Guernsey is a picturesque island situated in the English Channel with a population of just over 60,000. Famed internationally for its great beaches, views and food, it offers a fantastic work-life balance as well as a range of other perks. We are looking to appoint a Specialised Dietitian to offer support and training to community colleagues at all levels (GP, Community Nurses, Community care staff, Care homes and nursing homes,

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GP support staff) in nutrition screening, nutrition support within our “food first” approach and enteral feeding and will encourage appropriate nutrition prescribing. We offer a full relocation package which includes interview and relocation travel, this is in addition to our competitive pay and annual bonus. Furthermore we offer subsidised accommodation for those travelling to the Island alone, and an 8-year employment permit for those wishing to bring a partner or family. Terms and conditions apply to all bonuses, relocation package, accommodation, travel and employment permits. Contact: Myfanwy Datta, Clinical Lead Dietitian on tel. 01481 707342 or email: myfanwy.datta@gov.gg.

Closing Date: 14th August 2018. For more information visit: www.gov.gg/dietitianjob

F2F

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

FACE TO FACE Ursula meets: Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.

If you would like to suggest a F2F (someone who is a ‘mover and shaker’ in UK nutrition) for Ursula, please contact: info@ network healthgroup. co.uk

ALISON SMITH Prescribing Support Dietitian Chair: BDA Older People Specialist Group Food Firster

We met in a pub. It was a really hot day, so I had the excuse to order a pint of cider. Alison had a lemony drink.

The three of us (Alison, myself and the barman) found we had one important thing in common: a complete disinterest in football, which was at fever pitch that week. Alison and I then found a corner to consider the topic that was becoming more and more interesting for me.

Alison is chair of the BDA Older People Specialist Group: surely a subject more important than two groups of men kicking a ball back and forth!

Alison had always known the job she wanted. But disappointing A Level results shut the door on her becoming a vet. Last minute clearing led her to Preston Polytechnic (now University of Central Lancashire), to study a combined degree in physiology and pharmacology with a nutrition option.

This sparked her interest in nutrition, which then led Alison to the twoyear postgraduate dietetics degree in Glasgow. “I really enjoyed the course and our small group of 11 dietitians-tobe became really close and supportive of each other,” said Alison. There was a slight hiccup to her student placement because she faced a period of depression, but was strongly supported when she started her clinical slot (take a bow, dietetic department of Hammersmith Hospital.) Her mother noticed a sad withdrawn person become a relaxed and happy one during this time.

Her first post in 1996 was as a basic grade community dietitian in

Cleveland. She enjoyed the variety of GP clinics, home visits and health promotion groups. A year on, she obtained a senior community dietitian post in Peterborough and had a great partnership with another community dietitian: “She was the ideas person and I was the finisher: we were perfect together,” Alison explained.

There was a constant increase in demand for nutrition support from care homes for the elderly and in 2001, Alison was asked to develop a more focused and sustained approach for this sector. “Care home staff often feel less respected and frequently criticised, but they do heroic work and really need support and reassurance from other healthcare professionals, including dietitians,” said Alison. Advising on the nutritional care of the elderly became the entire focus of the post and Alison developed many insights into markers of poor care versus good care. Most care home residents are very vulnerable and need diverse aspects of medical support, but nutrition status is often the underlying theme to poor health. In her post, Alison enjoyed the evidence of dietetic inputs: care staff were always impressed and delighted to observe the improvements to health from better diet and food intakes.

Some unhelpful confusions were due to public health messages in relation to lowering heart disease risk being misapplied to frail elderly people with poor appetites. Alison observed that foods provided were often diluted and

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F2F

The group advises on the development of national schemes to support better standards of food care for older people . . .

lacking taste and much of her focus was on how to increase intakes of energy, protein in particular.

Alison often engaged with relatives who insisted on long lists of likes and dislikes, but there were typical taste changes in some elderly with new preferences for sweet foods and desserts, or the enjoyment of stronger flavours. Alison advises, “Never forget to make friends with the cook and the caterer; they are often forgotten by medical staff, but can make all the difference.”

Increasingly, Alison worked outside dietetic department structures and within multidisciplinary teams. She really enjoyed the broader outlooks and insights from other healthcare colleagues, enjoying too, the many opportunities that were available to promote the importance of nutrition to them. During this time, she also became involved in feeding support for progressive neurological disorders and provided counselling and guidance for PEG feeding.

Not getting a promotion she had been hoping for, it was time to tear away and in 2013, she stepped into a pristine new job as a prescribing support dietitian in Buckinghamshire. This role was to scrutinise, assess and advise on GP prescriptions for nutritional products. “I knew all about feeding products of course, but had to do updates on paediatric and specialist metabolic products,” admitted Alison. GPs are all work heavy and time poor, and she has come to a greater appreciation of the need for brevity in communications with them. Her advice to dietitians is to keep requests for 10

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prescriptions brief, never more than two sides of A4, with formatted headings of what was needed and why, for how long, along with intended review plans. She observes waste when costly specialist feeding products are on constant renewed prescriptions that patients appear reluctant to decline.

She is currently doing a second new post as a prescribing support dietitian in Hemel Hempstead. She really enjoys her job (“the role I was made for”), working with other medical staff to review patterns of prescription and group data, with a view to balance provisions and optimise best practices. The Prescribing Support Dietitians Group is a sub-group of the BDA’s Older People Specialist Group and Alison strongly recommends joining (if this is your area of work).

In 2003, Alison joined the committee of the BDA Nutrition Advisory Group for the Elderly (NAGE), doing all things supporting PR and communication of their activities. Now she is Chair of the same newly named Older People Specialist Group. The group advises on the development of national schemes to support better standards of food care for older people, and Alison’s many fingers in many policy pies was rewarded when she received the BDA Ambassador of the Year Award in 2017.

When Alison turned to leave, I was very surprised to notice a huge ‘superwoman’ cape swishing around her. Amazing what you see in people, after getting to know them. Or perhaps it was just the effects of cider on a hot day.

DOES A SIP F ED CO TAIN EVERY HING A BOLUS PATIE T NEEDS? Sip feeds weren’t made for bolus feeding, but TwoCal is. It’s a unique 2kcal/ml tube feed in a 200 ml bottle with a higher electrolyte content than other commonly used ONS.1 And because there’s no decanting, there’s less mess and less kit, too. Isn’t it time you gave your bolus fed patients, a bolus feed?

1. Data on file. Abbott Laboratories Ltd, 2018 (TwoCal electrolyte comparison).

Date of preparation: July 2018 ANUKANI180187

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COVER STORY

MALABSORPTION AFTER SURGERY 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.

REFERENCES Please visit the Subscriber zone at NHDmag.com

The World Gastroenterology Organisation (WGO) describes malabsorption as defective mucosal up take and transport of adequately digested nutrients, including vitamins and trace elements.1 It can be caused by a number of conditions such as mucosal damage, pancreatic insufficiency, inflammatory bowel disease and intestinal resections.2 This article will discuss the effects of malabsorption post-surgery.

Many medical conditions can cause malabsorption. It may be generalised, or caused by a specific molecule.3 Examples of general causes of malabsorption include chronic pancreatitis, coeliac disease, inflammatory bowel disease (IBD), bile acid malabsorption and bacterial overgrowth or infections.

Malabsorption may also be specific to particular molecules, for example lactose in someone with lactose intolerance and fat malabsorption leading to malabsorption of fat soluble vitamins A, D, E and K.3 The most common cause of malabsorption in Western countries is villous atrophy caused by coeliac disease, an autoimmune condition in which the body reacts to gluten, resulting in damage to the villi in the small intestine and thus decreasing the surface area for absorption.3 Malabsorption can also occur following surgery, when there has been structural changes made to the digestive system. Bowel surgery can be as a result of a number of conditions, such as: diverticular disease, IBD (Crohn’s disease and ulcerative colitis), colorectal cancer, bowel obstruction, abdominal trauma and ischaemic bowel.3 Surgery of the pancreas may be as a result of cancer and bariatric surgery is used to reduce body mass index (BMI) of clinically obese patients.

NUTRIENT ABSORPTION

As displayed in Figure 1 overleaf, the majority of nutrients are absorbed in the small intestine, with the large intestine being responsible mostly for water absorption, short chain fatty acids and electrolytes. Most carbohydrates, proteins and fats are absorbed in the first 100cm of the small bowel. Many other nutrients can be absorbed by the ileum, but this depends on individual transit time.4 SURGERY

Surgery of the bowel Table 1 shows the different types of bowel surgery which may be performed as a result of cancer, IBD or other bowel conditions.5 Two types of stomas may be created depending on which part of the bowel has been resectioned: colostomy and ileostomy. Within these there are varying types of each stoma, as displayed in Table 2.

Surgery of the pancreas The pancreas - a small organ found behind our stomach and below our ribcage - has two main functions, which allow for the release of enzymes and hormones to aid the digestion of foods.

The exocrine function produces enzymes to break down carbohydrates, proteins and fats, and the endocrine function homes the islet cells responsible for the

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NHD0818

Figure 1: Absorption of nutrients across intestines

Many additional nutrients may be absorbed from the ileum depending on transit time.

Based on: Advanced Nutrition and Human Metabolism, fifth edition.

release of the hormones insulin and glucagon, to maintain blood glucose levels. Some patients require surgery to remove part of or their entire pancreas. Table 3 shows the different types of pancreatic surgery.

Bariatric surgeries Bariatric surgeries are carried out to aid obese patients with weight loss and these involve different procedures that both reduce gastric capacity and bypass areas of the small intestine.

Table 4 explains the different types of bariatric surgery in more detail.

MALABSORPTION POST-SURGERY

Bowel surgery The formation of a stoma in the small bowel causes a decrease in transit time, meaning that nutrients pass through the digestive system too quickly and can be malabsorbed. This can also

lead to weight loss and malnutrition. Studies show that malabsorption is common, especially in ileostomies and demonstrate that only 60-70% energy, 50-60% fat and 60-70% carbohydrate are absorbed.8,9 Dehydration is most commonly found when large amounts of the ileum have been removed and can often result in a readmission to hospital and acute renal failure.10 Postoperatively, the most common losses seen in ileostomy patients are fluids and sodium.

This is particularly seen in patients who have had a total colectomy, as this means that the entire colon has been removed, where most of the fluid and sodium is normally absorbed. Particularly within the first six to eight weeks, patients may lose 1200-2000ml fluid and 120-200mmol sodium/day. After eight weeks, the ileum then adapts to absorb and fluid losses reduce to 400-600ml/day.3 Due to the loss of sodium, patients are encouraged to add salt to their diet. www.NHDmag.com August/September 2018 - Issue 137

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CLINICAL Table 1: Bowel surgeries Right hemi-colectomy

Right half of the colon is removed.

Left hemi-colectomy

Left half of the colon is removed.

Abdomino-perineal resection

Rectum and anus removed, colostomy formed.

Anterior resection

Removal of cancer in the rectum.

Sigmoid colectomy

Sigmoid colon removed, two ends joined together.

Hartmann’s procedure

Sigmoid colon and upper rectum removed, end colostomy formed.

Total colectomy

Entire colon removed, permanent ileostomy or small bowel will be joined to rectum.

Pan proctocolectomy

Colon, rectum and anus removed, permanent ileostomy formed.

Table 2: Types of stoma3 Loop colostomy

The colon is sutured to the abdomen and there are two openings - one for intestinal waste and one for mucus produced by the GI tract.

End colostomy known as a Hartmann’s procedure

The sigmoid colon and upper rectum is removed, an end colostomy is formed.

Double barrel colostomy

Both ends of the colon are brought out onto the abdomen.

Temporary or loop ileostomy

A loop of the small intestine is brought to the skin, and the colon and rectum remain in situ. This is usually reversed 8-10 weeks later.

End ileostomy

The colon and rectum are removed and the end of the small intestine is brought through the skin.

Continent ileostomy

An internal pouch is created and the stoma is connected to a valve implanted in the skin, which can be emptied using a catheter.

Following a total colectomy, the absorption of other nutrients should be unaffected and the absorptive capacity of the small intestine remains intact. A small number (3-9%) of patients have been estimated to suffer from vitamin B12 deficiency and some patients may find absorption of bile acids are also affected.

This is thought to be due to reduced absorptive capacity due to ileal involvement, inadequate dietary intake or bacterial overgrowth.

The ileum contains B12 receptors and bile salt transporters, therefore, for those patients who have had ileal resection, they often suffer from B12 deficiency and fat malabsorption.

Fat malabsorption may lead to steatorrhea and deficiencies in fat soluble vitamins A, D, E and K.11 Colostomies have minimal impact on the digestion and absorption of nutrients and fluids and most patients are, therefore, encouraged to take a healthy balanced diet and keep to a healthy BMI.3 Following the formation of a colostomy, it is usually advised that the patient follows a low 16

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residue (low fibre) diet, to aid symptoms and reduce the risk of obstruction. After six to eight weeks, higher fibre foods may be reintroduced into the diet. Most colostomy patients should be able to return to a normal healthy diet, as there is no evidence for any particular diet to follow.

However, it is individualised as to what patients may be able to tolerate, particularly when it comes to some of the higher fibre foods.

Pancreatic surgery If a patient has part of, or all of their pancreas removed, this may affect production of pancreatic enzymes, which are vital for the digestion of proteins, fats and carbohydrates.

If the pancreas is unable to produce enough enzymes, or none at all, malabsorption will occur, as the body is unable to break down these nutrients for absorption. Patients may experience symptoms such as steatorrhoea, weight loss and fatigue. In this case, patients will need to be prescribed pancreatic enzyme replacement therapy (PERT).

Table 3: Pancreatic surgeries6 Whipple’s operation pancreaticoduodenectomy (PPPD)

Removal of the head of the pancreas, the duodenum, the gall bladder, part of the bile duct and surrounding lymph nodes.

Pylorus-preserving PPPD

Similar to the Whipple’s operation, but none of the stomach is removed.

The stomach valve (the pylorus), which controls the flow of food into the duodenum, isn’t removed either. The tail of the pancreas is joined to the small intestines or stomach.

Distal pancreatectomy

Removal of the body and tail of the pancreas and sometimes the spleen.

Total pancreatectomy

Removing the whole pancreas, the duodenum, the gall bladder, part of the bile duct and sometimes part of the stomach.

Table 4: The different types of bariatric surgery7 Laparoscopic adjustable gastric banding (LAGB)

A synthetic band is placed just distal to the gastroesophageal junction, creating a small gastric pouch with an adjustable opening.

Sleeve gastrectomy

Around 80% of stomach is removed, creating a long, banana-shaped pouch.

Roux-en-Y gastric bypass (RYGBP)

The top part of stomach is stapled, creating a small pouch and attaching it to middle part of small intestine. This encourages malabsorption by preventing the mixing of food and digestive enzymes.

Biliopancreatic diversion with duodenal switch (BPD/DS)

This surgery is in two parts. The first is similar to gastric sleeve surgery.

The second surgery redirects food to bypass most of the small intestine.

The surgeon also reattaches the bypassed section to the last part of the small intestine, allowing digestive juices to mix with food.

PERT works by mimicking the physiological conditions of a healthy pancreas, allowing the correct amount of enzymes to be delivered to the duodenum, where they are activated with food allowing it to be absorbed.12 Published treatment guidelines for chronic pancreatitis and pancreatic cancer recommend initiating patients on 40,000 to 50,000 lipase units per meal and 10,000 to 25,000 lipase units per snack,13 but this is often titrated to higher doses depending on symptom control.

In the case of partial pancreas resections, enzymes may be discontinued in the long-term follow-up, depending on the remaining pancreas function of the individual patient. Studies have shown that approximately 70% of pancreatic surgery patients will need lifelong PERT.14 Bariatric surgery As Table 3 demonstrates, bariatric surgery aims to aid weight loss, using techniques such as reducing gastric capacity and bypassing parts of the small intestine. This results in a reduction of

the total absorption surface area. As a result of this, post-operatively, bariatric surgery patients are at increased risk of developing nutrient deficiencies. In addition, these patients often also have a reduced dietary intake, vomiting and food intolerance.15 This can lead to the malabsorption of nutrients, in particular vitamin B12, folate, iron, calcium, vitamin D and fat soluble vitamins.

Some bariatric surgeries may induce fat malabsorption which can cause deficiencies of fat soluble vitamins, therefore, routine supplementation is recommended. Similarly, vitamin B12 and folate deficiency occurs commonly after bariatric surgery procedures, with reports suggesting rates as high as 45% after Roux-en-Y gastric bypass.16 This deficiency occurs due to the bypassing of portions of the small intestine, the main site of absorption.

Calcium and vitamin D deficiency after bariatric surgery has also been extensively investigated.17,18 Studies estimate that over 50% of post-operative patients develop low levels of vitamin D and that a progressive increase in www.NHDmag.com August/September 2018 - Issue 137

17

CLINICAL

When seeing patients with a history of surgeries involving any part of the digestive system, it is important to consider the implications these may have. the incidence and severity of these deficiencies occurs with time after biliopancreatic diversion with duodenal switch (BPD/DS).

When looking at iron absorption, it is known that post-bariatric surgery patients have reduced iron intake secondary to a considerable reduction of their meat intake. Ruz et al19 showed a reduction of almost 50% of the total amount of meat per day consumed. In addition to this, the reduced gastric capacity caused by bariatric surgery reduces the production of hydrochloric acid. This affects malabsorption, as hydrochloric acid is used to convert iron into a more absorbable form and not enough

NETWORK HEALTH DIGEST

• HEF/HPN

hydrochloric acid limits the release of iron from the structural proteins.19 CONCLUSION

When seeing patients with a history of surgeries involving any part of the digestive system, it is important to consider the implications these may have. Whether it’s offering support immediately post-surgery, or making lifelong recommendations, a clear understanding of the areas of absorption in the gut and how the body breaks down nutrients can help healthcare professionals to advise patients on the correct diet and supplementation.

Coming in the October issue:

• Cow's milk allergy • PEG: nutritional support • Goat milk

• Malnutrition

• Non-diet nutrition • Probiotics and gut health • Free-from bites

Check whether you are eligible for a FREE subscription to Network Health Digest (NHD) at wwwNHDmag.com . . .

18

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Don’t miss a single issue!

RESEARCH UPDATE

CYSTIC FIBROSIS: AN UPDATE IN RESEARCH AND RECOMMENDATIONS Jacqui Lowdon Paediatric Dietitian, Leeds Children’s Hospital Jacqui is a Clinical Specialist in paediatric cystic fibrosis at Leeds Children's Hospital. She previously specialised in gastroenterology and cystic fibrosis.

Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Recent research into cystic fibrosis (CF) has brought about recommendations to improve patient outcome measures. At the European Cystic Fibrosis Society Conference held in Belgrade in June this year, further key research studies were presented. Here, Jacqui reports on the hot CF topics.

Respiratory symptoms are the main feature and focus of treatment in cystic fibrosis (CF), however, gastrointestinal (GI) issues, such as constipation and distal intestinal obstruction syndrome (DIOS), are well-recognised complications. They remain two very distinct conditions, although symptoms can be very similar, such as bloating and abdominal pain.

Constipation is when there is a gradual faecal impaction of the colon, whereas DIOS occurs when there is a build-up of faeces and sticky mucus. This forms a mass in the final part of the small intestine (the terminal ileum and caecum), which can either partially block the intestine (incomplete DIOS), or completely block the intestine (complete DIOS). This then becomes connected to the bowel wall and the intestinal villi fix it into position, making it difficult to remove.1 This is potentially a serious symptom, which can affect quality of life and other aspects of care, such as nutritional status, exercise and airway clearance. Clinical practice of treatment of DIOS is inconsistent and there is a lack of consensus.

For these reasons, the Cochrane database of systematic reviews recently evaluated the effectiveness and safety of laxative agents of differing types for preventing DIOS (complete and incomplete) in children and adults with CF.2 Unfortunately, there was only one low-quality, cross-over trial eligible for inclusion, highlighting the need for more research in this area. As the pathophysiology of DIOS is multifactorial, it is highly likely that there will be more than one successful prevention strategy.

GI research is an important research priority in CF as highlighted in the 2017 James Lind Alliance Priority Setting Partnership in CF, a partnership between people with CF and healthcare providers.3 They reached a consensus, listing 10 of the most important research priorities in CF, the second one being, ‘How can we relieve gastrointestinal (GI) symptoms, such as stomach pain, bloating and nausea in people with CF?’ This research priority also emphasised the lack of patient-reported outcome measures (PROMs) for GI problems in CF. PROMs cover areas of particular concern to the patient. It has been recommended that to significantly improve any future research, an agreed consensus on validated GI outcome measures for symptoms should be included. Reliable evidence exists to support the use of PROMs in healthcare. A 2013 systematic review already demonstrated that effective PROMs improve patient-provider communication, patient satisfaction, monitoring of treatment responses and detection of unrecognised problems.4 THE EUROPEAN CF CONFERENCE NEW RESEARCH

Outcome measures The role of PROMs was highlighted at the recent European CF Society Conference.

A group from Nottingham University presented an analysis of outcome measures suggested by a community of patients with CF. They were seeking stakeholder suggestions about how to measure the outcomes in their proposed

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RESEARCH UPDATE Table 1: Nottingham University research - suggested outcome measures Theme

Popular professional outcome measures

Popular lay outcome measures

Diet

Weight, vitamin D levels, BMI, energy levels

Weight, overall wellbeing, nutritional status

Digestive system

Weight, GI symptoms, lung function (LF)

Weight, liver function

Mental health

Anxiety measures, mental health questionnaire

Happiness scale

Treatment burden

Adherence, measurable device, LF

LF, quality of life

Antibiotics

LF, quality of life

LF, frequency of intravenous antibiotics

Genetics

Quality of life, exacerbations

Quality of life

Infection

Culture, LF

Number of infections, LF

Physiotherapy

LF, exacerbations

LF, exacerbations

Respiratory

LF, exacerbations

Number of infections, LF

Table 2: The Clinical Trial Working Group’s questionnaire assessment Group

Suggestions for questionnaire

Adults (N=13)

Focus more on sense of self-identity, future aspirations and fears regarding relationships.

Young people (N=32, 14-20 years)

Questions on amount of time spent on treatments, how peers and family perceive them, potential difficulties with treatment adherence, attitudes towards sport, perceived limits imposed by CF.

Children (N=16, 6-19 years)

This group had problems understanding the questions.

Parents (N=15, of children 6-13 years)

More questions on life organisation, treatment burden, how to help their children cope with the day-to-day challenges of CF, social support from family and friends, future concerns, parental depression and anxiety.

CF research; 513 responded with 787 outcome measures suggested. There were a number of popular suggestions in different categories (see Table 1). It was highlighted that the outcomes suggested from the CF community tended to be more holistic and focused on treatment burden and quality of life, whereas professional responses were more focused on numbers and lung function.

This type of information would be invaluable when developing dietetic outcome measures and could be rolled out to other groups of patients.

Data for PROMs can often be collected by selfadministered questionnaires. The most widely used tool in clinical trials for patients with CF is the Cystic Fibrosis Questionnaire-Revised (CFQ-R). It includes quality of life measures, allowing the patients’ perspective on the pros and cons of a particular treatment. The Clinical Trial Working Group on patient reported outcomes presented their study at the European CF Society Conference, evaluating the CFQ. Their aim was to assess if the tool is relevant and sensitive enough to reflect patients’ daily experiences of living with

CF and the effectiveness of new treatments. The results are summarised in Table 2.

Dietetic outcome measures tool Clinical outcome measures are also being widely developed and the UK CF Dietitians Group (led

by L Cave, Paediatric CF Dietitian, Leeds, UK) presented their final version and evaluation of a dietetic outcome measures (DOMs) tool for adult and paediatric cystic fibrosis patients at the Conference. A working group was set up to develop a core set of outcome measures for routine use, to enable evaluation of the effectiveness of dietetic interventions. It also included identification of common barriers and facilitators, to inform evidence-based practice and enhance patient-centred care. The tool was trialled by 21 UK CF centres with 268 patients. Findings included that, time and practice were needed to become familiar with the tool, but it was easy and quick to use; it was comprehensive and prompted the user to focus on setting SMAART goals (specific, measurable, achievable, appropriate, www.NHDmag.com August/September 2018 - Issue 137

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RESEARCH UPDATE reliable, timed); it also managed to capture what was important to patients and their families and it assisted identification of gaps in resources.

Body composition Another big topic discussed at the recent CF Conference was the use of body composition (BC) to determine nutritional status in patients with CF. Whilst BMI and BMI percentiles are commonly used as indicators of nutritional status, they do not distinguish deficits, excess stores or changes in weight, fat or fat-free mass (FFM), or both. Assessment of BC can ascertain this information, which encompasses analysis of percent body fat, muscle, water and bone. This will help in identifying the body composition alterations frequently found in patients with CF.5-7 E Owen, Paediatric CF Dietitian at GOSH, London, presented her research, investigating BC changes in pre-pubertal children with CF diagnosed via newborn screening (NBS). Thirty seven children (20 boys), non-meconeum ileus, aged five to eight years were recruited to have their BC measured using dual energy X-ray absorptiometry. The results demonstrated that NBS boys had normal growth, BC and lung function (LF) compared to the reference norms. NBS girls had weight, BMI and fat mass index (FMI) significantly below average, but normal height and LF. Compared to unscreened boys, NBS boys were taller and had higher LF, with significantly lower BMI and fat-free mass index (FFMI). NBS girls were significantly younger with significantly higher LF than unscreened girls and with a trend towards higher weight, height and FFMI. In conclusion, despite normal LF, gender differences in growth and BC were seen in this contemporary cohort of NBS children. This supports BC assessment in girls especially and longitudinal monitoring. Whilst LF was better in the NBS cohort compared to the unscreened cohort, larger numbers are required to better evaluate differences in BC. A Belgium group from Ghent examined changes in body composition of tube-fed patients with CF compared to age and sex-matched controls. Tube feeding (TF) in CF is well recognised to improve BMI, but the influence of TF on BC is not well evaluated. Bio-electrical Impedance (BIA) measures were carried out in patients with CF with (2F, 7M) and without TF (controls). Fat%, body fat mass index (BFMI) and FFMI were examined. The patients were 22

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matched for age, gender and pancreatic function.

Age at start of TF was 12.8 years (8.7; 15.6). The TF patients were significantly shorter than the controls, but the BMI z score and LF were not significantly different between the two groups. However, BC was significantly different with a higher fat% (p=0.024), a higher BFMI (p=0.019) and a lower FFMI (p=0.04) in the TF patients. The study concluded that the patients in this cohort receiving TF had less FFM. Although TF is often the only remaining method in which to improve nutritional status. However, it can often lead to increased body fat proportions.

As dietitians we need to be aware of this and one option for future interventions would be to work with physiotherapists to incorporate physical activity.

An Australian group from Melbourne examined BC in the first year of treatment with lumacaftorivacaftor in adults with severe CF lung disease.

They defined severe lung disease as an FEV1<40% predicted over 12 months of lumacaftor-ivacaftor treatment. Data was analysed for 20 adults (10 male, mean +/- SD age 33.5 +/- 8.8 years, mean +/- SD FEV1 33.6 +/- 6.5% predicted, mean +/SD BMI 19.9 +/- 2.2kg/m2), who had received lumacaftor-ivacaftor for two months and had BC measured (multifrequency bioelectrical impedance analysis) at six and 12 months. Changes in weight, FFM and FM were measured.

Results demonstrated that at six months, mean +/- SD weight and FM significantly increased (weight 0-6 month; 2.3 +/- 3.9kg (p=0.02); FM 0-6 months 2.1+/- 2.7kg (p=0.003), but with no further increase by 12 months (weight 6-12 months; 0.3 +/- 3.1kg (p=0.66); FM612 months 0.3+/- 2.7kg (p=0.27). No changes were seen in mean FFM. A lower BMI at baseline correlated with greater weight and FM. No one became overweight; 50% gained >5%weight.

In conclusion, weight and FM gains seen at six months plateaued by 12 months. Underweight patients were more likely to have body composition gains. Preservation of FFM contrasts with earlier research that shows declining FFM in association with severe lung disease. Mechanisms underlying these body composition changes require further investigation.

The 2019 European CF Society Conference will be held on 5th to 8th June 2019 in Liverpool. It will be interesting to see what will be presented.

PUBLIC HEALTH

SWEETENERS: FRIEND OR FOE? Maeve Hanan UK Registered Dietitian Freelance Maeve works as a Freelance Dietitian and also runs the blog Dietetically Speaking.com, which promotes evidence-based nutrition and fights nutritional nonsense.

REFERENCES Please visit the Subscriber zone at NHDmag.com

There can be a lot of confusion about the role and safety of sweeteners. This article will explore the evidence related to artificial sweeteners and bulk sweeteners.

The term 'sweeteners' will be used to encompass both types of sweetener during this article.

Sugars (also called ‘nutritive sweeteners’ or ‘caloric sweeteners’), such as sucrose and fructose, contain carbohydrates and provide 3.75 calories per·gram.1 Nutritive sweeteners are found in table sugar, honey and syrups. Artificial sweeteners are used to provide sweetness while containing little to no calories.1 These are used in a variety of products such as diet soft drinks, jellies, yoghurts, desserts, chewing gum, sweets and table-top sweeteners.2 Artificial sweeteners can also be referred to as sugar substitutes, non-nutritive sweeteners, intense sweeteners and high-potency sweeteners.1 Polyols, like sorbitol, xylitol and mannitol, are sugar alcohols (also called ‘bulk’ sweeteners) which are technically nutritive sweeteners, but they are lower in sugar and calories than other sugars (2.4 calories per gram).1 The sweeteners listed in Tables 1 and 2 are licensed for use in the UK; each has a corresponding E number, which means that it has passed the safety tests for approved use in the EU and the UK.3 Artificial sweeteners range from 30 times sweeter than table sugar (or ‘sucrose’), to 37,000 times sweeter, whereas bulk sweeteners often have the same level of sweetness as sucrose, but can also be up to 50% less sweet. These are often used as fillers to improve the consistency of products, as well as their role as sweeteners.4 As part of the safety evaluation process by the European Food Safety Authority (EFSA), artificial sweeteners are given an acceptable daily intake (ADI)

value. This ADI, which applies to all food additives, is an estimate of the amount that is considered to be safe to consume everyday over a lifetime. It is measured as milligrams per kilogram of body weight per day.5 For example, aspartame has an ADI of 40mg per kg body weight per day; in order to reach this, a 70kg adult would have to consume over five litres of Diet Coke everyday over a lifetime.1,6 Rather than allocating an ADI, bulk sweeteners (which are licensed for use in the EU) are classified as ‘acceptable’, meaning that the expected exposure to these is considered safe.4 An excess intake of bulk sweeteners is not advised as this can cause gastrointestinal issues such as, cramping, bloating, flatulence and diarrhoea.7 DENTAL HEALTH

There is an EFSA approved health claim that replacing sugar with intense sweeteners (i.e. artificial sweeteners), certain sugar alcohols (xylitol, sorbitol, mannitol, maltitol, lactitol, isomalt and erythritol) and other nutritive sweeteners (D-tagatose, isomaltulose and polydextrose) is good for dental health.2 This is because these sweeteners don’t ferment and cause demineralisation of teeth; instead, they help to maintain tooth mineralisation.

DIABETES

Using artificial sweeteners in place of sugary options can be a useful strategy for managing blood glucose levels for some people with diabetes and also for

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*Vanilla, strawberry and banana REFERENCES 1. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Plus vs. PaediaSure Compact).

2. Data on file. Abbott Laboratories Ltd., 2017 (Sensory research and evaluation: PaediaSure Compact banana flavour and PaediaSure Compact strawberry flavour).

Date of preparation: July 2017 ANUKANI170158b

GIVE THEM A LITTLE TASTE FOR ADVENTURE. Not only does it taste fantastic, PaediaSure Compact packs balanced paediatric nutrition (and 27 years of PaediaSure experience) into just 125 ml. And it comes in three great-tasting flavours.*1,2 How else could they teach their unicorn to fly?

PAEDIASURE COMPACT. HELPING KIDS BE KIDS AGAIN.

PUBLIC HEALTH Table 1: ADI value of artificial sweeteners1,4,6,8-11 E number

Approximate sweetness compared to sucrose

ADI value (per kg of body weight per day)

Acesulfame K

E950

200 times sweeter

9mg

Advantame

E969

37,000 times sweeter

5mg

Aspartame

E951

200 times sweeter

40mg

Sodium cyclamate

E952

30-40 times sweeter

7mg

Neohesperidin dihydrochalcone

E959

1000-1800 times sweeter

5mg

Neotame

E961

7000-13,000 sweeter

2mg

Saccharin

E954

300-500 sweeter

5mg

Steviol glycosides (or ‘stevia’)

E960

200-300 times sweeter

4mg

Sucralose

E955

600-650 times sweeter

15mg

Thaumatin

E957

2000-3000 times sweeter

1.03-1.10mg

Aspartame-acesulfame salt

E962

350 times sweeter

15mg

Artificial sweetener

those with reactive hypoglycaemia.1,12 There is some evidence that saccharin and sucralose may increase insulin levels, but, overall, the research is conflicting, so more well-designed human studies are needed to investigate this.13-16 EFSA approved the health claim that replacing sugar with the same sweeteners outlined earlier (i.e. xylitol, sorbitol, mannitol, maltitol, lactitol, isomalt, erythritol, D-tagatose, isomaltulose and polydextrose) reduces the increase in blood sugars which occurs after a meal.2 However, EFSA could find no clear relationship between using artificial sweeteners to replace sugar and maintaining normal blood sugar levels overall.2 For those who carb count, it is not clear how bulk sweeteners should be counted, as the carbohydrate levels absorbed from these can vary.17 Bulk sweeteners are also used in products labelled as ‘diabetic food’. However, these products are not usually recommended as they can still be high in fat and calories and may cause gastrointestinal problems if consumed in large amounts.17 WEIGHT MANAGEMENT

Although swapping sugars for sweeteners reduces calorie intake, there are concerns that sweeteners may interfere with our metabolism and increase our appetite.1,18 Some studies have found that using artificial sweeteners as part of a weightloss program can help participants to improve 26

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weight loss;1,19-22 however, a review by EFSA in 2011 found no clear relationship between using sweeteners and weight management.2 A recent systematic review by Azad et al found evidence from cohort studies that consuming artificial sweeteners was associated with a slight increase in BMI, weight and waist circumference, but there was no association found from randomised-controlled trials.23 There is a small amount of research that suggests that those who consume sweeteners may have a lower overall diet quality and this may also play a role in terms of weight management.24 There is limited information about the effect of polyols on weight management.25 Furthermore, it has been found that sweeteners can alter gut bacteria which may be harmful. This has mainly been found in animal studies and the results of human studies have been mixed.26- 28 Other studies have found that changes in our gut bacteria can be been linked to our weight and overall health,29-30 so it is possible that sweeteners may promote weight gain via changes to our gut bacteria, but more human trials are needed to test this.

Overall, more research is needed to clarify the role that sweeteners play in weight management. The BDA acknowledges this, but also highlights that sweeteners can be helpful in some cases, as they ‘allow patients and (or)

Table 2: Bulk sweeteners compared to sucrose3-4 Bulk sweetener

E number

Approximate sweetness compared to sucrose

Erythritol

E968

20-40% less sweet

Isomalt

E953

50% less sweet

Lactitol

E966

50% less sweet

Maltitol

E965

Same level of sweetness

Mannitol

E421

30% less sweet

Sorbitol

E420

40% less sweet

Xylitol

E967

Same level of sweetness

clients to alter their calorie intake without making significant dietary changes’.1 CANCER

Some studies in the 80s and 90s found an association between aspartame, saccharin and cancer development in rats. However, more recent large studies carried out in humans provide strong evidence that artificial sweeteners do not increase cancer risk.6,31 As discussed above, both types of sweeteners have undergone rigorous evaluation

by EFSA and are licensed as safe to use in the EU within their respective ADI levels.1,6 PHENYLKETONURIA (PKU)

This rare genetic condition is a deficiency of the enzyme phenylalanine hydroxylase, which means that the amino acid phenylalanine (Phe) cannot be metabolised and can build up to dangerous levels if not carefully excluded from the diet. As aspartame contains Phe, it is a legal requirement in the UK to clearly label that a food product contains a source of Phe if it contains aspartame.1,32 PREGNANCY

ADI levels are very conservative, as they are calculated at one hundredth of the amount that is safe to consume. Therefore, sweeteners are considered safe to use during pregnancy, as long as consumption remains below the ADI. However, low calorie options shouldn’t replace nourishing options during pregnancy; for example diet pop shouldn’t replace milky drinks.1 INFANTS AND YOUNG CHILDREN

In the EU, artificial sweeteners are not allowed to be used in any food which is designed for

infants or young children (up to three years old), including baby food.1,33 An important reason for this is because infants and children have high energy needs to support growth and development.1,33 There is also a lack of safety data in relation to the use of artificial sweeteners in this age group.1,33-35 A recent study found that breastfeeding mothers who drank diet drinks which contained sucralose and acesulfame K, resulted in these sweeteners transferring to their breast milk.36 However, this was a small study and more research is needed to investigate whether this might have any negative health effects for a baby consuming this breast milk.

CONCLUSION

The evidence base shows that artificial sweeteners and bulk sweeteners are safe for the general public to consume, including pregnant women (up to the advised ADI in the case of artificial sweeteners).

However, artificial sweeteners are not recommended for infants and children under three years old. People with PKU need to avoid aspartame.

There is no strong evidence that sweeteners increase the risk of cancer in humans; but there is good evidence that they are good for our teeth and can help to manage blood sugar levels. Sweeteners can also be useful as part of weight management interventions, especially for those with a sweet tooth.

Overall, sweeteners can be used as part of dietetic interventions, but, as with most aspects of nutrition, this should be assessed on a caseby-case basis. www.NHDmag.com August/September 2018 - Issue 137

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PAEDIATRIC

FEEDING THE PRETERM INFANT Martha Hughes, Scientific and Regulatory Executive, BSNA Martha is an Associate Nutritionist with a degree in Nutrition from the University of Surrey. She has research and regulatory experience in specialist nutrition.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Thanks to advances in antenatal care, the overall survival rates for preterm infants has increased in England over the last two decades.1 These infants are vulnerable and specialist paediatric dietitians have a crucial role to play in providing the nutritional support and intervention required to make sure that the diet of these infants is effectively managed.

A preterm infant is an infant born before 37 completed weeksâ&#x20AC;&#x2122; gestation. Missing some or all of the third trimester of pregnancy has a significant impact on an infantâ&#x20AC;&#x2122;s growth and development.

Therefore, these infants have higher nutritional requirements than term infants and need to be managed appropriately.

Physiological and metabolic stresses, such as respiratory distress or infection, will also increase additional nutritional demands, all of which need to be carefully and appropriately managed.2,3 Inadequate nutrition, particularly in preterm infants, can have short- and long-term health effects, including an association with longer stays in the neonatal unit, an increased risk of infection and worsened developmental outcomes.4 It is important that the multidisciplinary team assesses every infant before feeding is started.

life. Parenteral nutrition is valuable and often lifesaving for preterm infants who are unable to tolerate sufficient enteral feeds to meet their nutritional needs.

According to NICE,4 the current practice for using neonatal parenteral nutrition for preterm infants is in the immediate postnatal period whilst the preterm infant is attempting to establish enteral feeding, but has not yet established a nutritionally adequate breast milk or preterm formula intake. This can last a few hours, days, weeks, or longer, depending on the prematurity of the infant and whether they have digestive problems.

Neonatal parenteral nutrition may also be used for infants whose feeds are being withheld because necrotising enterocolitis (NEC) is present or suspected, for critically ill infants, or for infants with gastrointestinal disorders who require surgery.4

PARENTERAL NUTRITION

BREAST MILK

For most preterm infants, especially if an infant is under 30 completed weeks gestational age, or has a birthweight below 1kg6 (Table 1), nutrition support is likely to be provided by parenteral nutrition within the first few hours of Table 1: Definition of low birthweights Birthweight: The first weight of the newborn obtained after birth (ideally within one hour of delivery)5 Low birthweight (LBW)

<2.5kg

Very low birthweight (VLBW)

<1.5kg

Extremely low birthweight (ELBW)

<1.0kg

When an infant can tolerate milk, breast milk should be the recommended choice of feeding for a preterm infant. Breast milk offers many health benefits for premature infants, including providing antibodies to help mature the infants gut and immune system, along with reducing the risk of NEC.7 If an infant is under 35 weeks gestational age, or too immature to suckle, a mother can express her breast milk and the infant can be fed via an orogastric or nasogastric tube which goes directly into the stomach from day two of life.

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29

S* N

EW

LA TI O

U RM

FO

N

FOR HEALTHCARE PROFESSIONAL USE ONLY

NOW NUTRITIONALLY CLOSER TO BREASTMILK THAN EVER BEFORE 1,2, our latest reformulation of nutriprem 1, hydrolysed nutriprem and nutriprem 2 Preterm infants deserve the very best chance to thrive into their childhood years and beyond. Inspired by breastmilk, we’ve introduced our new “best yet” nutriprem formulations.

Now enriched with milk fat*, to aid calcium and fat absorption, ease digestion and soften stools3-7 Nutriprem 1 and nutriprem 2 are the only preterm products that contain prebiotic oligosaccharides, proven to beneficially support gut health8-10

Healthcare Professional Helpline 0800 996 1234 eln.nutricia.co.uk

Important notice: Breastmilk is best for babies. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants.

References: 1. Ballard O., Morrow A.L. Pediatr Clin North Am 2013;60(1):49-74. 2. Innis et al. Lipids 1994;29:541-5. 3. Bar-Yoseph F et al. Prostaglandins Leukot. Essent. Fatty Acids 2013;89(4):139-43. 4. Carnielli et al. Am J Clin Nutr 1995;61(5):1037-1042. 5. Carnielli et al. J Pediatr Gastroenterol Nutr 1996;23(5):553-560. 6. Kennedy et al. Am J Clin Nut 1999;70(5):920-7. 7. Quinlan et al. J Pediatr Gastroenterol Nutr 1995;20(1):81-90. 8. Boehm G et al.

Arch Dis Child Fetal Neonatal Ed 2002;86:F178-81. 9. Mihatsch W et al. Acta Paediatr 2006;95:843-8. 10. Knol J et al. Acta Paediatr 2005;94(449):31-3. *Nutriprem 1, hydrolysed nutriprem and nutriprem 2 only 18-079/March 2018.

PAEDIATRIC Once the infant is mature enough to suckle, tube feeding may continue whilst the infant is learning to breastfeed, or bottle feed, to ensure sufficient nutrition.

According to the GOSH clinical guidelines:6 • Preterm infants who weigh more than 1.5kg should receive 150ml/kg to 220ml/kg of expressed breast milk. Feed volume should be maximised before considering the addition of a breast milk fortifier. Infants receiving unfortified expressed breast milk should receive multivitamin drops, iron, folic acid, phosphate and sodium supplementation.

Serum calcium should be monitored and supplements should be provided if necessary.

• Preterm infants who weigh less than 1.5kg will not be able to meet their nutritional needs using expressed breast milk alone.7 For these infants, expressed breast milk should be fortified to increase the protein content, along with the addition of vitamins and minerals.

• Breast milk should be fortified with a breast milk fortifier specifically designed for preterm infants. Infants should be tolerating 150ml/kg for expressed breast milk for 48 hours before starting a breast milk fortifier.

• If an infant is at term, weighs more than 2.5kg, but is not meeting growth expectations, a standard infant formula powder may be used to fortify feeds.

PRETERM FORMULA

A mother’s milk supply is not affected by premature birth. However, having a preterm infant can increase stress and fear for a mother which can lead to difficulties in milk production.

If a mother cannot breastfeed, or if a mother chooses not to breastfeed, a specialist ready-tofeed preterm formula should be used.8 A preterm formula should be used in all infants who are less than 2kg in weight and under 35 weeks gestational age and not receiving breast milk. These formulae have been specifically developed to meet the additional nutritional needs and metabolic requirements of preterm infants. Therefore, an infant who is receiving 150ml/kg/day of preterm formula does not need the addition of vitamin and mineral supplementation.

A preterm formula should be used until the infant has reached a body weight of 2-2.5kg and/ or discharged.6 Depending on the infant’s growth at discharge, a nutrient-rich post-discharge formula may be used until three months corrected age, or potentially longer. It is important that growth restricted infants are monitored and assessed by a paediatric dietitian.

GROWTH MONITORING

Weight gain is an important marker for preterm infants, showing optimisation of nutrition and growth. UK-WHO growth charts for Neonatal and Infant Close Monitoring (NICM), formally known as the Low Birth Weight chart, have been developed to plot the weight of preterm infants from 23 weeks gestation to two years corrected age.9 The management of adequate delivery of energy and protein is really important to ensure growth thriving. However, accelerated growth in preterm infants should be avoided as it can lead to negative long-term health outcomes.10 As well as measuring and plotting the infant’s weight three times a week and length and head circumference weekly, weekly monitoring of serum sodium, potassium, phosphorus, calcium, urea and creatinine, C-reactive protein (CRP), haemoglobin (Hb) and urinary sodium is also required for nutritional assessment. If the infant is receiving parenteral nutrition, routine blood measurements are also essential.11

Indications for inadequate growth include:6 • consistent weight loss over several days (other than when diuresis is expected); • weight, length and/or head circumference velocity decreases over one week; • weight velocity alone decreases over two weeks.

CONCLUSION

Appropriate nutrition for growth and development is fundamental for preterm infants, with any inadequacy in delivery of the correct nutrients potentially implicating longterm health. It is important that healthcare professionals monitor growth and adjust the nutrition accordingly, to ensure optimal development for preterm infants. www.NHDmag.com August/September 2018 - Issue 137

31

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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.

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PAEDIATRIC

PREVENTING FOOD ALLERGY IN HIGHER RISK INFANTS Mary Feeney Paediatric Allergy Dietitian, King’s College London

This article reports on BSACI/BDA FASG guidance for UK healthcare professionals (HCPs) on preventing food allergy in higher risk infants.

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.

The UK Scientific Advisory Committee on Nutrition (SACN) has recently published a review on feeding in healthy term infants aged 0-12 months: Feeding in the First Year of Life. This report forms part of a comprehensive risk assessment of infant and young child feeding up to five years (60 months).1 To inform their work, an examination of evidence relating to ‘the influence of infant diet on development of food allergy and atopic and autoimmune disease’ was carried out by the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT).2 In April 2018, a SACN-COT working group, established to carry out a benefit-risk assessment on the timing of introduction of peanut and hen’s egg into the infant diet and to provide integrated recommendations to the UK Health Departments, published a joint statement.3 This statement recommended: • exclusive breastfeeding for around the first six months of life; • the introduction of complementary foods in an age-appropriate form from around six months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child; • foods containing peanut and hen’s egg need not be differentiated from other complementary foods; • the deliberate exclusion of peanut or hen’s egg beyond six to 12 months of age may increase the risk of allergy to these foods.

REFERENCES Please visit the Subscriber zone at NHDmag.com

These recommendations relate to healthy term infants. Included in the SACN-COT statement was an acknowledgement that HCPs may need to take into account different clinical scenarios, and targeted advice may be appropriate for infants at a higher risk of developing food allergy. SACN-COT also advised that families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing peanut or hen’s egg.3 GUIDANCE FOR HCPS

To support UK HCPs, particularly those working in primary care to provide individualised advice to families of higher risk infants, guidance has been developed by the Paediatric Advisory Group of the British Society of Allergy and Clinical Immunology (BSACI) and the Food Allergy Specialist Group (FASG) of the BDA.4-5 This guidance document, Preventing food allergy in higher risk infants: guidance for healthcare professionals, provides scientific background and practical information for HCPs and parents/caregivers and is designed to complement the SACNCOT joint statement (see Figure 1

www.NHDmag.com August/September 2018 - Issue 137

33

Preventing food allergy in higher risk infants: summary for healthcare professionals

PAEDIATRIC

The'UK'health'departments'advise'exclusive'breastfeeding'until'around'six'months'of'life, and'to'continue'breastfeeding'throughout'the'first'year.

Figure 1: The management of infants with a known risk factor for food allergy

Infants'with'a'known'risk'factor'for'food'allergy:

• •

Eczema* Existing'food'allergy'in'your'baby

Avoid'any'foods'the'baby'is'known'to'be'allergic'to

These'children'may'benefit'from'the'earlier'introduction' of'cooked'egg'(and'then'peanut),'alongside'other'solids

When'the'baby'is'ready,'consider'introducing'solid' foods'– including'cooked'egg and'then'peanut – from'age'4'months,'followed'by'other'allergenic'foods§ *Some infants will already be allergic to these foods: infants with moderateOsevere eczema are at greatest risk. To date, no lifeOthreatening reactions have been reported in this context.

Allergy tests can help identify individual infants at higher risk, but systematically screening all infants with more severe eczema is not currently available in most areas and may not be effective.

Families may wish to seek advice from a healthcare professional with expertise in allergy; this should not delay introduction of common allergenic foods beyond 12 months of age.

Infants'with'a'household' member'with'food'allergy

No'risk'factors' for'food'allergy

Consider'how'to'introduce'the'food' into'the'baby’s'diet'whilst'keeping' the'foodOallergic'person'safe.

Some'families'may'benefit'from' reassurance'from'an'allergy' specialist'but'this'should'not delay' introduction'of'allergenic'foods.

When'the'baby'is'ready,'introduce'solid'foods'at around'6'months'of'age'(but'not'before'4'months).'

Include'peanut,'egg'and'other'foods§ that'are' eaten'as'part'of'the'family’s'normal'diet Screening'allergy'tests'are'not routinely' recommended'prior'to'introducing'solids § Common'foods'which'can'cause'food'allergy'include:'egg,' peanut'and'other'nuts,'dairy'foods,'fish/seafood'and'wheat

The'UK'health'departments'advise'that'breastfeeding'should'continue This figure has been edited. The complete figure includes advice on allergy symptoms and management. Click here for the full pdf throughout'the'first'year'of'life,'at'the'same'time'as'introducing'solid'foods.

for a summary). It was developed following which is also summarised within the guidance Monitor'for'any'symptoms'of'an'allergic'reaction: a consultation process involving BSACI and document.9 ImmediateCtype'food'allergy BDA members, HCPs including health visitors DelayedCtype'food'allergy Infants with a household member with a Typically'happen'within'30'minutes'of'eating'the'food: Symptoms'occur'hours'after'the'trigger'food: and general practitioners, parents and patient food allergy, who have no other risk factors MildOmoderate'symptoms: Gut'symptoms: support groups. allergy, are also recommended to follow • Swollen'lips,'face'or'eyes •for Recurrent'abdominal'pain,'worsening'vomiting/reflux This document, directed towards HCPs, •current UK infant feeding advice. This is with • Itchy'skin'rash'e.g.'“hives”,'urticaria Food'refusal'or'aversion • Abdominal'pain,'vomiting Loose/frequent'stools'(>6O8 provides background information on the •the proviso that some times'per'day)'or'''''''' families will benefit from constipation'/'infrequent'stools'(2 or'fewer'per'week) RARELY**: Severe'symptoms'(anaphylaxis): randomised trials investigating the timing the reassurance of an allergy specialist and Skin'symptoms: AIRWAY:' Swollen tongue,'persistent'cough,'hoarse'cry of introduction of allergen foods for allergy •allergy testing before introducing allergen foods.

Skin'reddening'or'itch'over'body BREATHING:' Difficult'or'noisy'breathing,'wheezing •However, Worsening'eczema prevention, including the LEAP and EAT studies. this should not delay introduction of CONSCIOUSNESS:'Pale'or'floppy,'unresponsive/unconscious It also considers**risk'estimated'to'be'1O2'per'1000'babies'at'higher'risk.' the impact of implementing earlier NB:'DelayedOtype'allergy'cannot'trigger'anaphylaxis allergen foods. introduction of egg and peanut on preventing these allergies in different population groups: general Existing food allergy • Stop'the'trigger'food,'symptoms'should'resolve'after' • If'any'severe'symptoms'(anaphylaxis),''''''' and infants with moderate-severe eczema.6-8 Infants with a known risk factor for food allergy a'few'days. immediately'dial'999'for'assistance. ‘higher risk infants’ are defined as those with •orIf'symptoms'are'not'severe,'consider'trying'the'food' • Avoid'the'trigger'food,'do NOT reintroduce. again'1O2'weeks'later.

Infant• feeding eczema (particularly moderate-severe eczema GP'review'recommended.

• Seek'GP'review'If'symptoms'recur'or'are'severe.

A single-page summary includes an algorithm or early-onset beginning in the first three (Figure 1) outlining the management of infants months of life), or an existing food allergy. It with •a GP'advised'to'take'allergyOfocused'history:' known risk factor for food allergy, •is GP'advised'to'take'allergyOfocused'history:' advised that such infants may benefit from https://www.nice.org.uk/guidance/cg116 https://www.nice.org.uk/guidance/cg116 infants with a household member with a food •earlier introduction of foods containing egg (if Seek'advice'from'a'dietitian'with'appropriate' • Referral'to'secondary'or'specialist'care'is'recommended' competencies,'if'needed allergy and infants with no risk factors for food part of the family’s diet) and peanut, i.e. from for'all'infants'presenting'with'symptoms'of' Refer'any'child'with'persistent'delayedOtype' allergy. immediateOtype,'IgEOmediated'food'allergy.

Breastfeeding is advised for all infants •four months alongside other complementary symptoms'(not'responding'to'single'food'elimination)' 10 throughout the first year of life, alongside foods.

It is recommended that these allergen and/or'faltering'growth'to'specialist'clinic

introduction of complementary solids as per foods are introduced as an age-appropriate the UK health departments' recommendations, texture to avoid risk of choking, i.e. no whole regardless of allergy risk. For infants with no nuts or chunks of peanut butter. Egg should be risk factors for food allergy, it is advised that given in cooked form, as the use of pasteurised they follow current UK infant feeding advice raw egg was associated with significant allergic 34

www.NHDmag.com August/September 2018 - Issue 137

Table 1: Introducing egg and peanut into a baby’s diet Egg (both egg white and yolk

Choose British Lion stamped eggs, then you can offer your baby scrambled egg, omelette, soft or hard-boiled egg. You can mash egg into other foods, e.g. pureed fruit/veg, yoghurt, or baby cereals such as rice. Aim for at least one egg over the course of a week.

If you are not using British Lion-stamped eggs, only give well-cooked or hard-boiled egg.

Peanut

Never give whole nuts, coarsely-chopped nuts or chunks of peanut butter to children under five years of age, as these are a choking risk.

You can use smooth peanut butter, ‘puffed peanut’ snacks, or grind whole peanuts to a fine powder. Mix with pureed fruit/veg, yoghurt, porridge, baby cereals etc, or add to baby’s milk.

Suggested recipe: Mix 1 teaspoon of smooth peanut butter with 1 tablespoon of warm water (boiled), or baby’s milk, or some pureed fruit/veg. Aim for a total of 2 level teaspoons per week.

reactions during a German study of early egg introduction.11 Practical advice, including recipes and tips for introduction, are provided in the accompanying information for parents/ caregivers.

Screening Systematic screening of all higher risk infants is not routinely recommended prior to introducing egg or peanut; this decision related to current limited availability of allergy testing and the lack of prompt access to supervised food challenges which would be needed should screening tests be positive. Negative allergy tests are highly predictive of the absence of IgE-mediated (immediate-type) allergy symptoms. Positive allergy tests are less predictive of allergy and require confirmation by a supervised food challenge to identify whether the infant is sensitised but tolerant, or already allergic.

The guidance aims to support HCPs to help parents/caregivers make an informed decision, weighing up the benefits of allergy testing prior to introduction against the possibility that a delay in introduction may increase the risk of their infant developing a food allergy. To date, no lifethreatening reactions have been reported in infants related to the introduction of allergenic foods.

Screening is not generally offered in those countries where peanut is introduced in infancy and this has not caused major public health concerns. However, some infants will already be allergic when these

foods are introduced and so information on allergy symptoms and how to manage them is included on the front page of both the HCP guidance and the information for parents/caregivers.

Referral Onward referral for specialist advice is recommended for all infants with a diagnosed IgE-mediated (immediate) food allergy and also for those with eczema that is poorly controlled or requires longer term or potent steroid use.

'PREVENTING FOOD ALLERGY IN YOUR BABY: INFORMATION FOR PARENTS'

The accompanying information for parents/ caregivers incorporates public health messages from the UK health departments for mothers during pregnancy and after birth, alongside more specific allergy prevention advice. Allergen avoidance during pregnancy and breastfeeding, omega-3 fatty acids, probiotics, healthy eating and the use of partial or extensively hydrolysed infant formula milks for allergy prevention, are discussed as well as the timing of introduction of egg and peanut.12-13 This information sheet includes practical advice about suitable textures and recipes for introducing peanut and egg (Table 1), how to spot an allergic reaction and how to manage it, as well as how to introduce these foods if someone else in the household is allergic. Further sources of information and recipes are also provided.

The new guidance is available to download at: www.bsaci.org/about/early-feeding-guidance or www.bda.uk.com/regionsgroups/groups/foodallergy/allergy_prevention_guidance www.NHDmag.com August/September 2018 - Issue 137

35

CONDITIONS & DISORDERS

EATING DISORDERS IN OLDER ADULTS Nikki Brierley Specialist Dietitian and CBT Therapist

Nikki has been a HCPC Registered Dietitian for 10 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 NHDmag.com

Eating Disorders (ED) are serious mental health (MH) conditions that can develop at any age, across genders, ethnicity and cultural backgrounds. They are most commonly associated with young women (12-20 years of age); however, it has been suggested that there is possibly a hidden epidemic in older adults.

ED involve disordered eating patterns (i.e. restrictions, bingeing and/or purging) and concerns about body image (BI). They can significantly impact on the quality of life, cause serious harm and are associated with the highest rates of mortality of all MH illnesses.1 There are various stereotypes, stigma and misunderstandings that surround ED and this can prevent individuals seeking help and accessing appropriate treatment.

For the older adult, this can be further compounded due to the misconception that they are no longer at risk. This can result in warning signs and symptoms being missed and can leave individuals struggling without support. Add to this the importance of early identification and treatment, and it is clear to see the importance of raising awareness and understanding of ED in older adults.

RISK FACTORS

As previously mentioned, ED are most commonly associated with young women (12-20 years). It is easy to assume that with age and wisdom body acceptance increases and the risk of ED reduces. However, research suggests that this is not the case and some risk factors associated with the development of an ED may actually increase with age.

Body image issues As an ageing body moves further away from the projected cultural ideals (i.e. young, thin, firm, unblemished), the risk of body dissatisfaction may increase.

Difficult life events With age, there is an increased risk of 36

www.NHDmag.com August/September 2018 - Issue 137

being exposed to a variety of difficult life events (i.e. possible loss of partners, parents and friends, moving home, divorce/separation, loss of employment, finanical concerns, loneliness and illness). These have the potential of significantly increasing stress levels and reducing overall wellbeing.

STATISTICS AND RESEARCH

There appears to be a growing number of women aged 30+ years who are struggling with disordered eating and, alarmingly, this trend is predicted to increase. It may be surprising to know that an estimated 80% of women, aged between 60-70 years, control their body weight and that 60% are dissatisfied with their bodies.2 Perhaps a little less surprising is the estimate that 70% of women >50 years of age are trying to lose weight.3 These figures suggest that, unfortunately, body acceptance does not appear to increase with age and that body dissatisfaction can potentially increase over time.

Prevalence estimates of ED in older adults (defined as >40 years) range from 1.8 to 3.8%, with binge eating disorder (BED) cited as being the most common category in this age group.4 Recent research to identify the prevalence of ED in women in midlife (40s and 50s) suggested that 15.3% of women meet criteria for a lifetime ED, with a 12 monthsâ&#x20AC;&#x2122; prevalence of 3.6%.4 Worryingly, this research also suggested that only 27.4% of all the women with ED had sought or received ED treatments, with only 4.9% receiving psychological treatment for ED and 4% receiving psychological treatment for

an alternative diagnosis.4 These results suggest a higher occurrence than previously reported, but are comparable to former estimates. They also highlight that a significant proportion of women will experience an ED by midlife, but that many are not seeking or receiving treatment.

This research only included females and, unfortunately, there currently does not appear to be comparable research across the genders. It is, however, possible to hypothesis that some of the same increased risk factors may be present when ageing, regardless of gender. Statistics suggests that approximately 25% of those experiencing an ED are male,5 so this would suggest that older females would be at greater risk, but highlights the importance of considering ED pathology in older males also.

ED AND MENOPAUSE

An additional factor which may increase the risk of ED in midlife females, is the changing hormone levels associated with the menopause (i.e. reduced oestrogen levels, increased testosterone and progesterone levels), potentially increasing appetite, altering metabolism and resulting in weight gain and/or a changing body shape.

This, combined with an increase in the visible signs of ageing (wrinkles, hair loss and changes in body fat distribution), may further increase the awareness and emphasis on appearance and thus potentially increase body dissatisfaction.4 This gives rise to the possibility of increased efforts to manipulate and control eating and/ or exercise, in an attempt to prevent the natural body changes that are taking place at this time (which is indeed, not too dissimilar to the increased risk associated during puberty).

A further consideration is the notion that women become increasingly devalued by society in later life which can have a negative impact on their mental health and wellbeing.4 LATER LIFE

The presence of ED in the elderly is also recognised, but there is a lack of research in the prevalence in this population. There are a number of additional factors that can potentially occur in later years which could contribute to the development of disordered eating and increase the risk of an ED.

Loss of purpose Retirement, children leaving home, perceived or actual reduced contributions to society, can all have a negative impact on mental health and wellbeing, resulting in changes in dietary intake.

Loss of independence/control over life The reduced ability to meet oneâ&#x20AC;&#x2122;s own needs and an increasing reliance on others to contribute to safety and wellbeing potentially increase the risk of a desire to control eating as a means of asserting some control.

Perceived or actual cognitive impairment and memory loss This increases the risk of skipping meals, forgetting to eat or overeating and potentially allows for irregular, avoidant or overeating due to ED cognitions going undetected.

Ill health/medical conditions and medications An increased risk of the development or deterioration of chronic health conditions potentially increases anxiety around eating (i.e. trying to follow a strict/restrictive diet after a diagnosis of a physical health condition).

Prescription medications may impact on appetite, resulting in changes to taste and/or increased nausea, all of which may lead to the concealment of changes in eating behaviours.

Changes in digestion and/or bowel habits This potentially increases awareness and anxiety surrounding the digestive process (i.e. needing access to facilities, or concerns about infrequent bowel movements, feeling bloated/ uncomfortable). The use of laxatives and possible restrictive changes in diet and avoidance of certain foods can contribute towards, or conceal, disordered eating/body image issues.

A literature review of ED in those >50 years (age range 50-94 years, mean age 68.6 years), suggested that a late onset ED is more common (69%) than early onset. It also suggested that anorexia nervosa accounts for 81% of cases in this age group and bulimia nervosa for 10%.6 There is an increased risk of weight loss and malnutrition in the elderly for a variety of reasons and there is the possibility that weight loss experienced due to adverse conditions, www.NHDmag.com August/September 2018 - Issue 137

37

TASTE

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Table 1: SCOFF questionnaire Do you ever make yourself Sick because you feel uncomfortably full?

Do you worry you have lost Control about how much you eat?

Have you recently lost more than One stone in a three-month period?

Do you believe yourself to be Fat when others say you are too thin?

Would you say that Food dominates your life?

such as ill health, or a difficult life event, could be viewed in a positive light and trigger an ED. Laxative use is also more common in the elderly population and can become problematic if used as a method of purging. As such, it is suggested that laxative use is monitored and that if unexplained weight loss occurs, ED should be included in the differential diagnosis.6 IDENTIFICATION OF ED IN OLDER ADULTS

ED can easily go undetected in older adults and the health risks can be greater, due to a less resilient and ageing body. The presence of ED behaviours can also progress chronic illnesses which are more common in elderly (i.e. osteoporosis, arthritis). Warning signs can easily be missed, as they can be attributed to other factors. Some of the key signs/symptoms to consider are as follows: • Change in behaviour (i.e. using the bathroom after eating, eating alone rather than with friends/family) • Increased sensitivity to cold • Excessive hair loss • Gastrointestinal problems including laxative use • Heart problems • Dental damage If the presence of an ED is suspected, the SCOFF screening tool (Table 1) may be a useful aid in considering the suitability of referral for specialist support within an Eating Disorder Service (EDS). The SCOFF screening tool was designed

by Professor John Morgan to indicate a possible eating disorder. A score of two or more positive answers is considered a positive screen (i.e. ED indicated). It is, however, important to remember that an individual may not be comfortable disclosing the information, or answering direct questions. As such, it is also useful to include

open questions around eating behaviours and any concerns regarding weight, shape and size. If an ED is suspected, making contact with local EDS to discuss possible referral might prove useful.

DISCUSSION

As dietitians and healthcare professionals, it is important for us to remember that individuals can present with an ED at any age and that this may be an initial onset, chronic or a relapsing ED. It is also essential to understand that it is often difficult for those struggling with ED to disclose their difficulties and that stigma, lack of understanding and other internal and external factors can make the process of asking for support even more difficult.

When considering ED in older adults, it might also be useful to reflect on our own views and opinions concerning ageing and explore the common held belief that body image issues reduce with age. We need to accept that many older individuals are indeed dissatisfied with their weight, shape and/or size and that some of the risk factors for developing an ED increase with age. This will help us to keep in mind the possibility of an ED when working with any patient group. It may also be useful to consider previous interactions and reflect on the possibility that ED cognitions might have been present and, therefore, could be preventing dietary changes.

SUMMARY

There is a common belief that ED mainly effect the young and that older adults are no longer at risk. However, research contradicts this and suggests that many older adults are experiencing body dissatisfaction and that the ageing process can indeed increase this further. The risk of experiencing difficult life events also increases over time, as do several other risk factors that can contribute/trigger the onset of ED. There is a risk that the warning signs and symptoms of ED can be overlooked in the older adult. This increases the risk of ED remaining undetected and untreated across this age group. Keeping all this in mind and completing simple screening questions (regardless of age, gender, ethnicity or cultural background), could help to identify those struggling with ED and will ensure that suitable treatment is then made available. www.NHDmag.com August/September 2018 - Issue 137

39

PAEDIATRIC COMMUNITY

DYSPHAGIA IN THE COMMUNITY: A PAEDIATRIC PERSPECTIVE Jenni Simmons Highly Specialist Speech and Language Therapist, Betsi Cadwaladr University Health Board (NHS) Jenni has worked as a Paediatric Speech and Language Therapist for eight years. She currently works with children with complex needs, assessing and providing intervention to develop both communication and feeding skills.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Speech and language therapists (SALTs) play an important role in supporting children with feeding and swallowing difficulties. Promoting safety and ensuring adequate nutritional intake are always primary goals1 for all SALTs and this is no different when working in the community.

Swallowing difficulties are collectively labelled ‘dysphagia’. Infants or young people who suffer from dysphagia may have: • problems with sucking, chewing, or swallowing effectively and safely; • difficulties developing their feeding skills; • aversion to a particular taste, texture or method of feeding; • behavioural difficulties associated with eating, drinking and mealtimes.2 Children with a neurodisability and those born prematurely are at a higher risk of having feeding difficulties; however, we cannot exclude a number of children in the typically developing population. The Royal College of Speech and Language Therapists (RCSLT) has summarised the incidence of feeding difficulties as occurring:2 • between 25% and 45% in a typically developing paediatric population; • between 32% and 44% for children with general neuro-development disabilities; • between 26.8% and 40% of infants born prematurely.

Although some of these children may be seen in the hospital setting, a large proportion of them will be assessed and given intervention in the community, either in their homes or in an educational setting. Many of the children on a SALT’s caseload will be seen in an educational setting, which is important, as children spend a large portion of their week in school and will

40

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have the opportunity for meals and snacks. Dysphagia can cause impaired health and nutrition, which clearly has an effect on a learner’s ability to attend to instruction and participate in the learning process. Educational settings offer unique challenges for SALTs.1 The therapist will rely on teachers, support workers and school staff to feed the child, food for the child will often be prepared by the school kitchen and modified to meet the specific recommendations for the individual child and there are many school-day distractions within the environment that may need adapting. Management of dysphagia is an educational priority because it threatens the academic, social and emotional wellbeing of students with disabilities.1 Building relationships within the school is vital. School nurses assigned to students with swallowing and feeding disorders can help facilitate communication3 between health and educational colleagues.

A MULTIDISCIPLINARY APPROACH

Today’s schools often have a diverse cultural population which needs to be considered. The American SpeechLanguage-Hearing Association (2007) (ASHA) comments that one of the most significant aspects of a culture is its relationship between food and eating.

Guidelines from this source state that:4 ‘Professionals who work with students with swallowing and feeding disorders need to be aware of the cultural beliefs and attitudes of each student’s family.

Table 1: MDT - the work involved for team specialists and parents Speech and language therapist

Parent

• Identifies at-risk students.

• Provides assessment and treatment.

• Establishes swallowing or feeding plan.

• Trains school-based personnel and the parent as needed.

• Provides therapeutic intervention.

• Communicates with the parent.

• Communicates with the medical professional.

•

• • •

School nurse

Class teacher

•

• • • •

•

•

•

•

•

Monitors the health, weight and overall nutrition of the student.

Monitors respiration if needed.

Assists in communicating with paediatricians.

Consults with parents and school staff.

Assists with tube feeding or medication.

Shares knowledge of student’s feeding habits, food preferences and mealtime environment.

Provides medical and feeding history.

Shares beliefs related to eating and foods.

Implements swallowing and feeding strategies in home and community environments.

Implements the swallowing and feeding plan in the classroom.

Monitors changes in the student’s swallowing and feeding in daily classroom activities.

Coordinates the personnel responsible for feeding students.

Oversees the mealtime environment to make it safe in the classroom or canteen.

Supports communication and social goals during feeding.

Occupational therapist

Physiotherapist

• • •

• Addresses postural skills and mobility issues.

• Addresses positioning and adaptive equipment needs related to positioning for mealtimes.

Addresses fine motor skills related to self-feeding.

Addresses sensory and regulation issues.

Addresses positioning and adaptive equipment for eating.

These attitudes and beliefs guide the family’s integration of the feeding program at home.'

This emphasises the importance of families collaborating and liaising with professionals continuously throughout episodes of care regarding their child’s feeding. This cannot just be to help inform about cultural issues, but should be for every aspect of the child’s feeding assessment and their intervention process. Some children can be very different at home than at school in regard to what they eat, how they are positioned when eating, where they feed and how they are fed and by whom. Parents need to be part of the process from the initial referral, so that the therapist can assess the child across all environments with all feeding partners to ensure the correct advice and strategies are provided.

Parents are one significant part of a larger team which, as a whole, needs to make sure the children receive a comprehensive and thorough feeding plan. A multidisciplinary approach is vital to ensure all the needs of the child are met.

The ASHA (2007)4 has produced guidelines with expected contributions between different members of the child’s team. This is summarised in Table 1.

Table 1 does not offer an exhaustive list; other professionals who may also be involved include: • a dietitian to monitor the weight and overall nutrition of the student and also offer advice regarding tube feeding; • a paediatrician to monitor and review the child’s overall health; • a psychologist to assess and offer advice and strategies regarding behavioural elements of feeding.

A study by Cowpe, Hanson and Smith (2014)5 investigated what parents of children with dysphagia thought about their child’s multidisciplinary team. This research states that, ‘without exception, parents reported a desire to be recognised as a key member of their child’s MDT.’ Parents were reported to value the specialist knowledge that the professionals could provide. It was also noted that parents valued the professionals more who listened and sought their opinion about their child’s condition. The impact of accessing services, the amount of time allocated to their child, the flexibility of service delivery (i.e. could the child be seen in different environments, such as home and school) and www.NHDmag.com August/September 2018 - Issue 137

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COMMUNITY

There is no single program that works for all children with dysphagia.

Feeding plans need to be tailored for each individual. staffing, were major contributors of parents being satisfied or dissatisfied with the service that was provided. The discussions within the research emphasise the differences and inconsistency of packages of care available to clients in different localities.

TREATMENT STRATEGIES

Generally, treatment strategies can be divided into compensatory procedures, which are particularly useful for children, and direct therapy strategies.6 The goal of any feeding plan is to ensure that the child is able to establish or return to a safe and efficient oral intake on a normal diet without the need to use any special strategies. This goal may not be attainable for all children.6 There is no single program that works for all children with dysphagia.1 Feeding plans need to be tailored for each individual.

Below are a few examples of interventions and strategies which may be implemented with a client when working with them in the community; this is not an exhaustive list: Feeding pattern alterations Changing the feeding pattern for the child can make a significant difference in the safety and efficacy of eating. 6 Suggestions may include: • slowing down the pace of the meal; • giving verbal and physical prompts that the food is being presented; • encouraging additional ‘fake’ or ‘dry’ swallows to clear food and residue in the mouth and pharynx by presenting the child an empty spoon; • encouraging self-feeding, if appropriate and safe, which will increase the child’s awareness that a swallow is needed.

Environmental changes The school environment in particular can be noisy and full of distractions, especially in some locations such as the canteen or busy classroom. Some children will benefit from reducing the distractions when they are eating, such as being fed in a quiet classroom rather 42

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than in the noisy canteen. When children can handle the distractions of a school cafeteria, their opportunities to be included in the lunchroom with peers with and without disabilities should be facilitated and supported.1 There are pros and cons of eating in isolation; safety needs to be weighed up against the reduction of time in socialising with peers. Also, encourage the use of adaptive feeding equipment to improve independence when possible.

Postural changes It is vital that staff working with the child understand the importance of body position for a safe swallow. The postural recommendations would be dependent on each child’s abilities and physical difficulties in relation to their swallow, so staff would need to be trained to ensure a child’s safety.

Diet modification This is the change of consistency of food and drink to ensure a safer and more efficient swallow.

Staff training Dependent on the needs of the staff, training would make sure that the ‘feeders’ were competent and confident in feeding the child in their care, but equally able to identify signs and symptoms of aspiration, or difficulties in relation to the child’s feeding.

COMMUNITY CARE

As discharging from hospital into community care becomes more frequent and more of the norm, the complexity and number of children with dysphagia needing ongoing care, assessment and intervention in their everyday environments is going to increase. The main goal for the SALT is to ensure that the child’s swallow and feeding are as safe as possible in order to reduce the risk of aspiration. This only works with a competent team of professionals working together in the child’s environments inclusive of parents and school staff, to create a unique feeding plan for the individual child.

NUTRITION MANAGEMENT

Alice Fletcher RD Community Dietitian, Countess of Chester NHS Foundation Trust Alice has been a Registered Dietitian for three and a half years, working within NHS communitybased teams.

She is passionate about evidencebased nutrition and dispelling diet myths. Alice blogs about food and nutrition in her spare time at nutritionin wonderland.com.

REFERENCES Please visit the Subscriber zone at NHDmag.com

HUEL: IS THIS THE FUTURE OF FOOD FOR HUMAN HEALTH AND SUSTAINABILITY OF THE PLANET? The aim of this article is to give you a balanced overview of what Huel is, why it has been created, its nutritional content and where it could be used in dietetic practice, alongside summarising the pros and cons.

I had not heard of Huel until the middle of last year and when speaking with my dietetic colleagues, none of them were aware of it either. There is a focus on its role as a sustainable source of nutrition, but just to be clear from the outset, I have not received any payment or suggestions from Huel regarding this article, aside from comments quoted from their head nutritionist James Collier when I asked him some questions via email in April 2018.

Huel very kindly sent me a large pack of their products to trial when I told them that I was writing this article.

I received the same pack that a paying customer would get.

WHAT IS HUEL?

You might have guessed it, but the name of this product is a take on the words ‘fuel’ and ‘human’. Google ‘Huel’ and you get over 3,130,000 results. Search for the hashtag on Instagram and you get 12,328 hashtagged posts (on 11/5/18). You’ll certainly find a lot of information on Huel online.

Launched in June 2015, Huel is a meal replacement thought up by Julian Hearn (who created Bodyhack). The product itself was created in conjunction with James Collier (Registered Nutritionist, former dietitian with seven years of NHS experience).1

Huel the company, states that we are in the middle of a food crisis; that modern food production methods are inefficient, inhumane and unsustainable. This is true. Food is listed as either the major (or one of the major) drivers of climate change, land use, water stress, biodiversity loss, soil erosion, deforestation and depletion of fish stocks.2-4 Our population is growing exponentially, estimated to reach over nine billion by 20505 and the world population is the most overweight and obese it has ever been.6 Based on our present consumption, something has to give. Huel claims to be the solution to these problems.1 Unlike other meal replacements available, Huel is not specifically aimed at those wishing to lose weight. It is aimed at those who live busy lives; their nutrition and sustainability is important to them and they don’t always have time to make a nutritionally balanced meal. They would prefer to have the safety net of a balanced, satisfying ‘just add water’ meal at the ready in their bag for when nourishing, balanced food is scarce and they don’t want to succumb to a supermarket meal deal. The simple black and white packaging is trendy and the website is very transparent and thorough. I can find everything I would need to know about Huel on there, with reputable references.

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NUTRITION MANAGEMENT Table 1: Huel products Product

Product summary

Palatability (my personal opinion)

Powder

Huel powder can be used to make drinks (use scoop provided to add to water or plantbased milk) and made up to the calories that you need, a bit like formula milk. This is the first product created, the granola and bars are supplementary to the Huel diet. Huel powder mix is available in three flavours (unflavoured, vanilla, coffee). You can also purchase 12 different flavour boosters presented as small sachets of sugar-free powder. Aside from drinking the powder, Huel recommends using it in recipes to boost the nutritional profile (for example in the place of flour). There are many recipes on their website.

Oaty, aroma of dried pulses, grainy in the mouth but not unpleasant. Due to its ‘bitty’ texture, I found that I chewed it as I drank it. I found that it increased the palatability when blended with some frozen berries. I tried doing this in the morning and keeping it in a cool bag for lunch at work, but it separated and wasn’t quite the same. With the addition of a flavour booster it became more palatable, but I found that I still needed to blend it to remove lumps, using the shaker provided didn’t quite cut it (but that is just my experience). Blending it did seem to defeat one of its objective selling points, as I couldn’t do this on the move/at work. However, lots of people report finding it very palatable and not lumpy without using a blender. Reviews of the products online have been mixed, but mostly positive.

Granola

This is available in plain and berry flavour and is very high in protein (14g per portion) and fibre (6.3g per portion). A portion is recommended at: 60g (twice that of many supermarket cereals). Per serving it contains between 15-45% EU Nutrient Reference Values of 26 vitamins and minerals.

I found the berry granola tasted slightly salty and again had a dry powdery texture. I did not particularly enjoy it, but it was very filling.

High protein Bars

A 65g bar contains 250kcal, 15.4g of protein, 7.5g of fibre and 26 vitamins and minerals (at between 15-52% EU Nutrient Reference Values).

They are brown in colour and quite dry in texture. I found the bar to be very filling, but not particularly enjoyable to eat.

THE PRODUCTS

Within the box sent, customers get a 12-page guide regarding how to use Huel. Within this guide you are given case study examples of calorie goals either to lose, maintain or gain weight using Huel powder for two meals per day. It also recommends a calorie counter to aid this decision making. It is transparent for the general public and I see no negatives.

Huel as a meal replacement is available in three main products at present (see Table 1).

Huel’s founder, Julian Hearn, states within the starter pack, “I use Huel (powder) during the day for breakfast and lunch, then sit down to a ‘conventional’ meal in the evening. It’s the best of both worlds.” This sounds like a reasonable approach to me.

HUEL PROMOTES ITSELF UNDER SIX MAIN HEADINGS

1. “It can give us complete nutrition without needing to carefully plan meals. No more ‘nutrition anxiety’” See Table 2.

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2. “It is simple and can save us time. Fewer trips to the supermarket and no cooking” As I have mentioned earlier, this is definitely the case if you find it palatable on its own with water. Time is often quoted as one of the main reasons why people struggle to eat healthy balanced meals and Huel aims to remove this barrier. However, should we be focusing on tackling the reasons for not being able to make a balanced meal for example, time, skill, misinformation regarding foods and nutrition? When discussing Huel with other dietitians, some of my colleagues have expressed concern that moving towards a Huel-based diet would de-skill people and make the reasons why cooking and food preparation is avoided all the more present. If people are consuming Huel at work because they are burnt-out and don’t have time for a lunchbreak, or there are not facilities to reheat leftovers, or the canteen does not provide any balanced meal options, shouldn’t such issues be tackled instead?

Table 2: A summary of the nutritional value of Huel Good points:

Any possible negatives:

a The ingredients do not include any allergens apart x from oat flour. The ingredients contain a lot of 'natural' foods, listing oat flour, pea protein, brown rice protein and flaxseed, sunflower and coconut as the first listed ingredients.

a Suitable for vegetarians, vegans and those with

x

The recommended dilution for 2000kcal per day would mean consuming 2.3 litres of fluid daily which may be too much for some people to manage. You can however add less water to the powder if this was the case, but this would result in a thicker product.

x

Huel contains a synthetic form of vitamin D (ergocalciferol) which is not as well synthesised as cholecalciferol. It does however provide 150% of the RDA in 2000kcal (which was updated to 10 micrograms per day in 20168). Vitamin D deficiency is rife in the UK.9

x

Some information on the website I found to be misleading, e.g. with a pancake recipe stating: ‘Add a scoop to your pancakes to make them nutritionally complete.’ Huel is nutritionally complete at a certain volume (made up to 2000kcal), adding a scoop would only add nutritional value, not make the pancakes nutritionally complete.

x

There are no clinical trials specifically on utilising Huel to demonstrate its efficacy for any particular clinical purpose (for example weight loss).

However, Huel has not been developed for such a purpose, therefore this is irrelevant.

lactose intolerance. It is soy free. A gluten-free variety is available (oats used in standard version are not gluten free). There is an extensive list of indications and contraindications on their website (including lactation, pregnancy, diabetes, IBD, eating disorders).

a In 2000kcal, it meets the UK recommended guidelines for percentage of energy as total fat, saturated fat and carbohydrate. 37% of the energy comes from carbohydrates, 30% from fats, 30% from proteins and 3% from fibre.

a Huel is a good source of protein and fibre (almost double the recommended intake) from both soluble and insoluble sources which are beneficial for gut health. From the NDNS report 2018, only 7-9% of adults met the recommended 30g per day fibre target.9

a 2000kcal of Huel powder per day includes at least 100% of the European Union’s daily recommended amounts of all 26 essential vitamins and minerals. Few people in the UK get this from their diet.9

Huel contains both omega-3 and MCT essential fatty acids in significant quantities. There is no recommended intake level for MCT, however, the European Food Safety Authority have suggested a safe upper limit of 5g/day omega-3 whereas this product would be providing 13.4g in 2000kcal, so this is an area of potential concern if used for a prolonged period of time (increased risk of bleeding7).

a Low in sugar (1.2g per 100g powder) and low GI with a score of 27. Plus, Huel is low FODMAP.

3. “Huel reduces food waste” The Food and Agriculture Organisation of the United Nations (FAO) estimates that one third of food produced for human consumption is lost or wasted globally, which amounts to approximately 1.3 billion tons per year.10 Huel has a shelf life of over one year. Huel products could certainly reduce food waste comparative to the population’s present diets.

4. “Huel is affordable” Huel costs just £1.61 for a 500-calorie nutritionally complete meal.1 Huel also offers bulk

and subscription discounts, where the cost starts at just £1.33 per meal. Using the latter, this equates to £28 a week if you consumed three meals per day of Huel powder made up with tap water. The most recent report from the Office of National Statistics (2016) found that the average person currently spends just under £58 per week on food and nonalcoholic drinks.11 Lower meat diets can also be cheaper, more sustainable and arguably healthier. If people were more aware of how to use their leftovers that would also save them money. www.NHDmag.com August/September 2018 - Issue 137

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NUTRITION MANAGEMENT

p

Is

et?

it

ti

e

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o li d f o o d t o quit s e sav tw et a he th

Animal protein is not sustainable, the global demand for it has been predicted to increase by 80% between 2006 and 2050.

5. “Huel is vegan, therefore humane” In the UK, the number of people identifying as vegans has increased by 350%, compared to a decade ago, according to research conducted

by Ipsos MORI and commissioned by the Vegan Society in partnership with Vegan Life magazine.

This study found close to half of all vegans were in the 15-34 age category (41%) compared to just 14% who are over 65 - evidence to support even greater growth in the future.12 There has been notable increased public concern regarding ethics of intensive farming over the last decade.

Vegan diets often can be low in protein, vitamin D and B vitamins, but Huel is rich in these nutrients.

starchy CHO and fruit and vegetable sections being increased when it was redeveloped, with the meat and dairy sections reducing in size.16 WWF-UK’s One Planet Food Programme (200912) has set goals to reduce UK food consumption related emissions by at least 25% by 2020 and by 70% by 2050, based on 1990 emission levels. The researchers found that it is possible to have a diet 25% lower in greenhouse gas emissions than today that meets nutritional recommendations.

This diet would include significantly fewer meat and dairy products. The researchers noted that choosing monogastric meat sources such as chicken, results in lower carbon emissions than beef.13

6. “Huel is sustainable” Is it time that we quit solid food to save the planet? Animal protein is not sustainable, the global demand for it has been predicted to increase by 80% between 2006 and 2050.13-15 The Eatwell Guide itself has been formulated keeping sustainability in mind, with the wholegrain

CLINICAL USES OF HUEL

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When I asked James Collier about Huel’s possible clinical applications, he recognised that Huel was not as energy dense as sip feeds available (Huel is around 0.8kcal/ml). He also stated: “I think Huel could have some clinical applications and we have had some dietitians,

If we all aimed for a mostly plant-based diet, with limited food waste and calorie control, the planet (and our health) would benefit. clinicians and patients who have used Huel. Indeed, I am aware of some who have administered Huel through NG and PEG tubes via syringe heeding appropriate tube care. For weight loss, Huel is easy to control calories, even though it’s not designed for weight loss.

Anecdotally, a large number of people claim to have used Huel successfully for weight control.

I have also read about diabetics who use Huel for BGL control. Huel is low GI-27.”

A recently published randomised twogroup dietary intervention study with 39 obese participants, has shown that a 12-week complete meal replacement diet was superior to a caloriecontrolled real food diet in terms of reducing food cravings and modulation of food reward pathways within the brain.17 Another study including 55 obese individuals has shown that meal replacement products were as effective and safe in order to lose weight and to modify other anthropometric parameters in a controlled dietetic program as a conventional dietetic treatment without meal replacement products.18 When it comes to systematic reviews regarding meal replacements and weight loss, the results are mixed. A systematic review conducted in 2011 included seven studies and found the evidence of the beneficial effect of meal replacement on long-term weight loss to be inconclusive.19 Huel could be utilised within programmes aiming for Type 2 diabetes remission. The new diabetes UK Dyson guidance this year concluded that 15kg needed to be lost in those who are overweight or obese to initiate remission.20 IS THIS POSSIBLY PROMOTING DISORDERED EATING?

I would not advocate someone living solely on Huel forever. I predict that this would hugely impact on social and emotional wellbeing. Huel references that it removes ‘nutrition anxiety’.

Orthorexia (an unhealthy obsession with eating 'pure' food) is a new phenomenon that I think

Huel could inadvertently encourage should its marketing change tact.

I know that many dietitians take the view that we are not machines - we do not just need fuel, because, as humans, food is so much more than just fuel. Viewing eating as a complete inconvenience does feel alien to me, but like many others, I have had days where I wish I didn’t need to cook from scratch. One of many dietetic/ nutritionist solutions to this would be having homemade, or good nutritional quality ready meals, in the freezer for these situations. I’m not sure a Huel drink would cut it for me in its place.

As dietitians, we closely monitor people who are unable to eat and drink and those who survive solely on enteral/parenteral nutrition.

We know that people can live long, nourished lives from complete medicated nutrition, yet, should we do this when there is not a clear indication to do so? Although recognising that, nutritionally, there would not be an issue with living on Huel for a lifetime, James Collier agrees that it is not necessary: “I have no concerns about people consuming 100% Huel for the rest of their life: I wouldn’t advocate it, as I feel there is pleasure from consuming solid food and other social aspects to consider.

I am more in favour of (like you say) people consuming Huel as part of a balanced healthy diet. There are many naturally occurring phytonutrients in Huel and we also add additional lycopene, lutein and zeaxanthin.”

MEETING IN THE MIDDLE

If we all aimed for a mostly plant-based diet, with limited food waste and calorie control, the planet (and our health) would benefit. I see absolutely no issue with utilising Huel as part of a healthy balanced diet, or to meet weight loss goals (and would support clients who decided to utilise it), but I would not recommend anyone to consume only Huel for the rest of their lives, solely for the purpose of saving time and money. Food is wonderful after all! www.NHDmag.com August/September 2018 - Issue 137

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COMPETITION WINNER

IN ASSOCIATION WITH BRITISH LION EGGS

EATING EGGS DURING PREGNANCY Cordelia Woodward RD Freelance Dietitian Cordelia is a Freelance Dietitian with an interest in pregnancy, cardiovascular disease, weight management and recipe analysis.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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For a healthy pregnancy, it is recommended that women follow a varied balanced diet to ensure the best outcomes for both mother and baby. Eggs are a valuable source of protein, fatty acids, vitamins and minerals, which all play important roles during pregnancy. This article will discuss the safety and nutritional benefits of egg consumption during pregnancy.

For many years, pregnant women and other vulnerable groups were advised to avoid eating eggs with runny yolks due to the risk of salmonella contamination, which can cause food poisoning.

However, recently, the Foods Standards Agency (FSA) updated their guidelines in response to a report showing that British eggs are highly unlikely to contain salmonella, and now state that pregnant women, infants, children and elderly people can safely eat raw or lightly cooked eggs, so long as they are produced under the British Lion Code of Practice.1 HOW MANY EGGS ARE SAFE TO EAT?

Many people ask the question, “How many eggs can I eat per week?” when in fact, the NHS advises that there is no recommended limit on how many eggs people should eat, whether pregnant or not.2 A small proportion of individuals with familial hypercholesterolaemia require restriction of dietary cholesterol, for which eggs are a source (as are other foods, such as prawns and liver).

However, for most people, it is now generally accepted that the cholesterol found in food does not have a significant effect on blood cholesterol levels and that there is no need to limit egg consumption if you have raised blood lipids or Type 2 diabetes. In the diet, saturated fats have the most dominant effect on blood cholesterol levels and should be limited to a maximum of 30g and 20g per day for men and women

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respectively.3 This advice also applies during pregnancy.

THE BENEFITS OF EATING EGGS DURING PREGNANCY

There are many nutrients in eggs which can all help play a role in a healthy pregnancy as outlined in Table 1.

Protein Eggs are a rich source of high quality protein; they contain all nine essential amino acids which cannot be synthesised in our bodies and must be obtained from the diet. Pregnant women require between two and three servings of protein foods per day (such as eggs, beans, fish, meat and other proteins including tofu, nuts and Quorn) to help ensure healthy foetal growth and development.4 Two medium eggs, as shown in Table 1, provide approximately 15g of protein, which would be considered as one serving.5 Fats and omega-3 The composition of eggs shows a beneficial breakdown for fats; 71% of the fats found within eggs are unsaturated.6 The contribution to omega-3 fatty acids that eggs can provide is particularly beneficial for pregnancy. Analysis of UK eggs has shown that they qualify as ‘a source’ of the omega-3 fatty acid Docosahexaenoic acid (DHA), according to European Commission (EC) nutrition claims regulations.7 DHA (alongside Eicosapentaenoic acid (EPA)), is critical

Table 1: Nutrient content of a medium-sized (58g) hen’s egg20 Nutrition Information

Per Medium Size Egg (58g)

Energy kcal (calories)

66

Energy kJ

277

Fat (g)

4.6

Saturates (g)

1.3

Monounsaturates (g)

1.7

Polyunsaturates (g)

0.7

Carbohydrate (g)

trace

Sugars (g)

trace

Protein (g)

6.4

Salt (g)

0.20

to foetal and infant central nervous system growth and development.7 Research has shown that higher intakes of omega-3 fatty acids in mothers are associated with reduced risk for intrauterine growth restriction, increased infant birth weight, reduced depression and reduced risk of preterm birth.8 VITAMINS AND MINERALS

Iron Two medium eggs provide 2mg of iron.6 Pregnant women require 14.8mg per day to prevent iron deficiency anaemia.9 Although this is not an increased requirement compared to non-pregnant women (due to the body’s natural compensating effects, such as cessation of the menstrual cycle), many women can still become deficient and require iron supplements which can have undesirable side effects such as constipation and nausea. Thus, ensuring adequate dietary intake of iron, for which eggs can certainly contribute, could help reduce the need for high dose supplements.

Vitamin B12 Eggs are a rich source of vitamin B12, with two medium eggs providing 3.1µg.6 The daily B12 requirement during pregnancy is 1.5µg9 and, so, just one medium egg will meet this requirement.6 During pregnancy, vitamin B12 helps maintain healthy nerve cells and red blood cells. It is also needed to make DNA (genetic material for all cells) and helps the body use folate, a B vitamin discussed opposite which is of utmost importance during pregnancy.

Folate Folic acid is the supplemental form of the B vitamin, folate. A daily prenatal 400µg folic acid supplement is recommended three months before conception and during the first trimester of pregnancy to help prevent neural tube defects and other negative effects associated with low folate levels.10 It is very hard to achieve adequate amounts of folate by diet alone hence the need for a supplement. Indeed, the latest National Diet and Nutrition Survey19 reported that the majority of UK women of childbearing age have an inadequate folate status. However, women are still encouraged to ensure good sources of folate in the diet, as well as taking a folic acid supplement. This is where eggs can help out again, providing 55µg of folate per two medium eggs.6 Iodine Iodine plays a key role in cognitive function and thyroid function. Iodine deficiency has been found in up to 40% of pregnant women11 and some UK studies have demonstrated that deficiency may be associated with low birth weight and delays in infant neurological and behavioural development.7 The European Food Safety Authority (EFSA) recommends that pregnant women should have 200µg of iodine daily12 to ensure healthy iodine levels for both mother and baby. There is an increased requirement in pregnancy because of the need for the mother www.NHDmag.com August/September 2018 - Issue 137

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COMPETITION WINNER to make sufficient thyroid hormones to transfer to the baby for brain development.13 Two eggs daily would provide about one quarter of this recommendation (58µg for two medium eggs).6

This is another nutrient where eggs can make a valuable contribution, with two medium eggs daily meeting 60% of the AI.7

Vitamin D There are a limited number of foods naturally high in vitamin D, but after oily fish, eggs are the richest source, providing 3.7µg of vitamin D per two medium eggs (coming from the yolk of the hen’s egg).6 Vitamin D deficiency in pregnancy is linked to an increased risk of preeclampsia, gestational diabetes, urine infections and caesarean deliveries.14 The National Institute of Health and Clinical Excellence (NICE) recommends 10µg per day15 of vitamin D for all adults, including pregnant women (some experts, including the Endocrine Society,16 believe this should be higher during pregnancy).

While we can obtain vitamin D from some foods, it will not be enough for pregnant women and so a supplement containing 10µg of vitamin D is advised. As some experts recommend higher amounts of vitamin D than the NICE advice, a diet with foods containing vitamin D, such as eggs, can only be of benefit.

There is an increasing amount of evidence to show that eating eggs could help with weight management due to their satiating effects.

A number of studies have shown that meals containing eggs can reduce hunger, desire to eat and subsequent short-term energy intake.7 In addition, an interesting study showed that the proteins from eggs were broken down and metabolised at a slower rate than comparable proteins, suggesting that eggs offer unique effects on appetite hormone production.18 It is certainly a myth that pregnant women should be ‘eating for two’; excessive weight gain is undesirable and can have serious negative effects on both mother and baby. It is only in the last trimester of pregnancy that women are advised to increase their energy intake by 200 calories per day. In view of the research mentioned above, eggs may be a valuable inclusion in a woman’s diet during pregnancy to potentially help with excessive weight gain by promoting satiety.

Choline Choline is a vitamin-like nutrient needed for the normal functioning of all cells, especially those in the liver and the central nervous system. In pregnancy, it is essential for foetal development, especially for brain development, neural tube formation and learning function. In the UK, there are currently no recommendations for choline. However, in 2016, the European Food Safety Authority (EFSA) set adequate intakes (AI) for pregnant women at 480mg per day (for adults the value is set at 400mg per day).17

WEIGHT MANAGEMENT

SUMMARY

Without a doubt, eggs can contribute significantly to nutrient intakes during pregnancy, a life stage when eating a nutritious diet is key for the good health of mother and baby. They are a low cost food yet provide high quality protein, healthy fatty acids and an array of vitamins and minerals. Pregnant women should be made aware of the overturning of previous safety concerns regarding egg consumption and enjoy eggs in many different ways.

Judges: Carrie Ruxton & Emma Coates “A thorough article which was well researched and enjoyable to read. The author demonstrates a broad knowledge of the areas of health associated with egg consumption and has been able to bust several myths around cholesterol and food safety. The standard of writing is particularly high. I am sure NHD readers will enjoy it.” Carrie “This article stood out for me as the most informative of all the competition entries.

It has been well researched and flows well. I enjoyed the read. It makes a for a great reference article.” Emma

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HAPPY 70TH BIRTHDAY NHS! 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 Howe, playing the cello and keeping up with her two little girls! www. dietitianslife.com

References 1 Mary Bownes (1993). The Work of Dietitians in Great Britain.

Social Policy and Administra-tion, vol 27, no 4, p 335 2 Health and Care Professions Council website. www.hpc-uk.org

I have always known the NHS, but my grandparents were there at the start! My paternal grandmother was a nurse working at Hartlepool Hospital and my grandfather a hospital engineer. My maternal grandparents were both doctors.

My mother was a physiotherapist and her calories, protein, inorganic elements and sister an NHS nurse. One sister-in-law is a vitamins and it is only an effort that we can speech and language therapist, the other imagine that there may be more legs for a clinical psychologist. Two of my cousins dietetics to stand on.’ He was quite right, work as doctors and one cousin has gone as these are still the principles of nutrition into NHS management. And there’s me: today (macro and micronutrients). He an NHS dietitian for 16 years. went on to say, ‘What directions the future Over the past 70 years, medicine, progress of dietetics will take is impossible nutrition and dietetics have evolved. to say. It is probably that more vitamins The first dietetic department appeared at will be discovered or subdivided further the Edinburgh Royal and new ‘accessory’ Infirmary in 1924. The We haven’t found many food substances may first meeting of the BDA be brought to light’. We more vitamins in 70 was in 1936 with 77 haven’t found many members.1 There are now years, but we have found more vitamins in 70 9,585 qualified working years, but we have found new ‘accessory food dietitians in the UK2 with substances’: probiotics, new ‘accessory food most having worked in prebiotics, antioxidants substances’: probiotics, the NHS at some point in prebiotics, antioxidants and FODMAPs. their career. and FODMAPs. Back in 2010, when There are forgotten we cleared out our old offices at Selly Oak diets too, such as the Lenhartz diet for Hospital in Birmingham ready to move into gastric ulcer. Simmons describes how the brand new Queen Elizabeth Hospital, gastric ulcers can be healed by giving I saved some old dietetic textbooks a diet of eggs and milk fed by a spoon, heading for the skip. They included The building up over a week. Another was Handbook of Diets by Rose Simmons, the Sippy Diet which consisted of small published in 1937 and Hutchinson’s Food repeated doses of alkali with milk to and the Principles of Dietetics 5th edition, neutralise acid in the stomach. She warns, published in 1922 and the 9th edition in ‘When patients are taking a continuous 1944. These books would have been used dose of alkali, watch for symptoms of by some of the first dietitians who worked alkali poisoning, such as bad dreams, at Selly Oak Hospital. headaches, nausea, delirium and tetany!’

Some of what we knew about What further complexities of diet nutrition 70 years ago hasn’t changed. and nutrition will we find out about Hutchinson’s 9th edition from 1944 states in the next 70 years and will the NHS that, ‘Dietetics stands foursquare upon still be around? www.NHDmag.com August/September 2018 - Issue 137

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Date of preparation: May 2018 ANUKANI180120q Like all juice-style ONS, Ensure Plus juce contains milk protein, and is not suitable for patients on a milk protein restricted diet.