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NETWORK HEALTH DIGEST The Magazine for Dietitians, Nutritionists and Healthcare Professionals
October 2018: Issue 138
FOOD ALLERGY EXAMINED: WHERE WE ARE NOW GASTROSTOMY FEEDING PROBIOTICS & GUT HEALTH HEAD TRAUMA & NUTRITION PLANT-BASED DIETS
NETWORK HEALTH DIGEST
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This information is intended for Healthcare Professionals only. Neocate Syneo is a Food for Special Medical Purposes for the dietary management of Cow’s Milk Allergy, multiple food protein allergies and other conditions requiring an Amino Acid-based Formula, and must be used under medical supervision after full consideration of all feeding options, including breastfeeding. *Accurate at time of publication, October 2018 Probiotic Biﬁdobacterium breve M-16V and prebiotic scFOS/lcFOS blend CMA: Cow’s Milk Allergy AAF: Amino Acid-based Formula References: 1. Candy et al. Pediatr Research. 2018;83(3):677-686 2. Burks W. et al. Pediatr Allergy Immunol 2015;26:316-322 3. De Boissieu D. et al. J Pediatr 1997; 131(5):744-747 4. Vanderhoof JA. et al. J Pediatr 1997; 131 (5):741-744 Nutricia Advanced Medical Nutrition, White Horse Business Park, Trowbridge, Wiltshire, BA14 0XQ
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FROM THE EDITOR
WELCOME Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.
If you have important news or research updates to share with NHD, or would like to send a letter to the Editor, please email us at info@network healthgroup.co.uk We would love to hear from you.
As a dietitian and/or nutritionist, what’s one of the most common questions you get asked by someone you meet when you tell them what you do for a living? How do I cut my cholesterol? Do you think I might be anaemic? How many units of alcohol are there in a large glass of red wine? I bet I won’t be too far off the mark when I say it’s highly likely to be, ‘How do I lose weight?’ World Obesity Day returns on 11th October, a campaign that has been highlighting key themes to raise awareness, promote prevention and improve intervention on a global scale. In the UK, 58% of women and 68% of men are overweight or obese, so we’re very much part of this global trend. This year, World Obesity Day focuses on ending weight stigma and is ‘calling on all media outlets to end their use of stigmatising language and imagery and instead portray obesity in a fair, accurate and informative manner.’ For more information visit www.obesityday.worldobesity.org/ world-obesity-day-2018. It shouldn’t just be for a day, so we are capturing some of the campaign’s ethos in this issue of NHD with two articles by Maeve Hanan. Here, she shares a timely article focusing on Non-diet nutrition, an approach which moves the focus from weight and dieting to a holistic approach that encourages healthy behaviours and overall wellbeing. Maeve also asks the question, ‘How healthy are plant-based diets?’ with her attention turning to the increasingly popular and varied nonmeat/fish/dairy diets. Our Cover Story deals with the complex issue of food allergy and
Jacqui Lowdon tackles the maze of evidence directing us through this dynamic area of dietetics, examining where we are now. In our clinical features this month, we welcome for the first time, Louise Edwards and Hazel Clark. Louise provides an overview of gastrostomy feeding tubes and their indications, whilst Hazel shares her insights into the challenges associated with providing adequate nutrition support in patients with a traumatic brain injury following ICU stepdown. Rebecca Gasche has taken up the challenge of unravelling the latest evidence surrounding the use of probiotics and prebiotics in gut health. In her article this month, she takes a look at what we really should be recommending when it comes to looking after our gut. Our IMD Watch is brought to you by our very own, Dietitian’s Life and adult metabolic dietitian, Sarah Howe. In this issue, Sarah discusses how PKU can be managed to support and enhance the sport and exercise experience. We also have our essential regular columns and other features such as F2F and Free From Bites. Don’t miss a word and enjoy. Emma
WORLD OBESITY DAY 2018 11th October Raising awareness about the prevalence, severity and diversity of weight stigma. www.obesityday.worldobesity.org #WorldObesityDay 2018 www.NHDmag.com October 2018 - Issue 138
15 COVER STORY Food allergy examined: where we are now
Latest industry and product updates
39 Gastrostomy tube feeding Indications and considerations
10 Face to face With Bridget Benelam
43 SPORT & PKU Enhancing the exercise experience
21 NEUROSCIENCES & TRAUMA Nutrition support
47 Free from bites News and FODMAP updates
27 Probiotics and prebiotics The future of gut health
49 Non-diet nutrition Examining the evidence
32 Food-focused nutrition Adult care services in the Highlands
52 Freelance practice How to get noticed
35 PLANT-BASED DIETS How healthy are they?
54 Events & courses Dates for your diary
55 Dietitian's life Dietetics and mental health 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 email@example.com 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
Advertising Richard Mair Tel 01342 824073
Publishing Director Julieanne Murray
Publishing Editor Lisa Jackson Publishing Assistant Katie Dennis Columnist Ursula Arens, Design Heather Dewhurst
Phone 01342 825349 Fax 0844 774 7514 Email firstname.lastname@example.org www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES
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Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.
MEET ‘LITTLE FOODIE’ – PARENT-FRIENDLY RESOURCE AND EXPERT ADVICE Two of our most recognised and respected childhood nutritionists have come together to create a new venture, which aims to provide expert knowledge and guidance around early years’ nutrition. Dr Emma Derbyshire, award-winning writer and founder of the successful consultancy Nutritional Insight and Charlotte Stirling-Reed, a prominent media nutritionist in the UK and founder of SR Nutrition are the masterminds behind LittleFoodie.Org. Both are passionate about bringing reliable, evidence-based information and advice to parents in a fun and accessible way. Emma understands the quagmire that many parents face when trying to access good quality advice: “We’re no strangers to headlines regarding rising childhood obesity and dental caries statistics, alongside poor quality, high fat, high sugar diets. There’s no doubt that the diets of many children are in need of improvement.” Many parents are left concerned over their children’s wellbeing, confirmed by a survey completed by Emma and Charlotte: only one-third of parents said that they felt confident when it came to feeding their children. Charlotte explains how Little Foodie aims to help here, “It’s so important to help young children build healthy relationships with food. I’ve seen first hand how many parents struggle with feeding their little ones. LittleFoodie.org aims to be the go-to-place for all parents on the topic of child nutrition, combining parent-friendly, online support with expert knowledge and guidance around early years’ nutrition. For more information, find Little Foodie on social channels @littlefoodieorg (instagram and twitter) and via their website - www.littlefoodie.org
COELIAC DISEASE DIAGNOSIS RISES TO 30% - BUT STILL MISSING HALF A MILLION Coeliac UK, the largest independent resulting in around half a million people charity for people who need to live gluten in the UK still living with undiagnosed free, has announced that recent research CD.² It also highlighted that one in four shows diagnosis of the autoimmune adults over 18 years diagnosed with CD disease, coeliac disease (CD), which had previously been misdiagnosed with affects 1 in 100 people, has risen in the IBS, the same percentage that had been UK from 24%¹ in 2011 to 30%² in 2015. The reported in research from 2013.³ research, commissioned by the charity, The NICE guidelines for CD and from the University of Nottingham, IBS recommend that anyone presenting searched UK patient records up to and with IBS symptoms should be screened including 2015 for clinical diagnosis of first for CD. Coeliac UK’s online CD and dermatitis herpetiformis (the assessment can be found at www. skin manifestation of CD). coeliac.org.uk/isitcoeliacdisease which The research showed that although allows people to quickly check if they diagnosis rose by a quarter in four should go to the GP and ask for a blood years (2011-2015), alarmingly the rate test. Coeliac UK also has a Helpline on of diagnosis was slowing significantly, 0333 332 2033. References 1 West et al (2014). Incidence and Prevalence of Coeliac Disease and Dermatitis Herpetiformis in the UK Over Two Decades: Population-Based Study. Am J Gastroenterol. May; 109(5): 757-768. www.ncbi.nlm.nih.gov/pmc/articles/PMC4012300/ 2 West et al (2018). Changes in the testing for and incidence of coeliac disease in the UK 2005-2015 (Abstract at Coeliac UK Research Conference, 2018). www.coeliac.org.uk/abstracts2018 3 Card T et al (2013). An excess of prior irritable bowel syndrome diagnoses or treatments in Coeliac disease: evidence of diagnostic delay. Scand J Gastroenterol. Jul; 48(7): 801-7. www.ncbi.nlm.nih.gov/pubmed/23697749
www.NHDmag.com October 2018 - Issue 138
NEWS NEW NICE GUIDANCE – PANCREATITIS NICE guideline (NG104) Published in September 2018. This guideline covers managing acute and chronic pancreatitis in children, young people and adults. It aims to improve quality of life by ensuring that people have the right treatment and follow-up and receive timely information and support after diagnosis. Key recommendations relating to dietetic intervention within this guideline include: • lifestyle interventions relating to alcohol consumption - to reduce or cease alcohol consumption where required and appropriate; • nutrition support during acute and chronic pancreatitis; • Type 3c diabetes; • appropriate use of and management of PERT. To read the full guidance document visit:www.nice.org.uk/guidance/ng104
PUBLIC HEALTH ENGLAND AND DRINKAWARE DRINK FREE DAYS CAMPAIGN PHE and the alcohol education charity Drinkaware have teamed up to raise further awareness of health risks of drinking alcohol. A YouGov poll conducted earlier this year by PHE and Drinkaware, surveyed nearly 9000 adults aged 18 to 85 and found that one in five were drinking more than the government's 14 unit-a-week guideline. Two-thirds stated that they would find cutting down on their drinking harder to do than improving their diet, exercising more, or reducing their smoking. The new campaign focuses in particular on people between the ages of 45 and 65, urging them to have regular drink-free days. Recent statistics show that middle-aged drinkers are more likely than other age groups to drink more than the recommended 14 units a week. Whilst ‘Drink free days’ is the campaign’s main call to action, it has other health focuses too, which include high blood pressure and heart disease and breast cancer. This campaign also ties in with PHE’s ‘One You’ campaign and falls under ‘Be healthier - Drink Less’, aiming the messages, advice and resources to all ages. For more information visit www.drinkfreedays.co.uk/, or www. drinkaware.co.uk/
PRODUCT / INDUSTRY NEWS BIMUNO TRAVELAID – PREBIOTIC BIMUNO® NEW STUDY Study shows significantly fewer episodes of travellers’ diarrhoea when using the prebiotic Bimuno® A study of 523 travellers to countries with an intermediate to high risk of diarrhoea found that taking the prebiotic Bimuno® (a galacto-oligosaccharide mixture also known as B-GOS®) resulted in an overall reduction of 33% in the incidence of diarrhoea in the 334 individuals who adhered strictly to the protocol. For more information, visit www.bimuno.com.
To book your company’s product news for
the next issue of Network Health Digest call 01342 824073 ERRATUM We apologise for incorrect information published in the article Huel: is this the future of food… by Alice Fletcher (NHD August/ September 2018 issue 137 p4347). The article states that: ‘The [EFSA] 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 bleeding)’ However, the EFSA report concluded that in fact there was no sufficient data to establish a tolerable upper intake level for omega-3s (EPA, DHA and DPA). A supplemental intake of 5g per day of EPA and DPA within this report found that this level does not increase the risk. Huel does not contain any supplemental EPA or DHA, only ALA at a level of 14g per 2000 kcal. The conversion of ALA to EPA and DHA would yield 840mg of EPA and 532mg of DHA; a total of 1372mg EPA and DHA, not the 13.4g stated in the article. More information can be gathered here: https://uk.huel.com/pages/guide-to-epa-and-dha. The article also states that ‘Huel contains a synthetic form of vitamin D’. However, the ergocalciferol in Huel is natural, not synthetic. The majority of the vitamin D source in Huel is plant-derived cholecalciferol.
www.NHDmag.com October 2018 - Issue 138
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FACE TO FACE Ursula meets: Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
Ursula meets amazing people who influence nutrition policies and practices in the UK. BRIDGET BENELAM Nutritionist Communication Manager: British Nutrition Foundation
I arrived early at the café. A woman I did not recognise waved madly, “Hi Ursula.” It took me a while to realise it was Moody Margaret (the actor, who did the voice over, in the cartoon of, the Horrid Henry books). We had last met as mums with tiny toddlers so many years ago, back when I worked at the British Nutrition Foundation (BNF). It’s a small world! But today I was meeting Bridget Benelam, the BNF’s Nutrition Communication Manager. Bridget graduated in 2000 from the University of Manchester with a BSc in Biochemistry. “I really enjoyed the course, but it was difficult. Especially the more theoretical and abstract aspects.” She had a year to think about her further career (while travelling and jobbing in Australia). The seeds of nutrition science planted within the biochemistry course blossomed in the Aussie sun and on her return to the UK, she knew this was the area she wanted to research. The one-year MSc course in Human Nutrition at Kings College London gave her the qualification. Her first job was as a scientist with the Food Standards Agency. This was almost the job that she didn’t get, but for the kindness of a stranger. “I had wanted to hand-deliver my application, as it was the last submission day. However, I left my application on the tube, so resigned to having missed the deadline.” To her surprise, she got a call from someone who had found it and kindly delivered it for her.
www.NHDmag.com October 2018 - Issue 138
Much of her work was as part of the secretariat for the Committee for Toxicity (CoT), who consider public health advice on artificial or natural hazards in foods, and balance the tightrope of assessment of benefits and risks. One example of a CoT project is the assessment of advice to pregnant women on the consumption of oily fish, which offered the benefits of long chain omega-3, but the risks of heavy metal contaminants. “Toxicity assessments are much neater than nutrition science evaluations, because there are clear and specific channels for decisions,” said Bridget. "But applying nutrition science to dietary guidance allows broader and more multi-layered interpretations, which have greater public relevance." In 2006, a new job at the British Nutrition Foundation was posted: someone (called Bridget) was needed to support dissemination of an EU-funded project to develop nutrient composition data. While M&W’s The Composition of Foods lies by the bedside and on the work desk of every UK dietitian, there are many other nutrition reference databanks, and the EU was keen to develop greater consistency of analysis and presentation. “For example, there were many fierce debates on methods of analysis for the fibre content of foods,” said Bridget. Fibre is an orchestra of components rather than a single player, and it is difficult to capture the diversity of effects found in different foods with a single number. Increasingly, Bridget also became involved with other projects. She wrote
This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO ENJOY MILK SOONER1† ONLY‡ NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
Versus an eHCF without LGG® or formulas based on soy or amino acids. The only cow’s milk-based formula.
Reference: 1. Canani RB et al. J Pediatr 2013;163:771–777. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
. . . liaison with the media is her main responsibility. “I have always really enjoyed the diversity of topics we are asked to comment on . . .” a briefing paper and organised a conference on appetite control and satiety. “Nobody only eats when they are hungry and never eats when they are full. This topic is fascinating because it brings together aspects of physiology and psychology,” she said. I wondered what data she was most persuaded by (in relation to weight control advice?). Choose foods with low energy density, which are generally those with a higher water and lower fat content. Lean protein-rich foods also seem to be helpful in enhancing satiety. A current BNF project that she is leading is the development of robust guidance on food portion sizes. The UK Eatwell Guide does not provide any specific advice; something that was provided in the national food models of other countries. As well as reviewing data on portion size, the BNF ran consumer research to assess the presentation of information, and Bridget hopes that lots of useful educational resources can be developed. A large part of her job at the BNF has always been the communication of nutrition science. And now liaison with the media is her main responsibility. “I have always really enjoyed the diversity of topics we are asked to comment on,” said Bridget. There have been many changes over the 12 years that Bridget has been at the BNF. Former comment allowed more time to assess data, and relationship building with staff at print or radio/TV media sources. Current BNF comment is often to tight deadlines and
NHD eArticles with CPD 12
many contacts are with streams of freelance writers who may have less expertise with science aspects of nutrition and are under pressure to sell hard-hitting stories. Also, with so many more channels of media, there is more competition for consumer attention. Nutrition faces the same challenges as all other fields where information is the currency: Fake News. Of course, everyone has always been able to develop their own right or wrong thoughts on any subject, including nutrition. But what used to be shared with a few friends and family around kitchen tables or in the pub is now mainlined onto public platforms via social media. Nutrition communication is paradoxically more of a challenge now: information routes to the consumer are clogged with attention grabbing titillations, and it is difficult to cut through contrary claims with ‘boring’ balanced diet messages. Bridget seemed depressed but denied this. “We cannot go back to traditional routes, so it is a matter of finding more interesting and innovative and less authoritarian tones with which to share nutrition science with the public,” she said. Twitter and other social media platforms are full of Moody Margarets and Horrid Henrys proclaiming nutrition expertise. Bridget offers calm and consistent clarity on nutrition science complications. She has my real ‘like’, but hopefully she will also gather the most cyberspace ‘likes’.
• Continuing professional developement • Answer questions • Download & keep for your files
TO VIEW OUR LATEST CPD eARTICLE PLEASE VISIT NHDmag.com
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This material is for healthcare professionals only.
DO MORE THAN JUST MANAGE COW’S MILK ALLERGY: HELP GIVE HER THE ABILITY TO PROTECT HERSELF FROM FUTURE ALLERGIC MANIFESTATIONS1† ONLY NUTRAMIGEN WITH LGG® CAN
TRANSFORMING THE LIVES OF BABIES WITH COW’S MILK ALLERGY
Versus Nutramigen without LGG®.
Reference: 1. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to your baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: September 2018 UK/NUT/18/0060i
FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies
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Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to ﬁve years1–3
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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.
18-044 (GOS/FOS)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018
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FOOD ALLERGY EXAMINED: WHERE WE ARE NOW Jacqui Lowdon Paediatric Dietitian, Leeds Children’s Hospital
Food allergy (FA) is a dynamic area, with advances continuing to be made in the understanding, diagnosis, prevention and treatment. The following article includes updates on prevalence, incidence, causes, management and treatment.
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.
In 2010, an Expert Panel Report sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), defined FA as ‘an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food’, and food intolerance as ‘non immune reactions that include metabolic, toxic, pharmacologic and undefined mechanisms’.1 Any reaction to food that results in objectively reproducible signs or symptoms should be described as food hypersensitivity. If immunological mechanisms are involved, then it should be described as a FA. Where immunoglobulin E (IgE) is involved, then the terminology IgE mediated FA should be used and where immune mediated reactions not mediated by IgE, the term non-IgE mediated FA is the correct term.
REFERENCES Please visit the Subscriber zone at NHDmag.com
PREVALENCE AND INCIDENCE
This article has been peer reviewed by Dr Rosan Meyer, RD,PhD Paediatric Research Dietitian, Honorary Senior Lecturer, Imperial College, London.
Data suggests that FA is common, with the prevalence of clinically proven FA as high as 10%, in preschool children in developed countries.2 In countries such as Asia and China, where societies are large and rapidly increasing and there are documented increases in FA, the prevalence of oral food challenge (OFC) proven FA is now approximately 7% in preschoolers. This figure is comparable to European reported prevalence. It also appears to affect those in industrialised/westernised regions disproportionately, more common in children as opposed to adults and only a few foods accounting for most of the more serious reactions, namely peanut, tree nuts, fish, shellfish, egg, milk, wheat,
soy and seeds.1,3,4 In children, FA affects up to 6% to 8%5,6 and the incidence has increased significantly over the past 20 years.7 All prevalence data, outside of non-IgE mediated cow’s milk protein allergy (CMPA), is based on IgE mediated allergies. Determining prevalence statistics remains difficult, however, due to a number of reasons: many manifestations of FA with varying degrees of severity; different allergy definitions being used; evaluation of specific study populations; focus on specific foods; different methodologies; geographic variations; diet exposure effects; and differences according to age, race and ethnicity.8 Self-reported FA rates are substantially higher compared to those by medically supervised OFCs.9 The systematic review and meta-analysis of FA to ‘common foods’ in Europe, by Nwaru et al, looked at 42 studies, finding an overall lifetime self-reported prevalence of 6% (95% CI, 5.7% to 6.4%). A EuroPrevall birth cohort study involving nine countries enrolled 12,049 infants, with 77.5% followed to age two years and included OFCs to confirm diagnosis when possible.10,11 Results showed an adjusted mean incidence of egg allergy at 1.23% (95% CI, 0.98% to 1.51%), with the UK having the highest rate (2.18%). Compared to egg allergy, the rates were lower for milk allergy (0.54%; 95% CI, 0.41% to 0.70%), with the highest rates for milk allergy in the Netherlands and the UK (1%). Of all children with CMA, 23.6% had no cow’s milk-specific IgE in serum, especially those from the UK, the www.NHDmag.com October 2018 - Issue 138
IS IN THE DETAIL Why might some eHFs show better clinical outcomes for symptom resolution?1–4 Our analyses of eHF samples from manufacturers around the world – which compared peptide size and residual protein content – showed that eHFs may have different allergenic potentials.4–6 Althéra® is proven to have a consistent, very low allergenic potential which may make all the difference in the dietary management of your CMA patients.4–8
Allergenicity analysis (peptide molecular weight & BLG residual protein)6 Peptides >1200 Da (%)
35 30 25 20 15 10 5 0
Allergenicity (µg BLG/g protein) Althéra®
Randomly selected eHF brands
Learn more about our latest research and clinical trials: www.nestlehealthscience.co.uk/althera IMPORTANT NOTICE: Mothers should be encouraged to continue breastfeeding even when their infants have CMA. This usually requires qualified dietary counselling to completely exclude all sources of cows’ milk protein from the mothers’ diet. If a decision to use a special formula intended for infants is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. Formula for special medical purposes intended for infants must be used under medical supervision. Althéra® and Alfamino® are for complete nutritional support from birth or supplementary feeding from 6 months and up to 3 years of age for the dietary management of CMA and/or multiple food protein allergies. Abbreviations: BLG, ß-lactoglobulin; CMA, cows’ milk allergy; Da, Daltons; eHF, extensively hydrolysed formula. References: 1. Dupont et al. BJN, 2012; 107(3): 325–338. 2. Chauveau et al. Pediatr Allergy Immunol, 2016; 27(5): 541–543. 3. Petrus, N.C. et al. Eur J Pediatr. 2015; 174(6): 759–765. 4. Kuslys M, et al. EMJ Allergy and Immunol. 2017; 2(1): 46–51. 5. Nutten S, et al. EMJ Allergy and Immunol. 2018; 3(1): 50–59. 6. Nutten S, et al. Abstract. EAACI Congress, 26-30 May, 2018. 7. Niggemann, B. et al. Pediatr Allergy Immunol. 2008; 194(4): 348–354. 8. Data on file. 9. Nowak-Węgrzyn A, et al. Clin Pediatr (Phila). 2015;54(3): 264–272. Version: ALLER51_August2018. For healthcare professionals only.
Explore the rest of our portfolio: Alfamino® is our non-allergenic amino acid formula for the effective dietary management of severe CMA.9 Learn more: nestlehealthscience.co.uk/alfamino
PAEDIATRIC Netherlands, Poland and Italy. Of those children with CMA who were re-evaluated one year after diagnosis, 69% (22/32) tolerated cow’s milk, including all children with non-IgE-associated CMA and 57% of those children with IgEassociated CMA. A systematic review and meta-analysis on the prevalence of tree nut allergy included 36 studies, half from Europe and five from the USA, mostly about children (n=24). A prevalence rate of <2% for OFC-confirmed allergy and between 0.05% to 4.9% for probable allergy (including reported IgE-mediated reactions or a medical diagnosis). Hazelnut was the most common tree nut allergy in Europe, with walnut and cashew being the most common in the US.12 UK studies have also suggested an increase in peanut allergy.13,14 The prevalence of fish allergy in children is low (</= 0.2%). Although the prevalence of shellfish is also low, it is higher than fish allergy (</= 0.5%).15 However, with its high nutritive value and promotion of healthy eating, increased consumption of seafood may lead to more frequent reporting of adverse reactions in the future. Cow’s milk allergy (CMA) (also known as CMPA) is an abnormal response by the body’s immune system in which proteins in cow’s milk are recognised as a potential threat. This can cause the immune system to be ‘sensitised’. When this happens, there is the potential that when cow’s milk is consumed the immune system remembers this protein and may react to it by producing allergic symptoms. CMA remains one of the most common food allergies worldwide and is one of the most common food allergies to affect babies and young children in the UK, but it is still rare with a prevalence in the UK of 2-3% in one- to three-year-olds.70 CMA can present with immediate onset of symptoms or delayed symptoms. If cow’s milk continues to be consumed in the diet, the immune system will continue to produce such symptoms over days or weeks. CAUSES OF FOOD ALLERGY
Many hypotheses have been put forward to try to explain the increase in FA, including a diverse microbiota (the hygiene hypothesis), integration of vitamin D deﬁciency and the ‘dual-allergen exposure’ hypothesis. A reduced microbial diversity
and vitamin D deficiency are thought to interrupt the regulatory mechanisms of oral tolerance, with vitamin D deficiency also thought to contribute to decreased epidermal barrier function. The dual-allergen exposure hypothesis suggests that allergic sensitisation to food occurs through low-level skin exposure to food allergens, facilitated by an impaired skin barrier and inflammation, whereas oral exposure could potentially facilitate tolerance in children who have had early exposure to food protein.16 There is also emerging evidence that an increased diversity of food during the first year of life may have a protective effect on asthma, FA and food sensitisation. It is also associated with increased expression of a marker for regulatory T cells.69 The NAS report3 has considered the evidence behind a number of environmental factors and theories that have been put forward as influencers on FA outcomes. They considered the dual allergen exposure hypothesis to have limited but consistent evidence that an impaired skin barrier plays a role in sensitisation as a first step toward FA. Support for the hypothesis includes the efficacy of peanut early feeding in infants with eczema and the increased risk of FA in those with mutations in filaggrin, a protein responsible in part for maintaining the skin barrier.17,18 DIAGNOSIS
The most important, single test for diagnosing a FA is probably the clinical history. It needs to be reviewed within the context of knowledge about the clinical presentation and epidemiology of the FA, as well as having a good understanding of disorders with similar clinical presentations that might be misconstrued as food allergies. Some groups have proposed schematic diagnostic algorithms that take into consideration the history, epidemiology, pathophysiology, and test results leading to a diagnosis, including identification of the trigger food/s.20-23 A number of recommended diagnostic modalities have also been developed, through expert panels, practice parameters, systematic reviews and guidelines.8,23-27 Tests include medical history, physical examination, elimination diets, skin prick tests, sIgE tests and OFCs. However, diagnosis is not usually based on a single test. Instead, a stepped approach is www.NHDmag.com October 2018 - Issue 138
PAEDIATRIC usually used, where the clinical history can lead to a test selection and the result can be used to determine whether an OFC is required. Nice guidelines on diagnosis and assessment of FA are key and Sicherer and Sampson provides a good summary on the pros and cons of different diagnostic testing.71,72,20 When the chances of tolerating the food item, based on clinical history and other tests, is probable for that individual based on their circumstances, e.g. age, dietary preference and nutritional requirement, then an OFC is offered for diagnostic purposes. Details for performing OFCs are available, with the gold standard being the doubleblind, placebo-controlled OFC.28-31 Although OFCs are time-consuming, resource intensive and carry an element of risk, they remain the gold standard and most data indicates that even when there is a risk, the impact on QoL is positive. If an OFC is indicated, families need to be counselled about the procedure even though it is generally safe. OFCs must be carried out with the required precautions by experienced clinicians.28-30,37 Severe and fatal reactions can and do occur. Also, for some families, fear of the procedure or lack of the potential benefits, result in them turning down the OFC38 and some families continue to exclude the previously avoided food, despite tolerance during an OFC. All of this needs to be included in the counselling,39 with benefits of a possibly improved quality of life40 and if a reaction does occur, it is not likely to result in an increase in sensitisation.41 Regarding CMA, the iMAP guidelines on mild to moderate non-IgE mediated CMA have contributed significantly towards improving diagnosis and management in the UK and now worldwide. The guidelines offer easy-to-use algorithms and newly added supporting material, as well as an updated milk ladder.70 The European Academy for Allergy and Clinical Immunology has published guidelines on IgE mediated allergy and is working on practice guidelines for non-IgE mediated allergies. ACTIVE MANAGEMENT
Active management of food allergies entails good knowledge and education. A systematic review confirmed concerns about labelling variations and errors, restaurant meals, eating at home and outside the home and risky behaviours leading to unexpected reactions.32 A more active approach to the management of FA is being adopted, 18
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which includes early introduction of potentially allergenic foods, anticipatory testing, active monitoring, desensitisation to food allergens and active risk management.75 Nutritional deficiencies can result from allergen avoidance diets and this is reported widely in the literature. In a recent study of 245 children (mean age four years) avoiding one to seven foods, those less than two years of age had a lower weightfor-length percentile, whilst those aged two years and older had lower body mass index profiles compared with healthy control subjects.33 These differences were especially noted in those avoiding milk and multiple foods. Other studies have also noted worse growth in those avoiding milk.34,35 A systematic review of six studies highlighted the risk of malnutrition and reduced height. They noted that children with food allergies who did not receive nutritional counselling were more likely to have inadequate calcium and vitamin D.36 It is essential then that children with FA receive nutritional counselling and growth monitoring.25 A recent article by Meyer discusses the nutritional disorders resulting from FA in children.73 Although strict avoidance is usually advised, approximately 70% of children with milk and egg allergy can tolerate these foods when extensively heated in bakery foods.42 However, this needs to be strictly and very carefully evaluated, such as using supervised OFCs, to determine whether the baked form can be tolerated, as severe allergic reactions are possible. It has been suggested that, for those who are able, ingestion of the baked form might result in faster resolution of the allergy,43,44 although the evidence is not conclusive.45 PREVENTION
There have been a number of recent reviews,46-48 detailing opportunities for prevention. Early peanut introduction in high-risk infants has the most convincing prevention approach data. In the Learning Early About Peanut (LEAP) trial, infants aged four to 11 months at high risk (severe eczema and/or egg allergy) for peanut allergy, but with peanut SPT wheals of 4mm or less, were randomised to eat or avoid peanut to age five years.17 Those sensitised to peanut and randomised to eating had a 10.6% rate of peanut allergy vs 35.3% in the avoidance group (P= 004; relative risk [RR] reduction, 70%). Among those infants not sensitised, 13.7% in the avoidance group
and 1.9% in the eating group had peanut allergy (P<001; relative reduction, 86.1%). Other studies that had the eating group avoid peanut for one year49 and evaluated nutritional outcomes,50 suggest that the protection was durable and did not result in reduced breastfeeding or nutritional concerns. Based on the results of this study, with evidence of possible protection in nonselected infants51 a NIAID expert panel has suggested applying the LEAP study results to highrisk infants and encouraging introduction of peanut early also for those at moderate risk.52 These new guidelines suggest that allergenic foods be introduced without any particular delay compared with non-allergenic foods.1,53,54 For high-risk infants, introducing peanut ‘as early as four to six months’ goes against the exclusive breastfeeding to around six months recommendation. However, the rationale to feed peanut earlier, so long as it is in a safe form to avoid choking and the infant has demonstrated an ability to manage solids, was to lessen the chance of the infant having increasing sensitisation over time.52,55 For high-risk infants, the guidelines suggest evaluation for sensitisation and possible OFCs, with dosing regimens that copy the LEAP study. Early introduction of other foods for allergy prevention have not been studied as much and so this area remains less certain. The Enquiring About Tolerance trial tried early introduction of six allergenic foods starting around four months of age.51 An intention-to-treat analysis did not demonstrate a preventative effect, but a per-protocol analysis suggested effectiveness for peanut and egg. A systematic review56 concluded that there was ‘moderate certainty’ of evidence for reduced egg allergy with introduction at four to six months (RR, 0.56; 95% CI, 0.36-0.87). However, this conclusion was mainly based on the results of the Natsume study.57 This study demonstrated greater sensitisation in the placebo group, produced low stepped cooked egg dosing and measured outcomes against the egg product used in prevention treatment, possibly enhancing the results or reflected the treatment rather than prevention. Currently, there is no recommendation to purposefully feed egg early, although there remains recommendations not to avoid including egg in the early infant diet.53,54
For more on the FA environmental risk factors from the NAS report,3 visit www.NHDmag.com/food-allergy.html Two studies58,59 noted high rates of reaction on raw egg introduction, raising questions of safety and the possibility that high-risk infants might already be allergic by four to six months. Data on milk is limited but also suggest delayed introduction can be associated with increased risk.60 Recommendations and guidance on the prevention of FA can be obtained from SACN, BASCI and the BDA.76-78 SACN recommends that advice on complementary feeding should state that foods containing peanut and hen’s egg can be introduced from around six months of age and need not be differentiated from other solid foods. The deliberate exclusion of peanut or hen’s egg beyond six to 12 months of age may increase the risk of allergy to the same foods. CONCLUSION
Whilst there are currently no approved treatments for FA,1,23,67 recent advances have made possible insights into the molecular mechanisms underlying FA, providing opportunities for the use of precision medicine to safely and effectively treat individual FA.68 Although some interventions (such as early introduction of dietary peanut) have demonstrated efficacy in a small number of well-conducted randomised clinical trials, evidence for broader effectiveness and successful implementation at a population level is still lacking, although epidemiological data suggests that such strategies are likely to be successful, at least for peanut. Finally, recent studies suggest that early allergen exposure may prevent FA. www.NHDmag.com October 2018 - Issue 138
A tasty low volume, energy boost your patients will warm to. Vitasavoury™ is a savoury supplement available in Chicken, Leek & Potato, Mushroom and Golden Vegetable flavours. For more information or to request our NEW starter pack with mug contact your local Vitaflo representation. Nutrition Helpline: 0151 702 4937 Web: www.vitaflo.co.uk Vitasavoury is a Food for Special Medical Purposes. A Nestlé Health Science Company
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NEUROSCIENCES AND TRAUMA: THE CHALLENGES OF NUTRITION SUPPORT Hazel Clark Dietitian, Salford Royal NHS Foundation Trust Hazel is a rotational dietitian with experience in neurosurgery and neuro-rehab in a specialist neuro trauma centre.
REFERENCES Please visit the Subscriber zone at NHDmag.com
Traumatic brain injury (TBI) is a physical injury to the brain tissue that temporarily, or permanently, impairs brain function. This occurs following trauma to the head, with the main causes of TBI being road traffic accidents (RTAs), assaults and falls.1 This article takes a look at the challenges associated with providing adequate nutrition support to prevent malnutrition and other associated risks in patients following ICU stepdown. In the UK, roughly 1.4 million patients per year attend hospital following a head injury.2 Whilst for some, the impacts of TBI can be minor, ranging from minor concussion and a period of post traumatic amnesia, for others, the impact is far more profound and can have life-changing consequences, with some studies reporting that 38% of patients with a severe head injury are deceased, or in a vegetative state at one year post injury.3 TBI is now one of the leading causes of mortality and disability among young individuals, particularly in high-income countries.1 Although traditionally TBI has been considered to be more prevalent within the young male population,4 it is predicted that in the future, due to the aging population, the elderly will comprise an increasingly significant proportion of the major trauma workload.5 The Glasgow Coma Scale (GCS) is used to classify the severity of TBI, by assessing coma and impaired consciousness. The scale is divided into three components: eye opening, verbal response and motor response and summed to give a total score ranging from 3-15. A severe head injury is classified as GCS 3-8, moderate GCS 9-12 and mild GCS 13-15. It has been suggested that the severity of a head injury correlates to the degree of hypermetabolism exhibited by TBI patients.6 Studies show that patients with moderate
to severe TBI demonstrate higher levels of hypermetabolism, increased energy expenditure and increased protein losses7 than those with mild head injuries. The metabolic changes observed in these patients in the acute phase are in part attributed to an increase in levels of cytokines and counter-regulatory hormones including cortisol, epinephrine, norepinephrine and glucagon,8 as well as the production of acute phase protein from the liver9 and increased cardiac output and hypertension leading to elevated CO2 production and O2 consumption.10 The increase in energy expenditure seen in severe head injuries is vital for synthesis of new tissue for healing and to meet the demands for the production of proteins for structural, transport, signalling, or immunologic functions. However, unless nutrition intake meets the increased demand for energy, the patient subsequently becomes catabolic11 and can begin to break down muscle as an energy source.12 A systematic review by Foley et al13 found that the mean energy expenditure can range from 75% to 200% during the first 30 days following the TBI. Anecdotal evidence from practice has demonstrated that a number of patients can remain hypermetabolic post the acute phase of the injury, lasting weeks or months. The hypermetabolic state following TBI can result in malnutrition with further complications of hyperglycaemia, impaired wound healing and increased www.NHDmag.com October 2018 - Issue 138
IF A FALL HAPPENS, TAKE IT IN YOUR STRIDE Let Fortisip Compact Protein help your patientsâ€™ recovery by improving their nutritional status
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Fortisip Compact Protein is a Food for Special Medical Purposes for the dietary management of disease-related malnutrition and must be used under medical supervision. For healthcare professionals only.
Date of preparation: January 2018
Nutritional Support - integral to the continuum of care
CLINICAL risk of infection and multiple organ failure.10 A recent Cochrane review7 states that, particularly in TBI, early feeding may be associated with better overall outcomes. It is, therefore, essential to ensure that adequate nutrition support is provided to patients with TBI. However, within this patient group, there are a number of barriers which impede the provision of optimal nutrition support, particularly following step down from the critical care environment. This has been discussed below, along with suggested management strategies to optimise nutritional status. AGITATION
Post traumatic agitation is a common issue following TBI.14 This is often difficult to treat using medication15 and, therefore, has to be managed at a ward level. Agitation can lead to difficulty in implementing dietetic plans as it can be challenging to site enteral tubes and ensure they are kept in situ. Management strategies: • Liaise with the medical team to ensure medical treatment for agitation is optimised. • Be aware of local policies on ‘specialing’ and 1:1 supervision. • Following local protocol, consider if mittens can be utilised. The Deprivation of Liberty Safeguards (DoLS) may need to be in place. • Liaise with therapy/neuropsychology for management strategies to help reduce agitation levels. ACCESS ISSUES
Within an ICU setting, patients with moderate to severe TBI may require mechanical ventilation and/or sedation, which removes the possibility of oral intake. Therefore, many TBI patients require alternative means of feeding. TBIs often occur alongside additional injuries, including: basal skull fractures, facial fractures and abdominal injuries. These can all lead to access issues for enteral nutrition (EN) and subsequently lead to a delay in feeding. Associated abdominal injuries from the initial trauma can preclude the use of gastrostomy/ jejunostomy placement for an extended period of time, meaning increased risk of tube displacement with nasogastric tubes (NGT).
Management strategies: • ENT input may be required to assist with placing a NGT. • Depending on prognosis and expected requirements for longer-term feeding, discuss with the multidisciplinary team (MDT) if early placement of gastrostomy should be considered when NGT is unable to be placed or is frequently dislodged. • Utilise the provision of parenteral nutrition (PN) when EN cannot be supported, or nutritional goals have not been reached by EN by one week post-injury.16 GAPS IN FEEDING
Patients with TBI often have other injuries which require multiple operations and thus the patient may have periods of being placed nil by mouth in preparation for surgery. Due to agitation, the patient can often have recurrent NGT displacements which may require x-ray confirmation once replaced, leading to delay in feeding and the patient not receiving the full amount of feed. The patient’s feed may regularly be put on hold if they are experiencing tolerance issues. Ileus may be propagated by repeated and prolonged periods where patients are not fed. Management strategies: • Consider aiming to meet full nutritional requirements (NRQs) within a shorter time period by utilising a higher calorie feed and/or increasing rate of feed. • Consider feeding outside of work hours, so gaps are not caused by therapy sessions. • Where tolerance is not an issue, catch-up feeding can be utilised, based on local policy. FEEDING INTOLERANCES
Impaired gastrointestinal function has been reported in up to 80% of TBI patients with a GCS < 12.17 Neurogenic bowel can occur in this patient group and can result in: diarrhoea, constipation, urgency and incontinence. Management strategies: • Ensure that the patient’s head of bed is elevated 30-40 degrees during feeding. • Consider use of alternative feeds (e.g. fibre free/tolerance feeds). www.NHDmag.com October 2018 - Issue 138
CLINICAL • Liaise with the medical team to ensure tolerance issues are medically optimised. • Liaise with the medical team and Nutrition Support Team to consider post pyloric feeding. • Consider the use of bridging PN. • Discuss with palliative care for symptom management advice as sometimes sickness cannot be resolved although treatment has been optimised. FLUID AND SODIUM DISTURBANCES
Syndrome of inappropriate diuretic hormone secretion (SIADH) may require patients to have a fluid restriction leading to difficulties in meeting their elevated NRQs. Diabetes insipidus and cerebral salt wasting can occur following TBI. Management strategies: • With SIADH, consider utilising a high energy/low volume feed. • Where diabetes insipidus has occurred, consider a low sodium feed if persistently raised sodium levels. • There is little nutritional change to consider with cerebral salt wasting; this is medically managed. REDUCED ORAL INTAKE
Altered levels of consciousness and cognition can result in memory issues and confusion, which can lead to difficulty in feeding and reduced oral intake. Low mood, shock, depression, fatigue and pain related to the initial injury, as well as medication effects can also lead to reduced appetite and poor oral intake. Communication issues and confusion may lead to patients being unable to communicate what their preferred foods or dietetic treatment plan would be. Taste fatigue can occur within this patient group due to long hospital stays, resulting in the patient becoming bored with the hospital menu or nutritional supplement drinks. Reduced ability for the patient to feed themselves can occur following injury. Dysphagia can be a common consequence of TBI, with as many as 61% of patients experiencing it.13 This may lead to reduced oral intake due to dislike of the textured foods and reduced 24
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variety available, as well as poor hydration with thickened fluids. Management strategies: • Consider if adaptive cutlery or assistance with all dietary and fluid intake is required – the patient’s family may be happy to assist with this. • Liaise with catering to provide the patient with alternative menu options. • It is important to keep enteral access for supplementary top-up feeding/ hydration/medication until oral intake is fully established and can be consistently maintained. • Longer-term EN may be needed in dysphagic patients due to poor oral intake and limited variety of high calorie supplements. ELEVATED NUTRITIONAL REQUIREMENTS
Anecdotal evidence from practice has demonstrated that often young males with TBI require in excess of 3000kcal/day. Paroxysmal sympathetic hyperactivity (PSH) is an excessive and uncontrolled increased activity of the sympathetic nervous system, which increases the patient’s fluid and energy needs. A report of indirect calorimetry in a 14-year-old with hypoxic brain injury and PSH revealed resting energy expenditure during an autonomic storm of 309% of the patient’s predicted resting energy expenditure.18 Management strategies: • Utilise high calorie feeds. • If the patient is able to eat orally, consider overnight NGT feeding alongside oral intake to assist with meeting the patient’s full NRQs. • Be cautious not to overfeed on protein if energy requirements are high and body weight is low; consider using high calorielow protein supplement (e.g. Vitajoule, ProCal Shot, Calogen etc.). MONITORING
Regular weights are essential to ensure metabolic demands are being met; however, this can often be difficult due to agitation or patient injuries requiring bed rest. Due to immobility, weight gain in this patient group tends to lead to an increase in fat stores, often making it more difficult to establish a ‘target
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Versus an eHCF without LGG® or formulas based on rice hydrolysate, soy or amino acids. Return to milk means the normal physiological process in which the daily diet plays a role. When achieved it allows milk and dairy foods to be fully introduced without experiencing an allergic reaction. ‡ Versus Nutramigen without LGG®. References: 1. Canani RB et al. J Pediatr 2013;163:771–777. 2. Canani RB et al. J Allergy Clin Immunol 2017;139:1906–1913. †
Nutramigen with LGG® is a food for special medical purposes for the dietary management of cow’s milk allergy and must be used under medical supervision. Nutramigen with LGG® is not recommended for premature and immunocompromised infants unless directed and supervised by a healthcare professional. IMPORTANT NOTICE: Breastfeeding provides the best nutrition for babies. *Trademark of Mead Johnson & Company, LLC. © 2018 Mead Johnson & Company, LLC. All rights reserved. LGG® and the LGG® logo are registered trademarks of Valio Ltd, Finland. Date of preparation: February 2018 UK/NUT/18/0026
Low mood, shock, depression, fatigue and pain related to the initial injury, as well as medication effects can also lead to reduced appetite . . . weight’, as a healthy BMI in this patient group may constitute a larger proportion of fat than a mobile patient. In the rehab phase, a TBI patient’s metabolism can change suddenly, leading to excessive weight gain. Management strategies: • Ensure patients are weighed at least twice weekly (where possible) to ensure appropriate monitoring of their nutritional status. • When patients are unable to be weighed using hoist/chair scales, bed scales can be used where available. • Alternative measurements (e.g. mid-upper arm circumference) should be taken early in admission and regularly thereafter to allow monitoring of nutritional status, for those patients who are difficult to weigh. • Where available, bioimpedence can be utilised to monitor change in the patient’s body composition and to prevent excessive gain in fat stores. UNDERSTANDING
Patients with cognitive impairment may lack understanding of their elevated NRQs and/ or may forget discussions with the dietitian, therefore, compliance with dietetic care plans may be poor. There may be a lack of knowledge within medical teams regarding elevated NRQs in TBI patients, which can lead to premature removal of feeding tubes once oral intake is commenced. Management strategies: • Consider liaising with the patient’s family who may have more regular contact with the patient, as they may be able to encourage and remind them of the importance of following a dietetic care plan. • Liaise with the medical team regarding your concerns of the patient’s nutritional status; educate them on the nutritional challenges in this patient group. 26
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Depending on the extent of their injury, the patient may lack capacity to make decisions around treatment (e.g. feeding tube placement). Management strategies: • The medical team should ensure a capacity assessment is carried out. • If the patient lacks capacity, act in their best interest and endeavour to attend best-interest meetings. • Where appropriate include the patient’s family in the decision-making process. CONCLUSION
The provision of adequate nutrition support for patients with TBI has been a clinical challenge for decades. The unique metabolic derangements, along with accompanying challenges of providing adequate nutrition support, means that this patient group is at particularly high risk of malnutrition. To help ensure the best outcome for the patient, in my experience, early dietetic input and an MDT approach to treating malnutrition is essential, as this can be a highly vulnerable and complex group of patients to manage.
PROBIOTICS, PREBIOTICS AND THE FUTURE OF GUT HEALTH 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.
The use of probiotics and prebiotics in gut health has been a controversial topic. This article hopes to pick apart the latest evidence and what we really should be recommending when it comes to looking after our gut. Gut health? Not the most inspiring of names, but definitely a topic that is at the forefront of both scientific research and media headlines. The ever-growing evidence of the importance of looking after our gastrointestinal (GI) system and how this can impact on our overall health is hitting the headlines more and more frequently, with emphasis on a high fibre, diverse plant-based diet, to help our ‘good bacteria’ flourish. THE GUT
REFERENCES Please visit the Subscriber zone at NHDmag.com
Our gut - or more scientifically known as our GI tract - is a functional organ to allow us to digest and absorb food. It is also the most heavily populated area of the body by bacteria. It ranges from our oral cavity, where digestion begins with mastication, before moving to the stomach and small and large intestine before reaching the rectum.1 The gut microbiota (previously referred to as gut flora) refers to the microbe population that lives within our GI tract. Within this gut microbiota exists a complex ecosystem of approximately 300 to 500 bacterial species, comprising nearly two million genes - which make up the microbiome.2 The number of bacteria within the gut is immense to say the least, as it is approximately 10 times that of all of the cells in the human body, and the collective bacterial genome is vastly greater than the human genome.3 The gut microbiota is now considered an important partner of human health, as it interacts with virtually all human cells. For this reason, there have been multiple studies looking into this area. In fact, in 2017,
approximately 4000 papers focusing on the gut microbiota were published, and between the years 2013 and 2017, more than 12,900 publications were devoted to the study of the gut microbiota. This represents more than 80% of the overall publications of the last 40 years (since 1977) on this topic, highlighting the fact that this field of research is not only blossoming, but there is a necessity for it to continue.4 The functions of the GI microbiota include modulation of the immune system, as it can form a protective barrier which decreases the chances of pathogen invasion. It also plays a role in bacterial metabolism, as it is able to breakdown non-digestible food products (for example, non-starch polysaccharides, oligosaccharides proteins and amino acids) into short-chain fatty acids. In addition to this, the composition of GI microbiota has been linked to human brain development and the effects on anxiety/motor control issues.1 Therefore, keeping our levels healthy and balanced is essential. PROBIOTICS
The WHO describes probiotics as ‘live organisms that when administered in adequate amounts, confer a health benefit to the host’,5 and the concept of using them to aid health dates back to 1907, where it was first thought to replace harmful microbes with beneficial ones by Nobel Laureate Elie Metchnikoff.6 Probiotics can come in varying forms, most commonly found in our supermarkets as yoghurts or drinks. These probiotics have live cultures www.NHDmag.com October 2018 - Issue 138
WHAT TO LOOK FOR IN A PROBIOTIC A guide for healthcare professionals CHECK THE LABEL AND QUALITY
Does the label state the full strain name of the microorganism(s) in the product?
Does the label state the number of live cells of the probiotic strain(s) in the product?
NOTE: This should comprise three components: genus, species and strain identiﬁer.
Yakult contains 1010 Lactobacillus casei Shirota per 100 ml, when refrigerated.
Genus (e.g. Lactobacillus), species (e.g. casei) and strain (e.g. Shirota) is stated in full on Yakult’s packaging.
This is equivalent to 6.5 billion live cells per 65ml bottle.
Contact the company. Are there quality control procedures in place? NOTE: This is necessary to ensure the product contains the correct strains and number of live microbial cells as stated on the label.
Yakult is acknowledged by experts to be a quality probiotic.
CHECK THE SCIENTIFIC EVIDENCE
Contact the company or access their HCP website, to ﬁnd the supporting research. NOTE: (i) Regulatory restrictions mean companies can share research information with HCPs but not the general public; (ii) Not all probiotic research papers can be found on medical literature databases.
The research evidence for Lactobacillus casei Shirota can be found at www.yakult.co.uk/hcp or by contacting firstname.lastname@example.org
CHECK FOR GI TRACT SURVIVAL
CHECK FOR EFFICACY OF THE STRAIN
For oral probiotics, are there human intervention trials showing survival of the probiotic strain(s) through the gut?
Check for trials and studies for the probiotic and the particular patient problem
NOTE : In vitro or model studies are not proof of gut survival in vivo.
(important for assessment of safety).
There are several research papers describing human studies showing the gut survival of Lactobacillus casei Shirota.
See expert advice in ‘LcS Insight: HCP Study Day 2014’ and ‘Your Guide to Probiotics’.
For further support on what to look for in a probiotic or to access the research behind Yakult, then please visit www.yakult.co.uk/hcp contact email@example.com or call 020 8842 7600 This resource is intended for healthcare professionals. Not to be distributed to patients.
PUBLIC HEALTH added to them, as most of the natural probiotics found in yoghurt products die during processing. Commercial probiotic supplements are also available in the form of powders, tablets and liquids. Some fermented foods are natural sources of probiotics too, such as kefir (a fermented milk). So, where to start? Currently, there is no form of probiotic that has been proven to work better than others. What is important in commercial products, however, is that the particular strains have the correct encapsulation to survive transit through our gut. This is strain specific.1 Most probiotics are bacterial, however, other microbes (e.g. yeast, fungi and viruses) also make up the human microbiota.7 Probiotics are named by their genus, then species and finally their strain. The most commonly proposed organisms are Lactobacillus and Bifidobacterium strains. PREBIOTICS
What about prebiotics? Confused? Prebiotics are described as non-digestible, fermentable food components that result in the selective stimulation of growth and activity of one or a limited number of microbial genera/species in the GI microbiota that provide health benefits to the host.8 Prebiotics are resistant to digestion in the upper GI tract and are fermented by the gut microbiota. This in turn impacts on the growth and activity of specific bacteria. For those familiar with the low FODMAP diet, the term prebiotics may be ringing bells. This is because the most common classes of prebiotics are also FODMAPs – fructans (oligofructose, fructo-oligosaccharides) and galactans (galactooligosaccharides). Therefore, those following a low FODMAP diet for the management of IBS are in fact restricting prebiotics during the elimination phase of the diet. THE EVIDENCE
There are many conditions to which probiotics are thought to have a benefit, from a wide range of GI disorders and diarrhoea to conditions such as allergies, dental caries and vaginosis.1 However, proven evidence for the use of probiotics remains lacking. There are only a few conditions to which the use of probiotics has been proven to be beneficial, including the following: 9-12
• • • •
Acute onset of infectious diarrhoea Antibiotic-associated diarrhoea The prevention of traveller’s diarrhoea The prevention of clostridium difficile (C. diff) associated diarrhoea • Helicobacter pylori eradication (as an additional therapy) • The prevention of pouchitis Despite the studies supporting the use of probiotics for these conditions, varying studies provide different outcomes, with results differing depending, for example, on the specific strain or the duration they are taken. For IBS-D specifically, it is thought that a multistrain probiotic is best associated with significant improvement in symptoms in IBS-D patients and is well-tolerated.13 Results from this particular study indicate that probiotic supplementation confers a benefit in IBS-D and deserves further investigation. Currently, probiotics are not recommended when following a low FODMAP diet. However, a study by Staudacher et al14 concluded that probiotics in combination with a low FODMAP diet improve the effects of Bifidobacteria abundance and stool acetate. The study also notes that more research is needed on the effect of the reintroduction of FODMAPs on the gut microbiota before a low FODMAP diet and probiotic therapy can be advised conjunctively. Research on both live and bio yoghurts has also been unclear. For example, two different studies looking at probiotics and the prevention of antibiotic-associated diarrhoea have provided conflicting results. Conway et al demonstrated no benefit from taking standard or bio yoghurts, whereas Beniwal et al showed a reduction in the incidence of antibiotic-associated diarrhoea when yoghurts were introduced.15,16 A number of studies have looked at the effects of prebiotics on GI disorders. Randomised control trials looking at the effect of prebiotics on various diarrhoea-associated conditions concluded that prebiotics had no impact on the duration of antibiotic-associated diarrhoea, however, they may reduce the relapse rate of C. diff patients or reduce the incidence of traveller’s diarrhoea. These studies typically used placebo groups and an addition of a certain number of prebiotics to the diet per day.17-19 www.NHDmag.com October 2018 - Issue 138
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Although not ALL diseases begin in the gut a vast amount do, and with advances in medical research we are learning that the connection between a healthy gut and a healthy body is both profound and undeniable. Imbalance of the gut bacteria (dysbiosis) has been linked to a number of conditions including IBS, acute gastroenteritis and nosocomial infections. With over 6 scientific publications a day, this area of research is rapidly growing and changing our understanding of the roles of gut bacteria in a wide range of conditions. To help improve your gut health knowledge and build upon your skill set we have three individually accredited CPD talks available, hosted by experts in the field.
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PUBLIC HEALTH It has been concluded that there is no effect on gut microbiota or disease activity in patients with Crohn’s disease and, therefore, specific prebiotic treatment is not advised in this patient group.20 Interestingly, two randomised controlled trials looking at prebiotics and functional bowel disorder/IBS concluded that the addition of some prebiotics at varying doses may reduce symptoms of abdominal pain, bloating and flatulence.21,22 This is obviously contradictory to other studies linking worsening symptoms of prebiotics and IBS and the basis of the low FODMAP diet, which reduces prebiotics in the diet to improve symptoms. It’s one example of how, even though prebiotics have been linked to worsening symptoms in IBS patients, considering the dose of prebiotics used, they may be worthwhile and ongoing research in this area is required. When looking at the use of probiotics in the general healthy population, there currently lacks robust evidence to suggest that probiotics may be of any benefit. A recent systematic review concluded that there was no overall benefit of probiotics on bacterial diversity when trialled in healthy people.23 GUT-BRAIN AXIS
While on the subject of gut health, I wanted to touch on the gut-brain axis (GBA) which consists of communication between the central and the enteric nervous system, linking emotional and cognitive centres of the brain with peripheral intestinal functions. There is strong evidence to suggest that gut microbiota has an important role in these interactions between the gut and the nervous system, by interacting with the central
nervous system (CNS), by regulating brain chemistry and influencing neuro-endocrine systems associated with stress response, anxiety and memory function. One study describes how many of these effects appear to be strain-specific, suggesting a potential role of certain probiotic strains as a novel adjuvant strategy for neurologic disorders.24 In addition to this, the effects of CNS on microbiota composition are likely mediated by a change of the normal luminal/mucosal habitat that can also be restored by the use of probiotics and possibly by diet. In clinical practice, an example of this interaction is constituted by conditions such as IBS, which is now considered to be a microbiome-GBA disorder.24 Further studies have also noted how probiotics can reduce the stress-induced release of cortisol, anxiety- and depression-related behaviour,25 and can reduce exam-induced stress in medical students.26 Also, studies have shown that probiotics significantly affect the areas of the brain that deal with emotions and sensation, when compared to a placebo.27 CONCLUSION
I’m sure the advice for the use of probiotics, prebiotics and how to manage our general gut health will continue to change. However, the current evidence suggests that the use of probiotics and/or prebiotics may be advised for patients suffering from certain GI conditions such as IBS, traveller’s diarrhoea and C. diff. Evidence for the use of probiotics in other medical conditions, or in the healthy population remains limited; but ongoing research may change this, particularly with the focus of our gut microbiota and mood.
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SUPPORTING A FOOD-FOCUSED FUTURE WORKFORCE Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland
In December 2012, NHS Highland took the lead agency role for adult care services, overseeing all services previously managed by Highland Council. This included responsibility for the 73 care homes and a number of independent and inhouse care-at-home teams.
Award winning dietitian, Evelyn Newman, is well known throughout the profession for her writing, volunteering with the BDA and innovative work. She currently holds a unique role in The Highlands.
By April 2014, I had been appointed to my current role, working within the corporate senior social work team. The expectation was that I would work with care home managers and owners to support both catering and care staff to assist residents and service users to receive safe, nutritious, high quality meals and mealtimes. Health and care standards1 provide broad guidance about a number of aspects related to eating and drinking, which service users should be able to expect when living in any care home. It became clear to me, however, that many care staff were not as well informed about food, fluid and nutritional care as their health service counterparts. I carried out a training needs analysis to be clearer about how staff might feel better equipped to best support residents’ needs, using a personcentred, asset-based approach. Many staff had historically received little or no formal nutrition training and contact with healthcare staff had usually been via 1:1 consultations. It wasn’t unusual for them to look to (unevidenced) articles on the web, or in magazines and newspapers, for nutrition information. Very few care catering staff were familiar with therapeutic diets, except perhaps diabetic and weight management (often from personal experiences). The key to engaging the workforce was to understand what would work best for them, in whatever location or situation they found themselves. Conventional training in one central
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location was certainly not going to work, given the very remote and rural landscape of the largest health board, by geographical area, in Scotland. Eighty percent of our care home residents have a degree of cognitive impairment and with that comes the prospect of dysphagia, which can result in a 70% risk of dehydration and a 50% risk of malnutrition. I like to make use of educational games, such as the Dysphagia game2 to support informal, fun, interactive learning for staff, residents and relatives. Highland care homes were also used to test the Hydration game,2 which I helped to develop in 2016/17. Since August 2014, I have coordinated quarterly texture modification training sessions, in a variety of locations across the north Highlands to maximise attendance. These are very practical, interactive and always positively evaluated. SLT, OT, dental colleagues and a professional chef contribute to these, demonstrating the impact of poor positioning and the dangers of not assisting someone to eat safely. Hundreds of care staff have attended to date and have experienced first-hand, the vulnerabilities of residents being fed by them, especially when food looked very unappetising. When we first started this work, it wasn’t uncommon to hear that meals were being liquidised, or that residents were taking up to 40 minutes to eat an ultimately cold meal. A number of staff left the session close to tears as they realised how they had been
Conventional training in one central location was certainly not going to work, given the very remote and rural landscape of the largest health board, by geographical area, in Scotland. inadvertently letting people down. Many changes were soon implemented in care home kitchens, in particular the purchase of more suitable equipment and improvements to the presentation of texture modified food. Residents in Highland care homes are fortunate that such a large investment in training and awarenessraising information on the subject has led to so many positive improvements to the texture modified meal service and dining experience. In Scotland, the duty for monitoring and grading standards of care lies with the Care Inspectorate. My role is very much a supportive rather than an inspection role. Care inspectors are able to objectively highlight inaccuracies with residents’ nutrition screening, which can have a knock-on effect to their personal care plans and the potential to inappropriately refer to dietitians. Links to the BAPEN MUST site and use of the MUST calculator are encouraged to assist more accurate person-centred nutrition screening. MUST training continues to be made available throughout the Highlands, either in individual care homes, or as part of larger nutrition and hydration events. We are all encouraged to consider how new technologies can support better care, so the purchase and completion of the BAPEN e-MUST tool is proactively promoted. Quarterly newsletters, provide examples of good practice from Highland care settings, residents’ perspectives and a seasonal themed focus on nutritional aspects of care.3 They are well evaluated and provide another perspective, sharing
insights and encouraging new practices. They also offer NHS staff an insight into the valuable work being delivered in social care settings. I work closely with community dietitians within our three operational units. They are a scarce, valuable resource and, most recently, we have delivered a huge change to the way nutritional support is delivered to residents. We are building on all the good work on nutrition and hydration, which care chefs and staff have been developing. We are now proactively promoting a food-first approach rather than recommending the prescribing of oral nutritional supplements. This allows dietetic time to be more focused on supporting the care of the most vulnerable highpriority individuals and has many benefits for residents and staff. This supports Highland’s delivery of the Scottish government’s vision for ‘Realistic medicine’.4 The development of innovative social care dietetic placements5 supports a changing workforce profile for the future and has allowed a greater appreciation and understanding of residents’ lives, their rich histories and has helped students to understand a social model of care, which puts the resident in control, rather than a conventional clinical model, which is dominated by organisational standards and regimented routines. In Evelyn's next article she will describe the opportunities, successes and insights which have come from this award-winning, widely recognised work with HEIs, NES, the BDA and Highland care homes. www.NHDmag.com October 2018 - Issue 138
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HOW HEALTHY ARE PLANT-BASED DIETS? 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.
This article will examine the nutrition considerations and health impact of plant-based diets (PBDs), which are becoming increasingly popular. A PBD involves consuming foods and drinks which mainly come from plant sources such as: fruit, vegetables, legumes, wholegrains, nuts and seeds. Most PBDs involve limiting or avoiding animal sources such as: meat, poultry, seafood, eggs and dairy. There are different types of PBDs (as explained in Table 1) and there are different reasons why people choose to follow these type of diets; ranging from perceived health benefits and food preferences, to environmental protection and animal welfare. NUTRITIONAL CONSIDERATIONS
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PBDs tend to be low in saturated fat and high in fruit, vegetables, wholegrains, beans, pulses, soy products, nuts and seeds (i.e. high in fibre and antioxidants).1 Animal sources of food tend to be high in protein, but when calorie needs are met on a PBD, protein requirements are usually met or exceeded.1 Those on a PBD can get a good range of essential amino acids in
their diet by including a variety of protein sources every day.28 PBDs can also be low in calcium, iron, vitamin B12, iodine, omega-3 and selenium.1-2 This is especially true with more restrictive diets such as veganism; for example, a recent European study found that vegans were at a high risk of inadequate iodine and vitamin B12 intakes.3 Furthermore, a number of studies have found that vegetarian children may have low levels of vitamin D and vitamin B12.4 It is also important to remember that the recommended daily amount of iron for vegetarians is 1.8 times higher than for non-vegetarians, as iron coming from plant sources (nonhaem iron) acts less efficiently in our body than iron from animal sources (haem iron).5 Overall, PBDs can be balanced and healthy as long as they include all-important nutrients.28 As PBDs are not automatically healthy, it is still important to include plenty of fruit,
Table 1: Different types of PBDs Name of diet
No animal products are consumed (i.e. no meat, poultry, fish, dairy, eggs or honey). Other animal based products are also usually avoided like: leather and cosmetics which contain ingredients derived from animals.
No meat, poultry, seafood or dairy - but eggs are consumed.
No meat, poultry, seafood or eggs - but dairy is consumed.
Vegetarian (a.k.a. lacto-ovo vegetarian)
No meat, poultry or seafood - but eggs and dairy are consumed.
No meat or poultry - but fish, seafood, eggs and dairy are consumed.
Flexitarian (a.k.a. semi or demi-vegetarian)
Mainly follow a vegetarian diet, but occasionally eat animal based products (e.g. a few times per week or when eating at a restaurant).
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NUTRITION MANAGEMENT vegetables and fibre; while limiting foods high in saturated fat, salt and sugar. Extra dietary planning, which may include support from a registered dietitian, can be needed for groups which are more nutritionally vulnerable, such as pregnant and breastfeeding women, babies and young children. Supplements may also be indicated, depending on the level of dietary restriction. For example supplements which include vitamin B12 and iodine are often needed by those following a vegan diet.2,6 HEALTH OUTCOMES
Studies have found that PBDs lead to lower total and low-density lipoprotein (LDL) cholesterol levels and improvements in serum glucose levels and inflammation.1,8 These factors are thought to contribute to a reduced risk of chronic disease overall. For example, a recent meta-analysis of observational studies by Dinu et al9 found that a vegetarian diet was associated with healthier ranges for BMI, lipid variables and fasting glucose, as well as being modestly associated with reduced rates of ischemic heart disease and cancer. However, there was
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no significant association found for all-cause mortality, other types of cardiovascular disease and stroke, cancer mortality, or breast cancer incidence. There is less available evidence in terms of vegan diets. However, Dinu et al found no association between a vegan diet and improved all-cause mortality, and a possible association was found between a vegan diet and a reduced incidence of cancer.9 A limited amount of conflicting evidence has found a lower risk of dementia among those who follow a PBD, but more evidence is needed to investigate this.10 For those with Type 2 diabetes, PBDs have been associated with improved glycaemic control.11 PBDs have also been linked with a lower risk developing Type 2 diabetes in observational studies based in Adventist populations.12-13 It is important to be aware of the numerous confounding factors effecting studies of PBDs which arenâ€™t always fully corrected for. For example, those who follow PBDs are more likely to be female young adults, educated, nonsmokers and physically active.14 Furthermore, a
. . . a high intake of fruit and vegetables (regardless of whether meat and dairy is included) is associated with a lower risk of heart disease, cancer and early death.
high intake of fruit and vegetables (regardless of whether meat and dairy is included) is associated with a lower risk of heart disease, cancer and early death.15-16 A large systematic review from 2017 found that 5.6 million early deaths worldwide in 2013 may have been related to having a low intake of fruit and vegetables.16 Benefits of animal-based foods should also be highlighted. A moderate intake of lean red meat as part of an overall balanced diet is associated with a low risk of chronic disease and improvements in overall nutrient profile.17 Similarly, some studies have found that including dairy as part of a vegetarian diet carries more health benefits than avoiding dairy; in terms of bone, heart and metabolic health.18 Meat and dairy can also provide energy and important nutrients in lower volumes than plant-based foods, which can be especially important for those who are unwell, or for those with a poor appetite. There are some negative health outcomes associated with PBDs. A study by Appleby et al (2007)19 found that although vegetarians and pescatarians had a similar fracture risk to meat eaters, vegans had a higher fracture risk which correlated with a lower average intake of calcium. Some studies have also found a higher risk of anaemia in those following PBDs.20-21 PBDs can feel overly restrictive for some people, which may lead to a disordered relationship with food. For example, studies
have found that vegetarians may have a higher risk of disordered eating, binge eating and extreme behaviour related to controlling weight.22-23 But there is not enough evidence as to whether vegetarianism has a causal role in the development of an eating disorder, or whether this emerges in order to mask symptoms of an existing eating disorder.23 Well planned PBDs can be used at all stages of life. Normal growth and development has been observed in infants, children and adolescents who follow a PDB.24-26 However, raw, macrobiotic and fruitarian diets have been associated with malnutrition and impaired growth in infants.27 CONCLUSION
Well-planned PBDs are associated with a healthy nutritional profile and a reduced risk of chronic diseases. However, some of the supporting evidence for this can be confounded by the fact that vegetarians and vegans tend to make other healthy lifestyle choices beyond diet. Animal-based foods are also nutritious and cutting out food groups runs the risk of nutritional deficiency and related health problems. Although most people would benefit from eating a PBD, many of the benefits can be achieved by eating more plant-based products and less animal-based products; without avoiding animal-based products altogether. Therefore, adopting a â€˜flexitarianâ€™ approach may provide a more realistic and balanced diet for many people. www.NHDmag.com October 2018 - Issue 138
GASTROSTOMY TUBE FEEDING Louise Edwards Community Team Lead/Specialist Dietitian, Central Cheshire Integrated Care Partnership Louise is a Specialist dietitian working in the NHS. She has an interest in high output stomas and supported the development of a service for this patient group at the Mid Cheshire Hospitals NHS Foundation trust.
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This article will cover the different types of gastrostomy feeding tubes and their indications. NICE guidelines state that enteral feeding should be considered for individuals who are malnourished or at risk of malnutrition and have an inadequate or unsafe oral intake and a functioning accessible gastrointestinal (GI) tract. Gastrostomy feeding refers to providing liquid nutrition via a feeding tube directly into the stomach and should be considered where enteral tube feeding is likely to be required on a longer-term basis, specifically more than four weeks.1 However, for some patients, there may be contraindications to progress from nasogastric feeding to gastrostomy feeding, such as ascites, previous gastric surgery and gastric varices.21 Clinical indications for gastrostomy feeding may be dysphagia as a result of a stroke, or a neurological condition, i.e. motor neurone disease (MND). Inadequate oral intake that leads to gastrostomy feeding being considered may be due to surgery (stomach, bowel, head and neck), radiotherapy or chemotherapy. Gastrostomy tube insertion may be prophylactic for those patients with a progressive condition such as MND where worsening dysphagia is likely. The decision to insert a gastrostomy feeding tube should take into account the impact on the individualâ€™s quality of life, personal wishes and social circumstances.
be assessed individually by the NST and supported by the team during preassessment and post-procedure care.6 Since the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)11 report highlighted concerns regarding morbidity and mortality associated with percutaneous endoscopic gastrostomy (PEG) placement, patient selection is important and all factors should be considered by the NST. The decision-making process requires consideration of psychological, social and ethical factors.6 The NST is paramount to facilitating decision making, with evidence suggesting that complications related to tube feeding are less common in settings where a multidisciplinary nutrition team is set up.12 Patient and carer perceptions and expectations of gastrostomy feeding should be considered. The benefits of the procedure, what the procedure entails and the risk and burden of care should be fully explained before initiating feeding.20
NUTRITION SUPPORT TEAM (NST)
PEG is the preferred method of placement to administer nutritional support in patients with a functional GI system who require long-term enteral nutrition.4
The provision of an enteral tube feeding service should be supported by an NST. Each patient who is referred for gastrostomy tube placement should
TYPES OF TUBES
Insertion of a gastrostomy feeding tube can be performed in three ways: 1 endoscopically - a percutaneous endoscopic gastrostomy tube (PEG); 2 radiologically - a radiologically inserted gastrostomy tube (RIG); or 3 surgically - a surgical gastrostomy.
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Stroke remains the commonest indication for PEG placement, with gastrostomy feeding being considered at 14 days post stroke. PEG placement PEG feeding tubes were first used in the 1980s.2 Acceptability of PEG tube feeding still varies with long-term nasogastric feeding more prominent in many Asian nations.3 In order for PEG placement to be appropriate, a patient must be able to lie flat and tolerate an endoscope being passed. Placement should be carried out under full aseptic technique, as the procedure carries risk of bleeding, bowel perforation and peritonitis, etc.6 Infection is reported to occur in 39% of patients post procedure8 and, as such, prophylactic antibiotics are recommended to reduce the incidence of peristomal wound infection.21 Stroke remains the commonest indication for PEG placement, with gastrostomy feeding being considered at 14 days post stroke.6 Dysphagia is common in chronic progressive neuromuscular disease, i.e. MND, Huntingtonâ€™s disease, etc. Gastrostomy feeding in this patient group is being increasingly used9 with an improvement in functional status, prolonged survival13,14 and improvement of quality of life9 being demonstrated. PEG placement could also be indicated for other clinical conditions such as head injury, Crohnâ€™s disease, short bowel syndrome, AIDs and severe burns.6 Although PEG placement is preferred, it may not always be clinically safe for the patient. RIG placement might be deemed to be more appropriate.
With advanced neuromuscular disorders, a RIG may be considered, since sedation required for PEG may represent a significant risk of ventilatory failure.6 This emphasises that timing of gastrostomy tube placement is paramount in this patient group, as supported by recent NICE guidance15 for MND, highlighting that gastrostomy feeding needs to be discussed at an early stage of diagnosis and at regular intervals as the disease progresses. This may partly be due to the evidence that delaying gastrostomy tube placement until severe bulbar dysfunction negates benefit.16 There is limited evidence to suggest that RIG rather than PEG placement in MND patients has increased survival, which is perhaps due to avoiding risk of sedation with a lower forced vital capacity.17 For patients with compromised ventilatory status, endoscopic gastrostomy tube placement should only go ahead following respiratory and anaesthetic assessment. If deemed not safe, then radiological placement should proceed.6
RIG feeding A RIG would be considered for patients who are unable to have an endoscope passed; this may be linked to the presenting clinical condition or their anatomy. RIG feeding tubes may be indicated for individuals with oropharyngeal or oesophageal malignancy, since a PEG would carry the risk of the tumour seeding within the tract.6
For PEG tubes which have been placed with no known complications, gastrostomy feeding can commence four hours post insertion,18 but Trusts may have their own policy on this. For radiologically or surgically placed gastrostomy tubes, often the radiologist or surgeon will advise when nutrition can commence. In my experience, this can be over 24 hours, with water being
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Surgical gastrostomy A surgically placed gastrostomy tube may be used when patients cannot tolerate an endoscopic or radiological placement. Possible complications are similar to that of PEG placement, being infection, leakage and peritonitis, etc. Oesophageal obstruction could be a potential indication for this method of tube placement. NUTRITION VIA GASTROSTOMY TUBE
There is limited evidence to suggest that RIG rather than PEG placement in MND patients has increased survival, which is perhaps due to avoiding risk of sedation with a lower forced vital capacity. commenced initially and tolerance monitored. Bolus or continuous methods of administration of nutrition should be considered, taking into account a patient’s preference, feasibility in the home setting and drug administration.1 CONSENT AND ETHICAL CONSIDERATIONS
There is concern that due to nutrition administration via a PEG tube appearing simple, PEG tubes are being placed with no clinical benefit.3 Ethics need to be considered before placement of a gastrostomy feeding tube is proposed.6 If an individual’s prognosis is weeks, then percutaneous enteral nutrition is deemed inappropriate since the burden of the insertion is likely to outweigh any benefit.6 Evidence suggests that patients with advanced dementia do not benefit from PEG feeding in terms of prolonging life or comfort.6 However, enteral feeding may still be considered in individuals with dementia where the presentation of eating difficulty is not associated with dementia.6 Once the NST has provided the patient with the information of what a gastrostomy tube is, the process of its placement and details of the after care of the tube, the patient can then make an informed decision and give consent. Studies have shown that patients who have had previous PEG tubes do not have issues with tube-related problems such as leakages or blockages,19 but report problems with interference of family life, intimate relationships, social activities and hobbies.19 I think this highlights how important
it is for the NST to provide as much information as possible about ‘life with a gastrostomy feeding tube’ and to offer ongoing support to this patient group. Capacity should always be assumed unless determined otherwise.6 If an individual is deemed to lack capacity, an assessment must be given as to whether the individual has an advanced decision directive in regards to artificial nutrition provision. If this is not present, the medical team must act in the patient’s best interests. This involves consideration of what the patient would have chosen and the views of family and carers, etc. Often a best-interests meeting with members of the MDT and the patient’s family and carers is the best way to facilitate decision making. CONCLUSION
In summary, it could be said that successful gastrostomy tube placement requires support of a functioning NST, support of the patient’s wishes and consideration of capacity and ethics. In my experience, the window of gastrostomy tube insertion is paramount. I have seen individuals who have been referred for a PEG placement, suffer deterioration in respiratory status, which has resulted in radiological placement being required. This poses increased requirements with tube after care. Hence, considering the NICE guidance in regards to MND, if deterioration in swallow is likely, discussions around long-term enteral feeding should happen as early as can be facilitated. www.NHDmag.com October 2018 - Issue 138
LIFE WITH PKU DONâ€™T LET ANYTHING STOP YOU This information is intended for Healthcare Professionals only. The PKU Lophlex range are Foods for Special Medical Purposes used in the dietary management of PKU and must be used under medical supervision of a Healthcare Professional.
SPORT AND PKU Sarah Adam Metabolic Dietitian Royal Hospital for Children. Queen Elizabeth Hospital Sarah provides the dietetic support to adults with IMD at the Royal Hospital for Children, Queen Elizabeth Hospital. She also works with the metabolic paediatric dietitians and gets involved with infants and children too. She attained a post graduate certificate in Sports Nutrition from Coventry University in 2012.
Sarah Howe Specialist Dietitian Sarah is an experienced NHS Dietitian specialising in the area of Inherited Metabolic Disorders.
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Sport’s nutrition is becoming increasingly recognised by the general population, by those who either participate in sport and exercise to enhance their athletic performance, or who simply want to improve their physique. This article takes a look at how PKU is managed to support and enhance the sport and exercise experience. Social media is full of toned bodies and picture-perfect meals with carefully calculated macros and, with well-known athletes promoting their nutrition regimes; so much so that it is often hard to decide what diet is best to follow and if and when you need to change your diet when you exercise. This is no different for people living with Phenylketonuria (PKU), an inherited disorder of the metabolism of the essential amino acid, phenylalanine (Phe). The challenge for people with PKU is to control their blood Phe within tight parameters by adhering to a diet severely restricted in natural protein and supplementing it with a Phe-free amino acid substitute. This typically provides 60g protein equivalent for adults to meet the majority, if not all, of their protein requirements and usually contains the full complement of vitamins and minerals. Energy needs are mostly met with the use of specially manufactured low protein foods, such as bread, milk, flour and pasta prescribed by their GP, and fruits and vegetables that are allowed without careful measurement. It is not a diet of convenience and it requires a certain level of skill for cooking and food preparation, as well as organisation, to follow it successfully. The goal of nutrition for sport is about meeting the nutritional demands specific to the chosen sport, by supporting the metabolic and physical
adaptations to that type of exercise. In turn, this can enhance athletic ability, reduce the risk of injury and illness through appropriate recovery nutrition strategies, tailored to the goals of the individual athlete. Dietitians specialising in inherited metabolic disorders are often asked for dietetic advice by adults with PKU regarding how or whether their diet for PKU can be incorporated into their physical training. Questions patients often ask include: “Will sport affect my Phe control?”; “How can I build muscle on a low protein diet?”; “How can I best recover after exercise?”. Presently, there is limited evidence on the effect of exercise on blood Phe concentration in PKU patients. Two studies have shown that acute exercise did not change blood Phe concentration in PKU patients.11,12 However, more studies are needed in larger numbers of patients, as well as controlling for dietary intake and the type of exercise to confirm results. There is evidence in the PKU population that women in particular are vulnerable to weight gain.4 A recent study concluded that a low protein PKU meal had a reduced thermic effect of feeding and reduced postprandial fat oxidation, speculating that this could be contributing to obesity.1 Exercise can enhance fat oxidation and should be encouraged in PKU. www.NHDmag.com October 2018 - Issue 138
TASTE, OUR SECRET INGREDIENT. Discover more on www.Mevalia.com firstname.lastname@example.org Tel: 0800 988 2488 Fax 01925 865101 Dr. Schär UK Ltd. 401 Faraday Street WA3 6GA Warrington · UK
IMD WATCH DIETARY ASSESSMENT
To help answer these questions and to determine nutritional needs, there are many factors to consider in the dietetic assessment in relation to exercise. This includes the individualâ€™s own sporting objectives, their anthropometry, body composition and nutritional objectives, the training program they follow to determine their level of fitness and activity and, of course, their current dietary intake. Nutritional requirements can then be determined and compared against the current intake in order to help identify the main dietary issues that need to be addressed and negotiated. A key guideline which may be referred to regarding meeting the nutritional and fluid needs of physically active adults and athletes, is the Joint Position Statement by the The Academy of Nutrition and Dietetics and Dietitians of Canada on Nutrition and Athletic Performance.8 HOW CAN I BUILD MUSCLE ON A LOW PROTEIN DIET?
Protein is essential for tissue repair and muscle protein synthesis (MPS) in response to physical exercise, as well as for general body protein turnover. There is little evidence in the scientific literature on muscle building and sports nutrition specific to those on a low protein diet for PKU. However, what is known about the metabolic and physical response to exercise and nutrition can at present be applied to individuals on a low protein diet. To support muscle growth and the physical adaptations to exercise, overall it is important to consume both sufficient protein and calories. Most exercising individuals will typically require 1.2-2.0g of protein/kg body weight/day.8 An adult with PKU on diet requires 0.8g protein/ kg/d plus 40% to account for the digestibility of amino acids and the effect of amino acids on Phe control.10 This equates to 1.12g protein/kg/d for sedentary adults with PKU. Exercise and protein both stimulate MPS and are synergistic when protein is consumed before or after exercise. The timing of protein consumption appears to be most effective for muscle growth when consumed within 30 minutes to two hours after exercise and at regular three- to four-hourly intervals across the
day.7,2 Furthermore, MPS is enhanced for at least 24 hours after resistance, sprint and endurance exercise, plus the muscle becomes more receptive to protein consumed over this period of time.3,8 However, the effect of protein timing in relation to exercise is perhaps lessened for those who are already consuming sufficient amounts of protein (e.g. 1.6g/kg/d).5 The optimal dose of protein to consume immediately after exercise is 15-20g (or approximately 10g of EAA).7-9,2 The protein substitutes for PKU typically contain 20g of protein equivalent, of which 10g is essential amino acids (EAA), making these substitutes ideal for supporting muscle growth. Older adults and those wishing to maintain muscle mass and restrict energy intake may benefit from higher doses of 30-40g.5 For a person with PKU, these recommendations could be achieved by consuming one 20g protein equivalent substitute at each mealtime, with one immediately after finishing the training session. Studies looking at pre-sleep protein consumption show that consuming protein after an evening training session improves the nitrogen protein balance.13 This may be of particular relevance to individuals with PKU, as the highest Phe level is the morning sample after the overnight fast. The natural protein from the food exchanges can be divided between the three main meals or in a pre- or post-exercise snack. The PKU protein substitute is also a rich source of branched chain amino acids. In particular, leucine can independently drive protein synthesis, although sustained effects are seen when combined with EAA.6 For example, an 80kg athlete would need 1.2-2.0g of protein/ kg body weight/day. This equates to 96g-160g/ day of total protein. If they required a low protein diet for PKU and their daily allowance for natural protein is 6g (six exchanges) to control their blood Phe, then they would need 5 x 20g Phe-free protein substitute to meet the remainder of their protein requirements. In total, 106g/day of protein (1.32g protein/kg/d) would be consumed: 100g from the protein substitute and 6g from the protein exchange foods. Due to the restrictive nature of the PKU diet, most protein substitutes contain the complete range of vitamins and minerals, the provision www.NHDmag.com October 2018 - Issue 138
IMD WATCH Table 1: Suitable isotonic drinks for PKU Sports Drink
Gatorade Tropical Burst, Cool Blue, Orange
Lucozade Sport Mango and Passion Fruit, Brazilian Guava
of which should be considered for those with particularly high protein requirements to avoid excessive intakes. Powdered tablets and capsule protein substitutes free of micronutrients could be used to supplement protein only. HOW CAN I IMPROVE MY RECOVERY FROM EXERCISE?
A good recovery is important, as it helps the athlete train harder and ultimately leads to improved performance in competition. The goals of recovery are to: • refuel energy (muscle glycogen) stores and rehydrate; • promote muscle repair and growth; • promote physiological adaptation to training; • support immune function. An effective and quick recovery is particularly important when participating in repeated high intensity, strenuous, or highly skilled training sessions multiple times a day, or in close succession. Individuals involved in fitness activities three to four times a week, for 30 to 60 minutes at a time, will not require additional carbohydrate; recovery needs can often be met from usual meals, protein substitute and snacks, including appropriate amounts of complex carbohydrate foods such as low protein pasta, rice or bread. Some protein substitutes contain 20-30g of carbohydrate per dose. Glycogen is the key fuel for exercising muscles and its stores in the muscle are limited depending on the exercise intensity and duration. The availability of carbohydrate to the muscles is important, as it will influence performance, so glycogen stores should be optimal prior to exercise. Glycogen stores are maximised by consuming a high carbohydrate diet, 8-12g/ kg/d depending on the level of fitness, volume and intensity of training.8. Prolonged exercise over 60 minutes of moderate to high intensity 46
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exercise will deplete glycogen stores, so dietary strategies to offset this are required. For example, consumption of a 6-8% carbohydrate containing fluid, consumed at regular intervals and/or snacks with a high glycaemic index to deliver 30g-60g carbohydrate per hour, can be employed. Isotonic sports drinks typically contain 4-8% carbohydrate and 10-20mmol/l sodium. The taste is designed to encourage drinking, supplement glucose and reduce the risk of hyponatraemia if consumed in large quantities, due to the addition of electrolytes. For PKU, fluids need to be free of aspartame, so labels need to be checked. See Table 1 for suitable isotonic drinks for PKU. Speedy refuelling requires consuming appropriate amounts of fluid, carbohydrate and protein immediately, to within at least two hours of finishing exercise. Furthermore, taking protein and carbohydrate together during the recovery period can improve the overall body protein balance after exercise8 and minimise increases in muscle damage. CONCLUSION
Exercise is safe for those with PKU in regards to their metabolic control and should be encouraged for its health benefits. Individuals with PKU participating in general recreational exercise where the goal is simply to keep fit and be a healthy weight, can support their activities by consuming regular meals based on complex low protein carbohydrate to optimise their glycogen fuel stores and by taking their protein substitutes at timely intervals across the day and immediately post exercise for muscle repair and growth. For those exercising at higher volumes and intensities, the diet for PKU can be tailored to meet the nutritional demands of the sport. However, further research on this subject is required to underpin guidance.
FREE FROM BITES
Alex Gazzola Freelance Journalist Alex is a writer specialising in food intolerance, coeliac disease, IBS, restricted diets and ‘freefrom’ food. He is the author of five books and regularly blogs at his site: www. allergy-insight.com
GLUTEN-FREE WHEAT: A STEP CLOSER? In August, the International Wheat Genome Sequencing Consortium (IWGSC) announced the publication of the most detailed ever genome sequence for wheat. This is the result of an extraordinary combined effort by over 200 scientists from over 70 research institutions in 20 countries that has taken well over a decade. The work’s touted benefits include the future prospect of being able to develop varieties better suited to climate change, such as frost-tolerant and drought-tolerant breeds and improvements in yield, food security and nutritional quality. Inevitably, perhaps, questions have been asked as to whether this so-called Google Map for Wheat might serve as a tool to develop a wheat-allergy or coeliac-safe breed of wheat - and the answer could be encouraging. We have known about the proteins responsible for sensitivities, such as the gliadins in wheat gluten and the ATIs responsible for baker’s asthma, for some time, but what were not previously determined were the genes which encoded these proteins. They are now, thereby opening up the possibility for either new developments in selective breeding, or gene-editing to neutralise toxic gluten and other allergy-triggering wheat proteins, all the while maintaining wheat’s bread-making capabilities. Given the widespread GM controversy, much of this would need public and regulatory acceptance and, therefore, has to be seen as a long-term goal. Shorter term, however, the genome could potentially help shed light on the ongoing mystery of non-coeliac wheat sensitivity.
Two of the largest and most respected free-from brands have both launched wraps onto the market. Warburtons Gluten Free (www.warburtonsglutenfree.com) went first, with their new trio: High Protein Wraps with Super Seeds, White Wraps, and Beetroot Wraps. The High Protein (17%) Wraps are rich in pea protein, contain rice and tapioc, and are further enhanced with a seed/ grain mix of chia, quinoa, millet and flax. All have launched in Asda, with other retailers to follow suit in coming months and are free from all 14 designated allergens, but carry a precautionary warning for egg. RRP is £2.50 for the White Wraps, £2.79 for the other two. Packs contain four wraps. Swift on Warburtons’ heels were Genius Gluten Free (www. geniusglutenfree.com), who have launched a pair of Fibre Fest wraps in Beetroot, and in Kale, each with 13% fibre, which is roughly three times that of an ordinary wheat-based wrap. They boast wholegrain flours, including sorghum, buckwheat, millet and teff, and are also ‘14 free’, but with no precautionary allergen labelling. Both are marketed as ‘good for the gut’, thanks to the inclusion of chicory root fibre (inulin), but are, therefore, unlikely to be suitable for some FODMAP-sensitives. Four wraps cost £2.75 from Tesco, Ocado and Sainsbury’s.
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FREE FROM BITES MINI FREE FROM BITES
Tinned ready-meal options, particularly useful for students, campers and festival goers, are tough to find with multiple ‘free from’ attributes, but Free & Easy (www.healthysales.co.uk) make several options suitable for most restricted diets, and September saw the welcome launch of two more: Middle Eastern Chickpea Casserole, and Sweet Potato Coconut & Kale Curry. Each is vegan, gluten free and free from all EU allergens. Filling, flavoursome and nutritious, they retail for £2.35, from Ocado and independents. Corn cakes may be a gluten-free staple, but they generally struggle to excite the tastebuds. Looking to bring a new taste and nutrition dimension to them is Quinola Mothergrain (www.quinola.com), who produce quinoa grains, flakes, kids’ ready meals and other convenience foods. They have just launched Pulses & Quinoa Cakes which are still over 50% corn, but boosted with chickpeas, peas, lentils and quinoa for higher protein. Another product which is free from all allergens. From Ocado, £1.75. I have to confess a weakness for fruit, nut and cereal bars, bites and balls! The Protein Ball Company (www.theproteinballco.com) have added to their tasty eight-strong gluten-free protein snack ball range with the launch of a trio of oat-based vegan Breakfast Balls, in apple & blueberry, hazelnut & cacao, and strawberry & vanilla. High fibre and over 5g protein per pack. Handy for morning rush emergencies. From H&B, Ocado and other outlets, from £1.99. A very unusual product launch this - Vegbred. Only currently available online (www.vegbred.com), it’s a milk, egg and soya-free bread with no gluten-containing ingredients, and made from sweet potato, pulses, pumpkin and sunflower seeds and rice flour. A beautiful orange colour and ideal toasted, it’s an original new addition to the ever-widening array of free-from breads on the market. Gluten grains and nuts, however, are used in the bakery. TEFF TALK
Although a few teff-based products have broken through into the UK freefrom market in the past, they’ve not managed to gain a secure foothold, and this Ethiopian staple remains firmly in the shadow of its now established gluten-free counterpart, South American quinoa, which like teff has a complete essential amino acid profile. Looking to change the fortunes of this tiniest of ancient grains is, a company called Lovegrass, founded by an Ethiopian, Yonas Alemu, who left a long banking career with the aim of bringing teff to a wider European market. His range includes grain, flour and pasta in both brown and white teff varieties, plus white teff flakes and teff waffle and pancake mix. The mix contains egg, but otherwise the products are free from all designated allergens. Prices start from £3.99. See www.thelovegrass.com for more information. 48
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DATE FOR YOUR DIARY Food Matters Live (www. foodmatterslive.com), an annual combined exhibition and conference event focusing on nutrition and health, returns for a fourth year this autumn, running from 20th to 22nd November at ExCel London. Among the standout features are a series of ‘Future of Free-From’ seminars, focusing on the innovation underpinning the future growth of free-from. Topics include emerging ingredients, the role of fortification and functional food, free from in the drinks industry and new allergy research. Registration is free. Speakers include RDs Julie Thompson (The Low FODMAP Diet) and Julia Marriott (Putting Allergy Management into Practice).
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
This article was peer-reviewed by Laura Thomas (PhD, RNutr). Laura is a Registered Nutritionist who specialises in non-diet nutrition and intuitive eating. She also hosts the popular ‘Don’t Salt My Game’ podcast and runs regular online courses for both healthcare professionals and the general public about intuitive eating.
NON-DIET NUTRITION: EXAMINING THE EVIDENCE This article will discuss the evidence base related to non-diet (ND) nutrition which is gaining popularity both amongst healthcare professionals and in the media. Modern culture puts a strong emphasis on dieting in order to achieve an idealised weight. Many people feel that weight defines health status; which is compounded by the fact that traditional nutrition and dietetic practice is also very weightcentric. Weight can also be associated with personality traits, overall success and happiness; whether that be at a conscious or subconscious level. ND nutrition takes the focus away from weight and dieting and instead uses a holistic approach to encourage healthy behaviours and overall wellbeing. This approach celebrates weight inclusivity and body positivity. Therefore, weight is not measured during ND consultations and, also, weight stigma is opposed. The ND approach highlights too, that dieting is associated with weight cycling and health problems; including psychological problems, disordered eating and metabolic issues (as discussed below). Intuitive eating is an important part of the ND approach. This technique uses specific tools to teach clients how to listen and respond to their own hunger and fullness cues, as well as their psychological needs. ‘Gentle nutrition’ is a concept within intuitive eating which encourages clients to nourish their body with satisfying food, without imposing food rules or giving moral superiority to any type of food.
NON-DIET NUTRITION AND HEALTH OUTCOMES
There is contention about whether weight should be viewed as a key marker of health. Many people feel that there is a clear link between weight and chronic disease. However, some scientists feel that more research is needed to establish whether adipose tissue itself poses a health risk and to what degree this may affect health.1 A systematic review by Clifford et al (2015) of ND interventions, reported no evidence of significant weight gain, worsened blood pressure, worsened cholesterol, or worsened blood glucose levels as a result of this approach.2 Two studies in the review also demonstrated larger improvements in biochemistry as a result of the ND approach. A more recent Canadian study which used a healthy lifestyle intervention aligned with Health at Every Size (HAES), found a significant increase in intuitive eating, as well as improvements in overall diet quality as a result of the ND intervention.3 However, the researchers highlighted that more studies are needed to investigate the link between intuitive eating and diet quality. There is some limited evidence from randomised controlled trials that mindful eating may improve the quality of life of adults with Type 2 diabetes, as well as self-management of the condition.4-5 There is also some evidence that intuitive eating is associated with improvements in the www.NHDmag.com October 2018 - Issue 138
Intuitive eating is associated with improvements in psychological health.10 There is also strong evidence that intuitive eating is beneficial in the treatment of binge eating and binge eating disorder. following: HbA1c levels in adolescents with Type 1 diabetes;6 glycaemic control in women with gestational diabetes (when combined with dietary education and yoga);7 glycaemic control in non-diabetic people;8 insulin sensitivity; and glycaemic control and HbA1c in those with Type 2 diabetes.9 However, as this is still a relatively new concept, more research is needed to see whether intuitive eating is a useful approach on a public health level.1 Intuitive eating is associated with improvements in psychological health.10 There is also strong evidence that intuitive eating is beneficial in the treatment of binge eating and binge eating disorder (BED).11-12 Furthermore, Clifford et al (2015) found that ND health interventions significantly reduced disordered eating and depression; as well as improving selfesteem levels.1 Intuitive eating may have a role in relapse prevention for those with anorexia nervosa.13 There is also some preliminary evidence that intuitive eating may be useful for inpatient eating disorder recovery.14 However, more research is needed to investigate this, especially as this can be counter-productive in the acute treatment phase due to the tendency to ruminate at meal times.13-14 Furthermore, Richards et al (2017) highlight that, ‘Intuitive eating should never be used as the immediate intervention and dietary model for medical stabilisation and weight restoration’.14 THE EFFECT OF WEIGHT CYCLING
There is a common claim that 95% of diets lead to substantial weight regain in the long term; which seems to come from a study in 1959.15 More recent data has found that only 57% of those who participate in weight loss programmes4 lose a clinically significant amount of weight (i.e. 5% weight loss).16 Furthermore, five years after weight loss, individuals appear to regain 79% of 50
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the weight they initially lost on average.17 It has also been reported that roughly 20-30% of men and 20-55% of women have a history of weight cycling.18 These high rates of weight cycling may be related to difficulty in adhering to diets in the long term, whereas ND interventions may have higher compliance rates. For example, a sixmonth randomised controlled trial found that the drop-out rate of the traditional diet group was 41%, compared to 8% in the ND group.19 Although some observational studies have found that weight cycling is associated with an increased risk of mortality, cardiovascular disease and Type 2 diabetes, overall the evidence is conflicting.18-22 A review of this topic from 2014 concluded that, ’the evidence for an adverse effect of weight cycling appears sparse, if it exists at all’.22 There does seem to be a consistent association between weight cycling and an increased risk of BED,23-25 but the direction of this relationship isn’t entirely clear. The association between weight cycling and other psychological issues, such as depression, is less consistent.23-25 However, a greater risk of psychological harm has been observed in higher weight people who weight cycle.26 There is also conflicting evidence about whether weight cycling itself makes it more difficult to lose weight on subsequent attempts.27-28 Interestingly, some studies have found a higher risk of major weight gain with weight cycling among adolescents and among those who begin within the ‘normal’ BMI category.29-30 There also seems to be an increased risk of cardiovascular disease in those in the ‘normal’ BMI category who weight cycle.18 Weight cycling may be related to homeostatic feedback systems which maintain weight at a certain ‘set point’.31 Part of this feedback system is called ‘metabolic adaptation’, which is a larger than expected reduction in metabolic rate following weight loss (i.e. when the reduction in body mass is taken into account).32 A six-
year study from 2016, the longest study to date investigating metabolic adaptation, (based on The Biggest Loser TV show) found that following significant weight loss, the participants’ metabolism was approximately 500 calories per day lower than expected.33 It is suggested that this may occur due to changes in adipose tissue. Hormonal changes may also play a role, as levels of leptin and insulin drop and ghrelin levels increase during weight loss, which is associated with increases in appetite and weight regain in lab studies.33-35 However, there is not enough evidence to suggest that these changes have a direct impact on weight regain following weight loss in free-living humans.35 THE EFFECT OF WEIGHT STIGMA
Studies which associate weight with poor health outcomes often fail to account for the effects of weight stigma. A recent report from the UK All Party Parliamentary Group on Obesity found that 88% of people in the ‘obese’ weight category reported having been stigmatised, criticised, or abused because of their size.36 Feeling discriminated against due to weight has been associated with a significant increase in: physiological stress (measured as allostatic load), metabolic dysregulation, inflammation, depression and disordered eating; as well as a
reduction in health behaviours.37-39 In addition, it has been found that experiencing weight stigma during discussions with healthcare professionals can lead to avoidance of healthcare settings.40 Worryingly, weight discrimination has also been associated with increased mortality, even when physical and psychological risk factors were taken into account.41 CONCLUSION
The ND approach takes a holistic view of health rather than focusing on diets and weight loss. This approach carries a low risk of harm, especially from a psychological point of view; which is particularly important in view of the evidence that weight stigma can significantly contribute to health problems. Research is emerging about the beneficial effects of the ND approach. There is currently good evidence for the role of intuitive eating for those with disordered eating patterns and for the treatment and prevention of BED. However, more research is needed to examine whether the ND approach is also beneficial in other medical contexts and in a public health setting. Similarly, the effect of weight cycling, increased adipose tissue and the mechanisms related to metabolic adaptation warrant further investigation.
Coming in the next issue:
NETWORK HEALTH DIGEST
• Teenagers and nutrition
• Diabetes and carbohydrates • Enteral feeding
• Vitamins and minerals
• Motivational interviews
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HOW TO GET NOTICED AND GET MORE BUSINESS Priya Tew Freelance Dietitian and Specialist in Eating Disorders
So, you’ve decided to go freelance and are raring to go, but then realise you need clients; or maybe you’ve been freelance for a while and the referrals are drying up. Two huge issues are always around how to get noticed and how to get more work…
Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and Chronic Fatigue. She works with NHS services, The Priory Hospital group and private clinics as well as providing Skype support to clients nationwide.
When I was researching topics for this article, how to get clients kept cropping up and it made me question how I actually do get clients. I’d probably answer that I don’t do a lot, but that’s because it has become second nature, which I guess is how it needs to be. I probably spend an hour or more of my day focused on promoting my brand and attracting new business. Instead of taking in a flood of work, it is better to drip feed what you do and share your services constantly, a little at a time. First of all, I really think you need to decide what business you are trying to attract. A simple strategy I sometimes use is to ask these questions: 1 What business do you want more of? 2 Therefore, who is your target? Is it a type of brand? A specific disease state? Media work? Article writing? 3 Where does your target tend to hang out or search for things? Social media, the local community, google searches, doctors surgeries? 4 Who could you network with in order to increase your presence and get your name known as an expert in your field? Once you have answered those questions, you can target your focus to the right area. Here’s an example: I specialise in eating disorders clinical work and want to increase my referrals. My target is therefore people with eating disorders and more specifically those who are either not unwell enough for NHS treatment, or who have had NHS treatment and need some ongoing support. So, I target social media, mainly Twitter and Instagram and
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Google searches. I make sure I blog on this topic, sharing top tips and snippets of helpful information. I network with other eating disorder professionals, both in my local area and on social media and I respond to media stories on eating disorders whenever I can, reshaping these stories on my social media and blog. Paid advertising - I’ve tried numerous ideas, thrown bits of money at this and had very little results. For example doorto-door leaflet drops = 0 new clients; paid advertising in a hospital setting on a big screen in the waiting area = 0 new clients; leaflets in bags at events and stalls at events = limited success. All rather disheartening. So I’d say, ignore those phone calls asking you to advertise on the back of appointment cards and in magazines unless it is very low cost and see it all more as exposure rather than a way to draw in instant results. Someone may well see your leaflet and store your name in their heads for the future. Facebook - I have only used Facebook advertising for my pilates business and it works for me. If you have an event, a special offer, or a promotion running, then boosting your post is a great way to spread the word. I find my workshops fill up in about a week when I boost a Facebook post. To do this, click the boost on the bottom of the post and follow the steps to define your target audience. Think about who you are trying to attract and add in keywords. You can set the budget, so if you are new to it, start with £5 to £15 and see what happens!
Social media - This can again be slow as you have to build a following. However, it does pay off in the long term. Concentrate on a couple of platforms and use scheduling software such as Hootsuite or buffer. But, make sure you reply to messages and interact with people a couple of times a day. Posts about your business, top tips, recipes and nutrition facts are always great. Social media is about building trust and using hashtags, so research what others in your speciality are doing. Top tip: build up a document of posts that have been popular so that you can use them again, or adapt them. Quotes, media work and articles - These can be harder and take up more time, but they can be good for profile building and you can share the heck out of them. You won’t see instant results, but it makes you look like an expert in your area. Try putting yourself forward by contacting your local radio stations, the local papers and connect with journalists on social media. Word of mouth - This is the best form of advertising. It can be really hard to ask clients for a testimonial (and I certainly don’t find I always get one), but they are so valuable. Add these to your website and promote them on social media. Video testimonials are also a wonderful idea, but this won’t work for every speciality. Search engine optimisation (SEO) - These days, whenever anyone wants a service, they jump on Google. So, getting your SEO sorted is important. You want to come up top on that Google ranking. I’m definitely no expert, but I do find blogging really helps and then using hashtags, thinking about what people are going to type into that Google search bar. So, for eating disorders I may blog about top ways to help prevent a binge and then hashtag #eatingdisorders #eatingdisorderdietitian #bingeeatingdietitian #bingeeatingsupport #eatingdisorderspecialist #helpforeatingdisorders #helpforbinges #dietitian eatingdisorders #dietitianuk #priyatew. I think of as many as I can. Use Google Keyword Tool to help too. Also, take a look at the hashtags that others in your field are using.
Websites - Your website is your gateway; it showcases your work, your services, your experience and needs to show who you are. If you come up high on a Google search, or someone has your flyer, but your website is disappointing, then why would they contact you? Personally, I think it is worth getting some professional help with your website and then be shown how to update it yourself. However, you can also use WordPress, Squarespace or Wix to build your own - that’s if you have some technical knowhow, time and a lot of caffeine to hand! Networking - There are so many forms of networking, I bet you already do this and don’t realise. There are business networking groups, but I’ve not tried these very often as I find it hard work to attend them regularly and it’s tricky to fit them into my diary. Do not underestimate networking on a day-to-day basis with whoever you meet. My husband is an expert at this, he brings in new clients on a weekly basis for his business and mine by talking to everyone and anyone. Playgroups, school runs, the hairdressers, in the shops, church…you name it. There are people out there who will want your services and if they don’t, they’ll know people who will. If, like me, you don’t get out much, then online networking is the way forward and booking specific meetings with relevant people. Places like Twitter and LinkedIn can be good for finding other professionals who work in your field, be it GPs, surgeons, psychologists, therapists, SLTs, physios. Think of who else in your field is connected with your clients and connect with them. This is also something helpful to do in real life, trying to set up meetings, running free training sessions or workshops can be a nice way to get a foot in the door. Then also do not discount your local community. Places like gyms and GP surgeries, councils and schools can be very open to having a free nutrition session run on their premises. I don’t see this as working for free, but building my profile and in place of advertising. All of us need to be focusing on raising our profile, showing what we do and promoting ourselves. It may not come naturally, but it does get easier with practise. www.NHDmag.com October 2018 - Issue 138
DATES FOR YOUR DIARY STUDY DAYS AT THE ROYAL MARSDEN The 10th Annual Royal Marsden Head & Neck Conference: A decade of progress in Head & Neck Cancer Management Friday 9th November This year will focus on how the diagnosis and management of head and neck pre-cancer and cancer has changed over the past decade and look into the future to explore potential advances. Cost: £180 Full Delegate, £120 Trainee and CNSs Event ID: 679
Cutting Edge Management to Pancreatic cancers Monday 10th December
cancer. The event will span the breadth of this challenging disease with complex molecular biology and limited therapeutic options. Cost: £180 Full Delegate, £120 Trainee and CNSs Event ID: 678
Updates in Management of Thyroid Cancer Monday 17th December The aim of our meeting is to provide an update on what is new, clinically relevant and indeed controversial in the management of patients with thyroid cancer. Cost: £180 Full Delegate, £120 Trainee and CNSs Event ID: 671
Visit: www.royalmarsden.nhs.uk/studydays for full details.
This conference is for all practicing medical oncologists and trainees involved in the management of pancreatic
Upcoming events and courses World Obesity Day 11th October www.obesityday.worldobesity.org/ Next steps for policy on tackling obesity: reformulation, calorie reduction and driving behaviour change 17th October www.westminsterforumprojects.co.uk/conference/ obesity-policy-18
Probiotics in Practice: Workshops for Dietitians and Nutritionists 19th October www.hcp.yakult.co.uk/events/workshops Priorities for implementing the health and care workforce strategy 25th October www.westminsterforumprojects.co.uk/conference/ healthcare-workforce-18 Kindful Eating (Children and Families) Manchester 29th to 30th October Two-day course Email: email@example.com
You can find more at NHD.mag.com
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• Quarter page to full page • Premier & Universal placement listings • NHD website, NH-eNews and Network Health Digest placements
To place an ad or discuss your requirements please call (local rate) 54
www.NHDmag.com October 2018 - Issue 138
Sarah Howe Specialist Dietitian Sarah is an experienced NHS Dietitian specialising in the fascinating area of Inherited Metabolic Disorders in adults. In her spare time she enjoys helping her work colleague and good friend, Louise Robertson run her blog 'Dietitian's Life'. She also loves fitness and spending time with her two girls. www. dietitianslife.com
DIETETICS AND MENTAL HEALTH: HOW MUCH DO YOU CONSIDER IT? I was sat in clinic recently, reviewing one of my metabolic patients. It was a straight forward consultation and we had built a good rapport. She started to tell me about past periods of bad stress and how these times had given her physical symptoms. She had not found a relaxation strategy that worked for her; but knew she would get past it in time. I found myself giving baseline advice: had she tried mindfulness or meditation Apps like Headspace? We talked about worry charts, a technique used in Cognitive Behavioural Therapy to help people document their worries and see how usually they amounted to nothing. She hadn’t considered either and it was good to provide some basic advice. The 10th of October sees World Mental Health Day. Mind tells us that each year, one in four of us in the UK will experience a mental health problem. Given that dietitians often see patients who are acutely unwell or living with a chronic disease, the propensity to see someone with a mental health issue is very high. The impact on a patient’s diet and lifestyle can be huge. As an Inherited Metabolic Disorders Dietitian (IMD), I look after a cohort of patients living with chronic conditions. We see many PKU patients with anxiety which can affect their ability to follow diet and, in our more severe cases, even attend clinic. However, we are extremely lucky to have Clinical Psychologist Anne-Marie Walker in the team, who is a rich source of advice when we are struggling. Anne-Marie has been working in the NHS for 22 years, with a special interest in physical health psychology. She is able to signpost and support the patient’s mental health journey through the NHS and in the community. I asked Anne-Marie to give some advice for when a patient is in emotional
distress in an outpatient clinic. This is what she advised: • It can be invaluable to listen attentively and fully at first to what is being said without too much interruption. Sometimes the most important thing you can do is simply be with your patients, take the time to listen, understand and follow their lead. Try to resist the urge to do something, fix or provide solutions. • Be curious with the patient, using occasional questions to facilitate their need to make you understand. • Use occasional calming comments to show empathy and have an empathic interest in making sure you understand, without making guesses about meaning. • Reflect back and summarise what you have heard and understood and check out you’ve got it right, trying to use phrases that validate and acknowledge the emotional distress. • Ask your patient what might help and how you can support them. The important thing is to leave the patient with a way of making sense of what’s been happening and how they have been feeling. You may also need to enquire about suicidal or self-harm thoughts and gain a brief history of the problem. You will need to follow your service guidelines to keep your patient safe, and refer onto the appropriate service/s for further help. Seek advice from your team clinical psychologist when you can. Their help in invaluable. www.NHDmag.com October 2018 - Issue 138
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The Magazine for Dietitians, Nutritionists and Healthcare Professionals Issue 138