The Magazine for Dietitians, Nutritionists and Healthcare Professionals
LIVER DISEASE
FODMAPs ONS ON THE WARD DYSPHAGIA IDDSI IMPLEMENTATION GOAT MILK SPECIALIST FORMULA MILKS
ADULT FOOD ALLERGY Pages 36-38
NHDmag.com
April 2019: Issue 143
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WELCOME TO THE APRIL ISSUE ‘An idea makes a change; driving the idea makes a difference.’
Over the last 12 months, we have seen a significant shift in the management of dysphagia patients here in the UK. This has been due to the adoption and implementation of the International Dysphagia Diet Standardisation Initiative (IDDSI). As we move quickly through April, we see IDDSI becoming the standard approach to the texture modification of liquids and food here in the UK. Our Republic of Ireland counterparts will also start to see the adoption and implementation of IDDSI over the coming year too, as they prepare to make these changes to their national guidance and practice. Initially, the switch from the Dysphagia Diet Food Texture Descriptors (2011) to the new IDDSI framework may have seemed daunting, but the hard work and diligence of HCPs across the UK has paid off and the implementation is well and truly underway and even complete in many areas. To celebrate this great achievement, Evelyn Newman RD shares her experiences of implementing IDDSI in the care homes of the Highlands. Our clinical articles this month come from Rebecca Gasche, who provides our Cover Story on liver disease and the impact it can have on nutritional status, whilst Harriet Smith explores ways to increase uptake of ONS amongst patients on hospital wards. Harriet highlights tips from other dietitians working in clinical settings. Milks feature this month, as Alice Fletcher provides us with a report on goat milk and the role it plays in the human diet across the lifespan. Martha Hughes, Scientific and Regulatory Executive at the BSNA, takes a paediatric view through the importance of specialist infant formulas, discussing the role they play in ensuring
Hermann J Steinherr
optimal nourishment for all infants with a disease, disorder, or medical condition. We are all so busy with our patients and clients, do we ever consider nutrition and wellbeing in our place of work? Emma Coates Editor Evelyn Toner talks about the current eating and hydration habits within the Emma has been a dietitian UK workplace, explaining how healthy registered for 12 years, with changes can lead to healthier bodyweights experience of adult for employees and improved absent- and paediatric dietetics. eeism for companies and organisations. The low-FODMAP diet is becoming an ever more popular diet for managing a number of health issues, so we have asked Jess English to take a look at the development of this diet and discuss its applications, whilst Farihah Choudhury takes a look at the current understanding of food allergies, examining the reasons behind the increase in prevalence. Each day, many of us are never far away from someone experiencing the effects of malnutrition. ‘Today, malnutrition affects at least three million people in the UK. One in three people in care homes, one in 10 visiting their GP and one in four people admitted to hospital are malnourished and the number of malnourished people is increasing.’ Those are the stark figures taken to parliament by the BSNA recently and here, Catherine Hodgson, Public Affairs If you have important Manager, shares a report following news or research BSNA’s debut parliamentary event, updates to share which brought together parliamentarians with NHD, or would and HCPs to discuss the challenges faced like to send a letter by patients at risk of malnutrition and to the Editor, please how the NHS can better shape greater email us at info@ support for the future. networkhealthgroup. We’ve talked a lot about change in this co.uk. We would love Welcome. It can be challenging; it can be to hear from you. scary, but it’s good for us all! ‘The world hates change, yet it is the only thing that has brought progress.’ Charles Kettering. Enjoy the read. Emma www.NHDmag.com April 2019 - Issue 143
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11 COVER STORY Liver disease & diet News
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Latest industry and product updates
Malnutrition
8
36 Adult food allergies
Taking the challenge to Parliament
The increase in prevalence examined
15 ONS on the ward
39 Dysphagia in care homes
Increasing uptake in a clinical setting
Implementation of IDDSI
19 GOAT MILK
42 F2F
Interview with Judy More
44 BOOK REVIEW
24 Specialist formula milks
For special medical needs
28 NUTRITION IN THE WORKPLACE
46 Events, courses & dieteticJOBS Diary dates and job listings
47 Dietitian's life
Development and applications
31 Low-FODMAP diet
Where are the male dietitians?
Copyright 2019. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.
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INTERCOLLEGIATE
NEWS CLINICAL
SAFEGUARDING CHILDREN AND YOUNG PEOPLE: ROLES AND COMPETENCIES FOR HEALTHCARE STAFF In January 2019, the Royal College of Nursing (RCN) published the fourth edition of their intercollegiate document, Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff. To protect children and young people from harm, to improve their wellbeing and promote their welfare, all healthcare staff should know what to do if they have concerns about safeguarding/child protection issues. This responsibility also applies to staff working with adults. Staff in these settings need to be aware that any adult may pose a risk to children due to their health or behaviour. All healthcare staff must have the competencies to recognise child maltreatment, opportunities to improve childhood wellbeing and to take Published by the Royal College of Nursing on behalf o effective action. This document from the RCN, College provides a clear framework B of Paramedics R Institute of Health Visiting which identifies the competencies required and includes specific detail for chief School and Public Health Nursing Association R executives, chairs and board members, includingRoyal executives, non-executives College of Physicians & Surgeons of C Glasgow A and lay members. V Society and College of Radiographers The document is supported by a raft of professionals andof will bePractitioners of interest Royal College General R R Royal College of Speech & Language Therapists to all dietitians and nutritionists who work with children, or with adults who Royal College of Psychiatrists Fa may pose a risk to children. The guidance sets out National indicative minimum R Safeguarding Team - training Public Health Wales National arrangements Pharmacy Association B requirements and is not intended to replace contractual between C British Dental Association commissioners and providers or NHS organisations and their employees. It offers a template for practitioners to record relevant education and training, including, for example, reflective practice and case discussions, enabling them to demonstrate attainment and maintenance of knowledge, skills and competencies throughout their career. Safeguarding Child and Young Peop ren le: Roles and Com petencies for Healthcare Staff
Fourth edition:
January 2019
INTERCOLLEGIATE DOCUMENT
Emma Coates Editor Emma has been a registered dietitian for 12 years, with experience of adult and paediatric dietetics.
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Published by the Royal College of Nursing on College of Paramedics behalf of the contributing organisations: Institute of Health British Society Visiting of Paediatric Dentistry School and Public Royal College Health Nursing of Nursing Association Royal College Royal College of Physicians & of Midwives Surgeons of Glasgow Community Practitioners and Health Visitors Association/UN ITE Vision UK Royal College of Anaesthetists Royal College of Psychiatrists Faculty of Forensic and Legal Medicine Royal College of Paediatrics and Child Health British Association of Paediatric Surgeons College of Optometrists
Society and College of Radiographers Royal College of General Practitioners Royal College of Speech & Language Therapists Royal College of Psychiatrists National Safeguarding Team - Public Health National Pharmacy Wales Association British Dental Association
The full document can be read and downloaded via www.rcn.org.uk/professional-development/ publications/007-366.
COCHRANE REVIEWS – CHECK OUT THEIR PODCAST OPTIONS
The Cochrane reviews website has always offered a wealth of information and provides some great answers to some of our most complex questions. Some of their reviews are now discussed in short podcasts (less than four minutes long), which are available on the website. Examples that may be of interest to dietitians and nutritionists are: • Omega-3 fatty acid addition during pregnancy (November 2018) • Improving the implementation of health-promoting policies and practices in workplaces (February 2019) • Selenium for preventing cancer (May 2018) Find more Cochrane podcasts here: www.cochrane.org/evidence/podcasts
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NEWS DO BLUEBERRIES HELP TO LOWER BLOOD PRESSURE? A new study1 published in The Journals of Gerontology Series A has found that eating 200g of blueberries every day for a month can lead to an improvement in blood vessel function and a decrease in systolic blood pressure in healthy people. Researchers from King’s College London studied 40 healthy volunteers for one month, who were randomly given either a drink containing 200g of blueberries, or a matched control drink daily. The team monitored chemicals in volunteers’ blood and urine, as well as their blood pressure and flow-mediated dilation (FMD) of the brachial artery: a measure of how the artery widens when blood flow increases, which is considered a sensitive biomarker of cardiovascular disease risk. Effects on blood vessel function were seen two hours after consumption of the blueberry drinks and were sustained for one month even after an overnight fast. Over the course of the month, blood pressure was reduced by 5mmHg. This is similar to what is commonly seen in studies using blood pressure lowering medication. Lead researcher Dr Ana Rodriguez-Mateos from the Department of Nutritional Sciences at King’s said, “Although it is best to eat the whole blueberry to get the full benefit, our study finds that the majority of the effects can be explained by anthocyanins. If the changes we saw in blood vessel function after eating blueberries every day could be sustained for a person’s whole life, it could reduce their risk of developing cardiovascular disease by up to 20%.” Reference 1 Ana Rodriguez-Mateos, Geoffrey Istas, Lisa Boschek, Rodrigo P Feliciano, Charlotte E Mills, Céline Boby, Sergio Gomez-Alonso, Dragan Milenkovic, Christian Heiss. (2019). Circulating anthocyanin metabolites mediate vascular benefits of blueberries: insights from randomised controlled trials, metabolomics and nutrigenomics. The Journals of Gerontology: Series A, glz047, https://doi.org/10.1093/gerona/glz047
THE UK STRATEGY FOR RARE DISEASES: PROGRESS UPDATE
The European definition of a rare disease is a life-threatening or chronically debilitating disease that affects five people or fewer in 10,000. Around one in 17 people will be affected by a rare disease at some stage in their lives. Rare diseases often require special efforts to coordinate care given by many different specialists and agencies. In 2013, the publication of the UK strategy for rare diseases recognised and responded to the needs of those affected by rare diseases and was seen as a landmark for patients. The implementation of the 51 commitments in the strategy in England is shared by DHSC and NHS England. An implementation plan was then published in January 2018 and described the key achievements and future activities by DHSC and their delivery partners for the commitments, for which DHSC has lead responsibility. We now have a summary publication of the strategy's progress with further actions for the government and partner organisations over the next year. The latest summary publication can be accessed at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/781472/2019-update-to-the-rare-diseases-implementation-plan-forengland.pdf For the additional publications visit: www.gov.uk/government/publications/uk-strategy-for-rare-diseases-2019-update-to-theimplementation-plan-for-england
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PUBLIC HEALTH
Catherine Hodgson Public Affairs Manager, British Specialist Nutrition Association Ltd (BSNA) Catherine has 18 years' experience in policy, communications and public affairs, having worked in Parliament, a health charity, local government and most recently at a health and social care consultancy.
DISEASE-RELATED MALNUTRITION: TAKING THE CHALLENGE TO PARLIAMENT Today, malnutrition affects at least three million people in the UK. One in three people in care homes, one in 10 visiting their GP and one in four people admitted to hospital are malnourished and the number of malnourished people is increasing. These sobering figures were shared with parliamentarians at the BSNA breakfast roundtable last month by BSNA Director General, Declan O’Brien, in his introduction to the event. This was followed by a thoughtful discussion of the need for a greater focus on diseaserelated malnutrition across both health and social care settings. The BSNA event, sponsored by David Tredinnick MP, brought together parliamentarians and concerned healthcare professionals to discuss the challenges faced by patients at risk of malnutrition and how the NHS can shape greater support for the future. FOOD FOR SPECIAL MEDICAL PURPOSES
Also speaking at the event was Anne Holdoway, a dietitian from BAPEN, who pointed to the media focus on hospital food and people not wanting to eat it. For many, it is their illness that prevents them from eating, eg, patients may have difficulty swallowing, or have a reduced appetite. “This is where the food for special medical purposes, properly administered by a team who has the knowledge as to how to use it, translates into saving lives,” she said. Foods for special medical purposes (FSMPs) are a vital tool in managing disease-related malnutrition as they are designed to meet the nutritional or dietary needs of people who are temporarily 8
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or permanently unable to get enough nutrition from normal foods. However, it was also made clear in the discussion that FSMPs are not a solution in themselves, as the lack of understanding of diseaserelated malnutrition and the importance of effective nutritional support throughout the care pathway is a major issue among medical professionals. Anne said that it was a mistake for medical professionals to see malnutrition as, “just a small vitamin and mineral deficiency . . . it is actually quite profound – these patients, week after week, suffer from poor appetite and, without the right products and the right expertise, they continue to suffer from malnutrition, and as a consequence of that, the cost of healthcare and social care increase.” Yet, the direct costs of the medical foods themselves is stopping GPs from prescribing them. Suzanne Ford, dietitian advisor to the charity NSPKU, who also spoke at the event, said many Clinical Commissioning Groups (CCGs) dismiss medical foods for their costs without examining why they are essential. A recent survey by NSPKU showed that more than 10% of the PKU population attending clinics in the UK are having prescription problems, with half of the patients finding the GPs to be actively blocking access to these products. Two thirds of the cases involved children and over half were going on for over a year. “So, our patients in these cases are facing
PUBLIC HEALTH Left to Right: Anne Holdoway, Declan O' Brien (chair), David Treddinick MP, Eleanor Smith MP. Credit: Paul Heartfield
a failure in the duty of care to them in preventing the best outcome, which is to safeguard their brain growth and development,” Suzanne said. THE COST OF MALNUTRITION
The cost of malnutrition is high. Nearly £20bn is spent by health and care services to treat it each year. It costs over £5000 more to treat someone who is malnourished than well-nourished and it affects all parts of the country, regardless of relative wealth. Anne Holdoway commented that we have the solutions, “but we need to raise the profile of the importance of nutrition and embed it into all of our pathways. If we look at the priorities of the 10year plan – diabetes, cardiovascular disease, high blood pressure, cancer – all of those areas should have nutrition as an immutable part of care.” Ex-Health Secretary, Lord Lansley, agreed that nutrition must be integrated into the preventative structure, especially when it comes to caring for the vulnerable and aging population. Eleanor Smith MP, who is a former nurse, acknowledged the vital role dietitians should play within such a preventative structure. With just over 3000 registered dietitians working within the NHS, attendees at the BSNA event were clear that greater investment should be made to increase numbers and to ensure that both nutrition and hydration is a central part of care and support provided to people who are at potential risk of malnutrition. THE NHS LONG TERM PLAN
While the NHS Long Term Plan does make reference to equipping the NHS workforce to talk about nutrition, it is focused on the challenge
of reducing obesity levels in the UK. The Plan contains a commitment to ensure nutrition has a greater place in professional education training and also commits to upgrade NHS support to ‘all care home residents who would benefit’ by 2023/24, with the Enhanced Health in Care Homes (EHCH) Vanguard model to be rolled out across the whole country over the coming decade. As part of this, individuals will be supported to have good oral health and to stay well hydrated and well-nourished and will be supported by therapists and other professionals in rehabilitating when they have been unwell. The promised NHS workforce implementation plan will go some way to help determine if this ambitious NHS plan is feasible. The proposals will see an additional 20,000 posts created as part of a wider ‘local primary care network’, including physios and pharmacists. However, no mention is made of the role dietitians can play in managing and preventing conditions such as diabetes, and in helping to manage disease-related malnutrition. The roundtable also noted the lack of a senior accountable officer for nutrition and hydration at NHS England or at government department level. Such a person should address the wide range of factors leading to the rise in diseaserelated malnutrition and tackle poor nutrition across the population with better coordinated and resourced care and support given to health and social care. This call to action was supported by roundtable attendees and BSNA will be building on their enthusiasm to ensure nutrition is a priority, as the NHS implements its Long Term Plan. www.NHDmag.com April 2019 - Issue 143
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COVER STORY
LIVER DISEASE AND DIET This article provides an overview of the functions and diseases of the liver.
Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust
The liver is the largest solid organ and has over 500 functions. Located under the ribs on the right-hand side of the body, it sits within the biliary system, which includes the gallbladder and bile ducts. Around 60% of the liver is made up of hepatocytes (liver cells), which help to absorb nutrients and detoxify harmful substances from the blood. Other functions of the liver include:1 • processing digested food from the intestine to turn into energy; • regulating levels of amino acids, fats and glucose in the blood; • combatting infection; • neutralising and destroying drugs and toxins; • manufacturing bile; • storing iron and other vitamins; • manufacturing, breaking down and regulating hormones; • making enzymes and proteins. To name but a few!
Liver disease may occur at varying severities. It may start as steatosis (fatty liver), but if left unmanaged, it can lead to fibrosis, which is the excessive build-up of scar tissue, and lastly cirrhosis (permanent scarring) of the liver.2 Liver cirrhosis may be compensated or decompensated. Compensated liver cirrhosis is where there is irreversible scarring of the liver, but the liver is able to function as normal and carries no additional symptoms. Decompensated cirrhosis can be classed as end-stage liver disease and carries additional symptoms, for example, ascites, jaundice and encephalopathy. Dietary advice is particularly needed in alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD)
DISEASES OF THE LIVER
ALCOHOLIC LIVER DISEASE (ALD)
When our liver becomes damaged, this can affect a number of its functions. Damage to the liver may occur due to injury, infections, effects on the biliary system, alcohol intake, or an autoimmune condition (see Table 1). It may affect the hepatocytes directly, or the surrounding biliary system.2
Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions, to manage a wide range of gastroenterology conditions.
REFERENCES Please visit the Subscriber zone at NHDmag.com
ALD covers a range of liver conditions from steatosis to cirrhosis, as a result of damage caused by alcohol. Protein energy malnutrition (PEM) is common in people with ALD, effecting around 80% of patients3 and, more specifically, it is thought that 80100% of patients with decompensated
Table 1: Examples of liver disease1 Alcoholic liver disease (ALD)/hepatitis
Primary sclerosing cholangitis (inflammation/scarring of the bile ducts)
Non-alcoholic fatty liver disease (NAFLD)
Wilson’s disease (a build-up of copper in the body)
Autoimmune hepatitis (inflammation caused by the body’s immune system attacking the liver)
Haemochromatosis (iron overload)
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CONDITIONS & DISORDERS Table 2: Examples of a 50g carbohydrate snack4 • • • •
300ml milk and 3 plain or chocolate biscuits 1½ slices plain or fruit cake 5 plain or chocolate biscuits 1 bottle juice-based 1.5 kcal/ml supplement
cirrhosis will have PEM.4 This explains why nutrition support is vital in this patient group, but why is it occurring? The addition of symptoms in decompensated ALD can contribute to PEM. Ascites, which is the accumulation of fluid in the abdomen, can result in patients having increased protein requirements, early satiety, nausea, vomiting and increased energy requirements.2 Encephalopathy occurs as a result of the liver being unable to play its role in detoxifying the blood, which can lead to changes in the brain. This is not necessarily long term, but can cause patients to become confused or suffer from reduced consciousness. They may forget to eat, or think that they have already eaten, as well as have a suppressed appetite.1 Social isolation, poor cooking skills and financial aspects may also impact on a patient’s nutritional status.4 If a patient has been consuming high amounts of alcohol over a long period of time, it is likely that they have not been having sufficient nutrition, and that their main source of energy was coming from alcohol.2 In addition to this, patients with liver cirrhosis have higher energy and protein requirements. It is suggested that compensated liver disease patients aim for 25-35kcal/kg/day and 1.2-1.5g/kg/day of protein. In decompensated liver disease patients, these requirements are higher still at 35-40kcal/ kg/day and 1.2-1.5g/kg/day.4 DIETARY ADVICE FOR ALD
Dietary advice aims to prevent PEM, reduce symptoms of ascites or encephalopathy and ensure that the body has a sufficient supply of carbohydrate and protein. Patients with decompensated liver disease are advised the following:2,5-7 • Eat small, regular meals and aim to eat some carbohydrate every two to three hours. • Have a high-calorie high-protein diet. • Have a snack before bed which contains 50g of carbohydrate. 12
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• 2 thick slices of toast and jam • 1½ bottle milk-based 1.5 kcal/ml supplement • Breakfast cereal with milk and banana
• Follow a low-salt diet (no-added-salt diet). • Abstain from alcohol. Carbohydrate supply is important, as carbohydrates are broken down into glucose and stored in the liver as glycogen, to be used as the body’s main energy source. This is released between meals, or when fasting overnight, to supply the body with energy. However, the liver's ability to store glycogen is reduced in decompensated liver disease, resulting in the body looking to source energy from protein stores instead, in a process called gluconeogenesis.5,6,7 Having a regular intake of carbohydrate helps to prevent this from happening. Due to the body ‘fasting’ overnight, it is especially important that a 50g carbohydrate snack (see Table 2) is eaten before bed to keep stores supplied and prevent gluconeogenesis. A low-salt diet is particularly recommended for the management of ascites, as excess salt in the diet may worsen the amount of fluid stored. Studies have shown that a no-added-salt diet (120mmol/day sodium) is as beneficial as a low-sodium diet (40mmol/day sodium), and one small study actually found that patients adhering to a low-sodium diet compared to a no-added-salt diet, showed lower energy and protein intakes. As a result, patients with ascites should be encouraged to follow a no-addedsalt diet – reducing foods high in salt due to processing, such as, tinned products, processed meats and, obviously, salty snacks, such as salted nuts and crisps. OTHER CONSIDERATIONS
Anthropometry – assessing if a patient is at risk of malnutrition – is important in this patient group and, therefore, calculating BMI and percentage weight loss is a priority. However, for those patients with ascites, or oedema, a dry weight should be estimated first.2 Table 3 shows estimations for dry weight. In addition to BMI and percentage weight loss, alternative measurements should also be considered, such as hand grip strength and upper
CONDITIONS & DISORDERS Table 3: Estimations for dry weight Guide for assessing weight of:
Ascites
Peripheral oedema
Minimal
2.2kg
1.0kg
Moderate
6.0kg
5.0kg
Severe
14.0kg
10.0kg
Adapted from reference 4
arm anthropometry. These help to assess muscle function, and the results can be compared to an expected population.2 Hand grip measurements can be particularly useful in demonstrating rapid changes in a patient’s nutritional status.8 Encephalopathy Dietary treatment for encephalopathy aims to ensure that the patient is meeting their energy and protein requirements. It was once thought that low-protein diets were needed, however, this is no longer advised, as there is a lack of evidence that low-protein diets worsen encephalopathy and can actually worsen nutritional status.9,10 Meeting protein requirements helps to ensure that the body is not utilising amino acids from muscle stores, which produce ammonia and can worsen symptoms. Patients are often prescribed lactulose and aim to have their bowels opening two to three times per day, to eliminate any excess ammonia from the body.4 Vitamins Considerations for B vitamins, fat soluble vitamins (A, D, E and K) and calcium should be considered in patients with liver disease.4 Patients with ALD are often prescribed thiamine, as alcohol metabolism is dependent on thiamine as a co-factor.4 Calcium and vitamin D requirements are increased in cirrhotic liver patients due to the increased risk of osteoporosis and osteomalacia. Therefore, it is advised that patients aim for 1000mg calcium and 800IU of vitamin D per day.11 NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
NAFLD can be described as the liver manifestation of metabolic syndrome, and it is estimated that one in three people in UK have the early stages.12 It is often diagnosed as a coincidental finding from abnormal liver tests, as
it can be asymptomatic in the earlier stages. Risk factors for NAFLD include being overweight, Type 2 diabetes, high blood pressure, high cholesterol, age over 50 years, smoking, poor diet and a sedentary lifestyle.13-14 NAFLD can occur at varying severities:15 1 Steatosis – a build-up of fat in the hepatocytes. This may often go undetected and is usually discovered following tests for another reason. 2 Non-alcoholic steatohepatitis (NASH) – the liver starts to become inflamed, estimated to affect 5% of the population. 3 Fibrosis – persistent inflammation of the liver causing scar tissue to occur, but the liver is still able to function as normal. 4 Cirrhosis – irreversible scarring of the liver, which can lead to liver failure. Nutritional assessment As well as weight and BMI, it is important to monitor HDL, LDL, triglycerides, waist circumference and HbA1c if diabetic.16 Dietary advice Lifestyle advice is crucial for patients with NAFLD, due to the strong link between NAFLD and insulin resistance. Weight loss strategies can help to reduce the risk of developing Type 2 diabetes and can also improve liver histology.17,18 There are a number of studies supporting weight loss to reduce fat in the liver, and it is thought that a weight loss of 3-5% is necessary to reduce steatosis; however, a greater loss of 10% may be needed for more advanced inflammation.19 NASH can be reversed by reducing weight and increasing physical activity. Suggested physical activity recommendations are 150 minutes of moderate-intensity and 75 minutes of vigorous activity per week, in addition to muscle strengthening activity twice a week – the same advice provided for diabetes prevention trials.20 www.NHDmag.com April 2019 - Issue 143
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CLINICAL
IMPROVING ONS UPTAKE ON THE WARDS This article explores ways to increase uptake of ONS amongst patients on wards, featuring top tips from other dietitians working in the clinical setting. Oral nutrition supplements (ONS), sometimes referred to as sip feeds, are often prescribed for hospital or community patients who are struggling to meet their nutritional requirements through an oral diet alone.1 ONS products typically contain a mix of macronutrients (protein, carbohydrate and fat) and micronutrients (vitamins, minerals and trace elements), and in large enough quantities (this varies between brands), they are nutritionally complete. However, they are designed to complement oral dietary intake rather than serving as a meal replacement. These specially formulated nutrition supplements are used for medical purposes in patients who meet the Advisory Committee on Borderline Substances (ACBS) prescribing criteria (see Table 1), who have been screened using a validated malnutrition screening tool such as ‘MUST’ and who have been deemed to be at nutritional risk. ONS should be given under medical supervision and must be used appropriately. ONS products are sterile and often come in liquid, powders, or semi-solid textures, meaning there are plenty of options available for patients with different medical and
nutritional needs. For example, texturemodified supplements (such as prethickened liquids or pudding-texture supplements) are available for patients with dysphagia, whilst semi-elemental sip feeds are available for patients with malabsorption/maldigestion. There is a huge variety of options available, with a choice of different energy and protein densities, flavours and volumes. However, they are only effective if they are consumed. Studies have shown that dietary counselling given with or without ONS is effective in increasing nutritional intake and weight.3 Therefore, ONS and a food-first approach are often used in combination.
Harriet Smith Registered Dietitian and Health Writer Harriet is Founder of Surrey Dietitian providing private dietetic consultations and consultancy services, offering evidence-based nutritional advice, backed up by the latest research on food, health and disease. Harriet has written for national, consumer and industry media. www.surrey dietitian.co.uk @SurreyDietitian
APPROPRIATE PRESCRIBING
Recent audit data indicates between 57-75% of oral nutrition prescriptions are inappropriate.4 ONS can seem like an obvious choice for a malnourished hospital patient who is struggling to eat enough; however, it is important to ensure that the patient meets the prescribing criteria mentioned above and that food-first advice has been given. Ensure that a clinically beneficial dose is prescribed (many Trusts consider this to be two sachets/bottles
REFERENCES Please visit the Subscriber zone at NHDmag.com
Table 1: ACBS Indications for ONS2 • Short bowel syndrome
• Disease-related malnutrition (chronic/acute)
• Dysphagia
• Proven inflammatory bowel
• Intractable malabsorption
• Continuous ambulatory peritoneal dialysis (CAPD)
• Bowel fistulas • Pre-operative preparation of patients who are undernourished
• Following total gastrectomy • Haemodialysis
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CLINICAL
Offer a variety of flavours and always ask the patient if they have a preference regarding milkbased or juice-based supplements.
per day, which provides approximately 500-600 calories per day).5 One bottle could probably be met through food fortification techniques alone. Where appropriate, use an energy-dense high-protein version, as studies have shown that highest compliance with ONS is associated with high-energy sip feeds.6 CHECK SUITABILITY
Standard hospital sip feeds may not be suitable for patients with religious, ethical or cultural requirements who require kosher, halal or vegan supplements. You may need to contact the sip-feed manufacturer to confirm whether the product is appropriate for your patient, and if it isn’t, you may need to source alternative options. Similarly, if your patient has complex medical needs, such as dysphagia, renal disease, or malabsorption, they may require a specific type of sip feed (such as pre-thickened liquids or a semi-elemental sip feed). For patients at risk of refeeding syndrome, the volume of ONS given may need to be built up over several days and refeeding bloods may need to be monitored closely. For diabetic patients, broadly-speaking, it is recommended that they have milk-based or savoury supplements rather than juice-based supplements (which have a higher glycaemic 16
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load). However, there may be instances where juice-based ONS is indicated (for example, if the patient has an aversion to milk) and, therefore, regular monitoring of blood sugar levels will be required.1 ENCOURAGE UPTAKE
Dr Clare Shaw, Specialist Consultant Oncology Dietitian at the Royal Marsden, says, “We used to run a cocktail round using ONS and it was loved by patients.” Sian Shepherd, Specialist Gastroenterology Dietitian, added, “It was essentially adding fruit juice/fresh fruit/coffee/ ice cream to different flavoured ONS. Service was really important and we used cocktail glasses and umbrellas to increase uptake.” Sadly, this is no longer offered on a regular basis, but Dr Shaw believes that if the resources are available, it gives ONS uptake a boost. AnnMarie Jones, a Registered Dietitian at University Hospital Southampton, recommends that dietitians ensure the ONS is within reach for the patient and that if the patient can’t open it/feed themselves, they should receive assistance. MDT APPROACH
Build relationships with all the staff on your ward(s) who are involved in food service. For example, ward hostesses can assist with food fortification and opening lids for patients, whilst HCAs, nurses and dietetic assistants can assist with encouraging uptake of sip feeds
CLINICAL and recording consumption on food and fluid charts. Gemma Holloway, Prescribing Support Dietitian, recommends working closely with ward staff to ensure that sip feeds get handed out in the first place. She says, “A good matron is worth their weight in gold for ensuring this happens.” Rachel Whitehall, Registered Dietitian, told me that when she reviews ward patients on ONS, she always tries to bring them a chilled flavour of their choice at the end of their consultation, as it’s one less job for the busy nurses. PATIENT PREFERENCE
Offer a variety of flavours and always ask the patient if they have a preference regarding milk-based or juice-based supplements. Amy Williams, a dietetic student, says that she always double checks which flavours patients prefer and tries to match preferences as much as possible. If patients are not consuming their ONS, ask them why and determine if there is a way to improve uptake. For example, would the patient like to try an alternative flavour, or would they like to have the ONS mixed into a glass of full-fat milk? EDUCATE THE PATIENT
It’s important to explain to patients what ONS is and why it’s needed. Lindsey Allen, Registered Dietitian, recommends teaching ward staff and doctors about the importance of ONS and using a dietetic assistant to help with compliance and encouragement. Claire Irlam, Registered Dietitian at Manchester Royal Infirmary, suggests talking to the patient and explaining the importance of ONS with respect to their priorities. Claire says that patients often don’t care about ONS increasing calories, so, instead, she focuses on the role of ONS in terms of “getting stronger”, “getting home quicker” or “helping your body to heal”. MONITOR
All ONS patients should be regularly monitored to assess whether ONS remains clinically indicated. For example, a patient coming towards the end of their life may not require ONS. Similarly, if oral intake remains poor on
ONS and a patient’s nutritional status continues to decline, enteral feeding may be required.1 Your review might involve monitoring anthropometric changes (such as weight, BMI, handgrip strength, etc),1 speaking with the MDT and asking the patient about oral consumption and ONS compliance. If consumption is poor, work with the patient to come up with strategies to maximise their compliance (such as serving ice with the supplement, or offering alternative flavours). Ensure that you set clear goals and a care plan for all patients on ONS and if ONS is no longer clinically appropriate, it should be discontinued. PLAN AHEAD
Finally, it’s important to think about the aftercare that your patient will require once discharged from hospital. The acute setting also offers an excellent opportunity for you to deliver nutrition education (ie, food fortification advice) to relatives and/or carers on the importance of eating well at home. Given that 93% of malnourished individuals live in the community and 1.3 million are over the age of 65,7 it is important that we line up ongoing nutritional support in the community where indicated. ONS may be included on drug discharge summaries and some patients might be given a small supply to take home. However, if a patient requires ongoing nutritional support, they will likely require a letter to their GP asking for a repeat prescription for ONS, and ideally a referral to the community dietitians. Whilst this is being arranged, you could organise for a sample delivery of ONS to be delivered to their home, as well as provide advice on additional mealtime support (ie, Meals on Wheels). Whilst ONS is clinically effective and is widely used in hospital and community settings, it is not a replacement for oral intake and we shouldn’t underestimate the importance of a food-first approach. Evelyn Newman, Registered Dietitian, told me that in the Highlands, they are actively working to reduce the need for any ONS by proactively promoting a food-first approach by working with caterers to deliver personcentred nutritional support. www.NHDmag.com April 2019 - Issue 143
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Coming in the May issue:
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FOOD & DRINK
GOAT MILK: AN OVERVIEW OF ITS ROLE IN THE HUMAN DIET The smell and taste of goat milk may be unpalatable to some, but its nutritional profile is much the same as cow’s milk. Now that goat milk products are becoming more popular and goat milk-based infant formulas are available throughout the UK, this article examines the general efficacy of goat milk. Animal milks have been used to supplement the human diet for thousands of years. Goats (capra hircus) are thought to have been the first animals that humans have used for their milk and the second animal to be domesticated after the dog. They have the highest yield of milk of any dairy animal in relation to their body weight.1 Apart from coconut and other nut milks (that technically do not meet the definition of ‘milk’) now flooding the supermarket isles, goat milk (also known as caprine milk) is one of the main alternatives to cow’s milk. It is relied upon as a major source of nutrition in many developing countries. In the UK, however, cow’s milk remains the most commonly used milk.2 Goat milk can be purchased in selected supermarkets as skimmed, semi-skimmed, or whole milk, much the same as cow’s milk, retailing at around £1.72 per litre compared to £0.80 for fresh cow’s milk.3 SMELL AND TASTE
You may have noticed that the marmiteesque smell of goat’s cheese is not at all dissimilar to what you would smell standing downwind from a goat. This scent is from three fatty acids: caproic, caprylic and capric acid. These only
become a problem if they are released as free fatty acids from the milk fat by poor treatment of the milk. Goats have scent glands behind their horns that secrete a potently odorous oil that includes the same three fatty acids.1 Fresh goat milk, ice creams, cream, live yoghurts and goat milk-based spreads are available from UK brands. From tasting some goat milk yoghurt myself, I was pleasantly surprised; it is very mild and creamy and I found it to lack the tanginess of cow’s milk yoghurt. The goat scent was almost undetectable. NUTRITIONAL PROFILE
The energy content of whole cow’s milk and goat milk is very similar (see Table 1 overleaf).4
Alice Fletcher Registered Dietitian within the NHS, Countess of Chester NHS Foundation Trust (Community Dietitian)
Alice has been a registered dietitian for four and a half years, working within NHS Community based teams. She is passionate about evidencebased nutrition and dispelling diet myths. In her spare time, Alice blogs about food and nutrition at nutritionin wonderland.com.
REFERENCES Please visit the Subscriber zone at NHDmag.com
Vitamins and minerals • Potassium, magnesium, iron and vitamin A are all slightly higher in goat milk compared with cow’s milk. • Both cow’s milk and goat milk are good sources of iodine (full-fat cow’s milk = 30μg per 100ml). The exact quantity of iodine in goat milk is not known, but is thought to be significant. • Both cow’s and goat milk are poor sources of vitamin D (unless fortified). www.NHDmag.com April 2019 - Issue 143
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FOOD & DRINK Table 1: Macro and micronutrients contained within goat, cow’s and unsweetened soya milk Per 100g*
Goat
Soya
Cow
(unsweetened)
Per 100g
Goat
Cow
Soya (unsweetened)
Energy (kcal)
62
63
26
Iron (mg)
0.12
0.02
0.43
Protein (g)
3.1
3.4
2.4
Zinc (mg)
0.5
0.5
0.3
Fat (g)
3.7
3.6
1.6
Vitamin A (µg)
44
38
Saturated fat (g)
2.37
2.29
0.24
Vitamin D (µg)
0.1
Tr
0.8
Carbohydrate (g)
4.4
4.6
0.5
Thiamin (mg)
0.03
0.03
0.06
Sugars (g)
4.4
4.6
0.2
Riboflavin (mg)
0.04
0.23
0.2
Potassium (mg)
170
157
74
Niacin (mg)
0.8
0.8
0.1
Calcium (mg)
100
120
120
Vitamin B6 (mg)
0.06
0.06
0.03
Magnesium (mg)
13
11
15
Folate (µg)
1.0
8.0
14
Phosphorus (mg)
90
96
48
Vitamin B12 (mg)
0.1
0.9
0.4
Highlighted = lactose content. Contents of table sourced from McCance and Widdowson4
Table 2: Macronutrients of goat yoghurt vs cow’s milk yoghurt Nutrient
Full-fat goat yoghurt per 100ml
Full-fat Greek plain yoghurt per 100ml*
kcal (calories)
105kcal
133
Fat (g)
7.3
10.2
5.0
6.7
4.3
4.8
3.2
4.5
- of which saturates (g) Carbohydrate (g) - of which sugars (g) Protein (g)
5.5
5.7
*Greek yoghurt based on McCance and Widdowson, goat milk yoghurt was not available on this spreadsheet, I have used St Helen’s Farm original natural Goats Milk Yoghurt. 4
• Goat milk contains only 1µg of folate per 100ml, mature breast milk contains approximately 5µg per 100ml and cow’s milk the most at 8μg per 100ml.4 • An interesting study using rats found that consumption of goat milk resulted in greater bioavailability of zinc and selenium and a greater deposit of zinc in key organs compared with both a milk-free diet and one containing cow’s milk. However, much more research is needed.5 Digestibility • Goat milk is higher in medium chain fatty acids than cow’s milk and the fat molecules are smaller. It is theorised that this is one of the reasons why people report finding goat milk easier to digest than cow’s milk.6 • Goat milk forms a softer curd in the stomach compared with cow’s milk.7 20
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• Goat milk contains only 0.2g per 100g less lactose than cow’s milk. • In vitro, when the human digestive system is mimicked, caseins from goat milk have been found to be more efficiently digested compared with caseins from cow’s milk.8,9 • In vitro studies found that although the protein quality does not differ between goat milk formula (GMF), cow’s milk formula (CMF) and human milk, the kinetics of protein digestion of GMF is more comparable to that of human milk than CMF.10 OLIGOSACCHARIDES, GUT HEALTH AND IBD
Human milk oligosaccharides are complex sugars that function as selective growth substrates for specific beneficial bacteria in the gastrointestinal system. Goat milk contains the highest amount of oligosaccharides amongst the milk of domestic animals, and has significant
FOOD & DRINK similarities to human milk oligosaccharides from a structural point of view.11,12 Goat milk oligosaccharides have been found to have anti-inflammatory effects in rats with experimental colitis and may be useful in the management of inflammatory bowel disease. One study published in 2006, looked at 20 rats with artificially induced colitis. They were fed the same diet, but with different sources of fibre, cellulose, or a mixture of goat milk derived oligosaccharides and cellulose (this made up 5% of the diet). Those consuming goat milk oligosaccharides showed less severe colonic lesions and a more favourable intestinal microbiota.13 A similar study published in 2006, found that rats with colitis who were fed goat milk whey (rich in oligosaccharides) lost less weight compared with the control group.14 These results have been repeated once again within a 2017 study using rats, but this appears yet to progress to human studies.15 Interestingly, similar results were also found when goat yoghurt was studied in rats with induced colitis.16 GOAT MILK AND ATOPIC DERMATITIS
The internet is awash with anecdotal reports of goat milk dairy products curing (or at least hugely improving) the severity of atopic dermatitis (AD). The proposed causes of AD vary widely, including soaps, detergents, stress, the weather and sometimes food allergies.17 Dietary manipulation by parents with the premise of improving symptoms has been found to be increasingly practiced.18 One crossover study found ass milk to improve AD’s severity compared with goat milk, which did not find significant improvements.19 Evidence for goat milk holding an advantage over cow’s milk for AD remains largely anecdotal. The incidence of eczema assessed using SCORAD was 14% in a clinical trial of infants randomised to goat milk formula from birth compared to 23% in infants fed cow’s milk formula.29 The difference was not statistically significant as the trial was powered to assess growth outcomes, not allergy, and hence would need to be confirmed in a larger study. IS IT LESS ALLERGENIC?
It has previously been suggested that goat milk could be an alternative for those suffering with
cow’s milk protein allergy (CMPA). Incidence of CMPA in adults is extremely low. The World Health Organisation has estimated it to affect 1.9-4.9% of children.20 More than half of children with IgE-mediated CMPA outgrow their milk allergy by five years of age. Most children with non-IgE-mediated cow’s milk allergy will be milk tolerant by three years of age.21 Goat-milk-based formulas should not be given to infants with CMPA, unless directed by a healthcare professional.22 Some of the proteins in goat milk are sufficiently similar to those found in cow’s milk and may cause cross-reactivity.23 There have been case reports of babies and children who have had severe allergic reactions to goat milk.24,25 A study in 1999, undertaken to ascertain the cross reactivity of milk proteins between different species of mammals, found that IgEs from children who were allergic to cow’s milk, were capable of recognising milk proteins from ewe, goat and buffalo, while none of the children reacted with the more obscure camel milk. Camel milk was also not recognised from circulating IgEs from a child specifically allergic to ewe’s milk. Specific antibovine monoclonal antibodies cross-reacted with proteins from other mammalian species, apart from those of camel. This was thought to be due to phylogenetic differences (camels are not as closely related as the other species24). A later study in 2011 (n=38) found similar results.26 A small study published in 2003, tested 12 patients with cow’s milk allergy for tolerance to goat milk protein through radioallergosorbent assay (RAST), specific IgE, skin prick and challenge tests. Only 25% of the patients showed adequate immediate and late oral tolerance and had negative results of immunological tests for adverse reactions, demonstrating the close cross reactivity between the proteins.24 GOAT MILK FORMULA (GMF)
You may be wondering if GMF has the same scent/taste that we have already discussed; you will be pleased to hear that this can be prevented by careful handling during manufacturing, leaving a neutral scent. The safety and nutritional adequacy of GMFs have previously been questioned. Until March www.NHDmag.com April 2019 - Issue 143
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FOOD & DRINK 2014, it was illegal to market infant formula based on goat milk proteins (GMF). In 2004, the European Food Safety Authority (EFSA) felt that small study sample sizes and the lack of a breast-milk-only control groups meant that the adequacy of GMF could not be confirmed.27,28 However, following on from new evidence since the initial 2004 review, EFSA overturned their position. Two main studies are discussed in the EFSA Report,29 one having taken place in Auckland, New Zealand (a pilot study of 62 infants)30 and a later study in Adelaide Australia (301 infants). The latter randomised, double-blind controlled trial compared growth rates and nutritional status of 200 infants with exclusive feeding of GMF or CMF for at least four months.31 An exclusively breastfed reference group (up to at least four months) was included as a control (n=101). The primary outcomes were body weight, length and head circumference at enrolment and at the indicated time points. The secondary outcomes were markers of nutritional status in blood at the age of four months (haemoglobin, haematocrit, creatinine, urea nitrogen, folate, albumin, ferritin, blood amino acids). There were not any differences in the occurrence of serious adverse events, general health and incidence of dermatitis, or medically diagnosed food allergy. The GMF used in both studies was based on whole milk with a casein whey ratio of 80:20 and was compared with whey adjusted 60:40 CMF. Nutritional outcomes and growth did not differ between GMF and CMF. As a result, GMF was permitted under both EU and UK regulations and is available across the UK. Digestibility of GMF It has been suggested that GMF may be easier for babies to digest, resulting in more frequent and softer stools. A large prospective cohort study of 976 infants from birth to 12 months of age was published in 2011. The study measured (amongst other things) the bowel movements of infants fed breast milk, CMF and GMF. Stool number and consistency were recorded between 0 and four months. The consistency of stools was graded by parents, using an analogue scale with these categories: runny, soft or pasty, soft but well formed, firm and hard. It was found that 22
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more of the infants fed CMF had fewer, but more well-formed bowel motions compared with breastfed infants. The stool characteristics of infants fed GMF resembled those of infants fed breast milk. Ultimately, it looked as though GMF was easier to digest than CMF, with less risk of forming hard stools.32 CAUTION
As with any milk given to babies, apart from breast milk, it must be supplemented with powdered formula to contain all the required nutrition in the correct amounts.33 Case reports detail babies becoming extremely malnourished from a homemade formula recipe based upon goat milk, or from feeding babies goat milk that has not been supplemented. Other morbidities have included severe electrolyte abnormalities, metabolic acidosis, megaloblastic anaemia, haemolytic uremic syndrome and infections.34,35 Now that correctly formulated powdered goat milk formulas are readily available, the risk of parents turning to inadequate homemade recipes should be reduced. SUMMARY
• Fresh goat milk is around twice the price of fresh cow’s milk in UK supermarkets. • Goat milk appears to be more quickly digested compared with cow’s milk and it is marginally lower in lactose (5% less). • Goat milk is not recommended as an alternative for infants with diagnosed CMPA unless directed by a healthcare professional. • GMF based on whole milk with a casein whey ratio of 80:20 provides growth and nutritional outcomes in infants, comparable to a standard whey-based CMF. • GMF is permitted under both EU and UK regulations and is now available across the UK. • Anecdotal reports show switching from cow’s milk to goat milk may help some people who suffer from AD; however, significant evidence within scientific literature is presently lacking. • Goat milk and goat yoghurt may attenuate symptoms in IBD, but research into this area very much remains in its infancy and recommendations for humans cannot be made.
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
PAEDIATRIC
SPECIALIST FORMULA MILKS
Martha Hughes, Scientific and Regulatory Executive, BSNA Martha is an Associate Nutritionist with a degree in Nutrition from the University of Surrey. She has research and regulatory experience in specialist nutrition.
REFERENCES Please visit the Subscriber zone at NHDmag.com
This article provides an overview of formula milks used for special medical needs, highlighting the important role that healthcare professionals make in prescribing and managing infant feeding when breast milk alone isn’t enough to provide the essential nutrients required. It is well established that breastfeeding is the best way to feed a baby, being important for both the mother and the infant. The World Health Organisation (WHO) recommends that babies are exclusively fed with breast milk until six months of age, after which breastfeeding should be complemented with the introduction of solid foods until the age of two.1 If a mother can and chooses to, she should be fully supported by a healthcare professional to breastfeed her infant. However, there are some mothers who cannot, or choose not to breastfeed for a variety of reasons. For these parents, so long as there are no other health concerns for the infant, a standard infant formula milk may be used. Although they cannot provide all the protective factors found in breast milk, formula milks have been specifically developed to contain all the ingredients needed to meet an infant’s nutritional requirements.2 They are safe, rigorously monitored and tightly regulated.3 WHEN A SPECIALIST FORMULA MAY BE NEEDED
It is essential that all infants receive optimal nutrition to ensure adequate growth, health and development.4 An underlying illness or condition can lead to malnutrition, with nutritional deficiencies, stunting and/or wasting presenting. This can be detrimental for an infant as it can lead to long-lasting health implications.1 The importance of breast milk for infants who are born prematurely, with 24
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a medical condition, or who develop a disease, disorder or a medical condition is universally recognised. For some infants, however, breast milk alone may not be able to provide adequate nutrition, or a parent or carer may choose to formula feed their infant, resulting in a highly regulated5 scientifically formulated specialist milk being required. These products are medical, intended for the exclusive or partial feeding of infants and young children, and should always be used under the advice of a HCP. CONDITIONS WHERE SPECIALIST FORMULA MILK MAY BE REQUIRED
There is a diverse range of specialist formula milks available to address a number of conditions which infants can suffer from; it is essential that infants receive the appropriate formula for their individual requirements so that they are able to receive optimum nutrition. The conditions for which a specialist formula milk may be used can vary greatly in terms of their permanence, severity and impact on day-to-day life. The age at which they should be introduced also varies, with some medical conditions being detected at birth by newborn screening, eg, phenylketonuria (PKU), and others having a later onset or diagnosis, such as cow’s milk protein allergy (CMPA), which is usually identified between six to 12 months of age. Cow’s milk protein allergy (CMPA) CMPA is the most common highly complex food allergy in infants and young
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
PAEDIATRIC children, affecting around 7% of formula- and mixed-fed infants, 0.5% of exclusively breastfed infants and 2-3% of one- to three-year-old children in the UK.6 It is an allergic reaction to one or both of the proteins, casein and whey, found in milk. CMPA can be categorised as immediate (IgE-mediated) or delayed (non-IgE-mediated). Symptoms include: skin problems such as eczema and hives, respiratory symptoms and gastrointestinal issues. In worst case scenarios, CMPA can lead to admission to A&E and/ or paediatric intensive care units, due to anaphylaxis, and can potentially lead to death. It is important that those affected by CMPA are diagnosed and managed appropriately by a healthcare professional. For confirmed CMPA in breastfed infants, strict avoidance of cow’s milk protein for the mother is currently the safest strategy for management. If this is not possible, or an infant is formula-fed, a specific specialist formula milk can be prescribed, such as an extensively hydrolysed formula (eHF).7 These are tolerated by the majority of infants with CMPA. However, for those who cannot tolerate an eHF, or for those with severe symptoms, an amino-acid based formula (AAF), which is made-up of free amino acids, should be prescribed,8 as stated by NICE and the iMAP guidelines.9,10 Lactose Intolerance Infants with lactose intolerance have the inability to digest the carbohydrate lactose because they lack the enzyme lactase, causing gastrointestinal symptoms such as loose stools, abdominal pain, flatulence, bloating and discomfort. Typically, lactose intolerance in infants only lasts from a few days up to a few weeks. It is during this time that a specialist formula milk containing an alternative carbohydrate source to the lactose present in standard formula, plays a vital role in managing the condition and ensuring the continued nourishment, development and health of the child. Although lactose intolerance can cause similar symptoms, it should not be confused with CMPA. Specialist formula milks for lactose intolerance are not suitable for infants with CMPA as they still contain cow’s milk protein. Preterm Thanks to advances in antenatal care, an increasing number of preterm babies are surviving. These 26
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babies are vulnerable and specialist paediatric dietitians have a critical role to play in making sure that the diet of these infants is effectively managed. Expressed breast milk supplemented by a breast milk fortifier is the preferred method of feeding. However, mothers of preterm infants may be under particular stress, which may affect their milk supply. If so, a specialist ready-to-feed preterm formula may be required,11 which typically contains higher levels of energy, a higher protein-energy ratio and higher levels of key micronutrients, such as iron and vitamin D, when compared with standard formula. These formulae are designed to support the increased metabolic requirements of preterm infants. Faltering growth Faltering growth is a term used to describe an infant who is not gaining weight or length as expected, over a period of time. Causes of faltering growth can include: higher nutritional requirements or an inability to consume enough nutrients to meet requirements, eg, through muscular disorders or respiratory disease; poor swallowing; vomiting and diarrhoea; or poor absorption of nutrients, such as digestive disorders including cystic fibrosis and chronic kidney disease. Faltering growth may be managed with a specialist high energy formula, which provides more calories and protein than a standard infant formula, to help achieve catch-up growth. Gastro-oesophageal reflux Reflux, or gastro-oesophageal reflux, is when stomach acid moves up into the oesophagus, or even into the mouth. It is common for this to happen in infants during or immediately after feeding. However, when the volumes of returned feed are significant and the infant has additional symptoms, such as excessive crying, poor growth and regular vomiting, then either an anti-reflux formula, which is pre-thickened or thickens in the stomach, or a feed thickener added to standard formula, may be required to manage this condition. THE ROLE OF THE HCP
If an infant shows signs or symptoms which indicate that a specialist product may be required, it is essential that the infant is diagnosed and managed appropriately. Paediatric dietitians
PAEDIATRIC
As infants have relatively high nutritional needs and growth trajectories, their nutritional support should be constantly monitored by a healthcare professional.
have the specialist expertise to collaborate with a GP to diagnose, advise and prescribe the appropriate product for an infant, ensuring that sufficient nutrients are provided to safeguard growth and development. As infants have relatively high nutritional needs and growth trajectories, their nutritional support should be constantly monitored by a healthcare professional. One size does not fit all; as children grow and develop, their nutritional needs change and, therefore, they may need different nutritional inputs at different stages. Moreover, some conditions are characterised by periods of relapse and remission, eg, Crohn’s disease, which makes ongoing monitoring even more important. The value of good paediatric dietetic advice in these situations cannot be underestimated. Not only is a medical condition stressful for the infant, it can be very upsetting for parents or carers. Conditions, such as gastro-oesophageal reflux, lactose intolerance and CMPA, can be very distressing and frightening for the parents of infants who suffer from them.12 Any concerned parent should be encouraged to see their GP and subsequently be referred to a paediatric dietitian to ensure support is provided and if necessary, the appropriate formula is recommended when their child is unwell and the condition is professionally managed. This eliminates the risk of the parent/ guardian receiving inappropriate advice about the dietary management of their child, which could put the health of the infant at risk.
PRESCRIPTIONS OF SPECIALIST FORMULA MILKS
All specialist formula milks available on prescription go through a strict application process, which the Advisory Committee on Borderline Substances (ACBS – the committee responsible for advising the prescribing of foodstuffs) assesses and approves. The ACBS takes into consideration the cost and efficacy of all these specialist formula milks for the dietary management of clinical conditions. PUTTING NUTRITION AT THE HEART OF PATIENT CARE
The role of a paediatric dietitian in diagnosis, treatment and review is fundamental. Prescribing the appropriate specialist formula milk provides optimal nourishment for all infants with a disease, disorder or medical condition. BSNA supports the following: • Specialist formula milks to be recognised as an integral part of the management of diseases, disorders and medical conditions which require nutritional support. • Specialist formula milks to be accessible to all patients who need them. All care pathways should clearly identify how and when a specialist formula milk should be used to help manage a patient’s condition. • Specialist formula milks to be prescribed and used appropriately when needed, and for patients to be regularly reviewed and monitored by a healthcare professional. www.NHDmag.com April 2019 - Issue 143
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PUBLIC HEALTH
Evelyn Toner Registered and Freelance Dietitian Evelyn’s specialist areas include sports nutrition, gastroenterology – especially IBS – health and wellbeing. She enjoys media work and running her social media persona ‘The Active Dietitian’ (on Instagram as @the_active_ dietitian).
REFERENCES Please visit the Subscriber zone at NHDmag.com
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NUTRITION AND WELLBEING IN THE WORKPLACE Unemployment is at its lowest level since 1975, with three quarters of UK adults (32.6 million people) currently in employment - the highest since records began in 1971. 74% are in full-time employment, spending approximately 37 hours/week at work.1 It, therefore, makes sense that health and wellbeing in the workplace is given adequate attention and resources. With this in mind, the UK government has placed a high importance on improving the health of the country’s workforce over recent years, with the development of guidance from NICE2 and the NHS Five Year Forward View.3 The BDA also picked this up and made it a priority for 2015-2017 with the creation of their ‘BDA Work Ready Program’,4 which aims to benefit both employers and employees by providing dietetic support and expertise to help reduce a wide range of preventable ill health conditions, improve resilience and mental wellbeing.4 Now, I’m not suggesting that weight is the only factor affecting health; but, much of the research has found links between being overweight or obese with increasing absenteeism and sick leave from work – often due to preventable ‘obesity-related health conditions’, such as musculoskeletal disorders and chronic diseases.4 Up to 10% of all sick leave has been attributed to lifestyle behaviours and obesity,4 with 25% of the UK working age population having at least one preventable condition, eg, diabetes or heart disease, which acts as a barrier to productive employment.5 This can be a considerable cost for both individual companies and for the economy as a whole, with NICE estimating the cost of lost productivity due to obesity alone in a company of 1000 employees to be £126,000/year.6 Ill health resulting from obesity can also be a precipitating factor in the transition to early retirement, disability pension, social welfare, or unemployment.4 Obesity, musculoskeletal conditions and
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depression have been identified as the top three causes of sick leave, all of which can be improved by optimising the nutritional status of our workforce.4 Therefore, it makes sense to look at the barriers to good nutritional health and consider some changes/practices that may help overcome these. Factors such as working patterns, including shift work, working long hours and lone working, can all affect an employee’s ability to make healthy food choices when at work. They can also lead to increased snacking and disrupt ‘normal’ meal patterns.4 Other disruptive working patterns include short, or a lack of structured breaks with limited time to eat, working in high-pressure environments, having limited access to healthier food choices, regular travel for work and long periods of sitting. EATING HABITS OF THE WORKING POPULATION
Let’s take a closer look at the eating habits of our working population to better understand what choices are being made, and therefore, provide insight on what could be targeted. Research has found that, typically, those working regular daytime hours usually eat breakfast at home. However, over half do ‘sometimes’ have breakfast outside of the home, with the top three choices on these occasions being a ‘hot roll/sandwich’, ‘cooked breakfast’ or a ‘pastry’.4,7 The habitual practice here could be exploited, and having breakfast at home could be encouraged and promoted.4 Certainly, encouraging regular breakfast
PUBLIC HEALTH Table 1: BDA guidance on vending machine food choices17 Max 250kcals per product Single serving sizes (30g) for savoury snacks Smaller bottles and cans of unsweetened and carbonated drinks – sugar free and low calorie drinks should make up 80% of provisions and be displayed prominently. At least 2 snack items with the following nutritional content – price competitively: • Total fat ≤17.5g/100g • Total Sugars ≤15g/100g • Saturated fat ≤5g/100g • Salt/Sodium ≤1.5g/0.6g/100g Unsalted nuts and seeds may exceed 17.5g fat/100g but the packet must still contain ≤250kcals/pack.
consumption is a key point, whether at home or at work, as one study of nurses found lower stress levels, fewer cognitive mistakes and fewer minor accidents amongst breakfast eaters.8 A survey of lunchtime habits found that almost 40% of workers brought in a homemade lunch between two to five times a week, with a third of people saying that they checked the nutritional content when purchasing lunchtime meals.4,9 This is positive and should be encouraged to increase the frequency with which people bring in their own lunch. The increasing awareness of nutritional labelling should be utilised by food establishments, including work canteens, to provide information for informed choices. The fact that at least 60% of workers are buying their lunch outside the home every day is interesting and could suggest a high reliance on work canteens, thus giving the employer a golden opportunity to effect change. However, a poll by the BDA found that 62% of employees sometimes, or always, skipped their lunch break,4 identifying a culture that employers could target for change. The Mintel snacking survey found that 97% of adults tend to snack between meals,10 a habit which is often prevalent at work, therefore providing an excellent opportunity for employers to offer healthy options, to educate employees and increase awareness of what a ‘healthy snack’ might be. A good example here would be the provision of readily available and attractive fruit and vegetable options – a recent 2019 study has found that increasing fruit and vegetable intake, even by one portion/ day improves mental health and wellbeing.11 Having access to more fruit and vegetables at work, therefore, would benefit not only the physical health of a workforce, but the mental health too.11 THE IMPORTANCE OF HYDRATION
We cannot discuss nutritional wellbeing without mentioning the importance of hydration. It
is well established that adequate hydration is important to maintain focus, concentration and safety and that dehydration can impact on both physical and mental performance,12 having a similar effect on brain structures as mild cognitive impairment13 and contributing to fatigue, headaches and impaired reaction times. One study of vehicle drivers found that those who were dehydrated made a similar number of errors when driving as a drunk driver.14 Hydration is an important consideration for employers as the work environment can contribute to the risk of dehydration, for example, working in a warm environment, needing to wear protective clothing, a lack of breaks to obtain fluids, or even a fear of taking toilet breaks as often as may be necessary. One particular workforce group I will quote as an example of this, are hospital workers. They are at increased risk of dehydration due to their environment – air conditioning, warm temperatures, long busy shifts, limited breaks and a ban on consuming drinks when face-to-face with patients or relatives.4 A 2016 study found that 45% of doctors and nurses were dehydrated by the end of their shift – this significantly impaired their cognition and shortterm memory.15 In the development of their program, the BDA’s evidence review found that targeting the individual alone is not effective and the surrounding environment is a big influencer on health and nutrition choices, with one study of 9000 workers concluding that obesity levels were higher in those who frequently ate in the staff canteen.16 Therefore, it’s important to provide not only individual education directed at behaviour change – either by one-to-one consultations, or in a group setting – but also to address the surroundings and food availability by targeting canteens, vending machines (see Table 1), www.NHDmag.com April 2019 - Issue 143
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PUBLIC HEALTH Table 2: Practical measures for change in the workplace • Plan the launch period of any new intervention strategically so it doesn’t clash with an especially busy or stressful time in the industry, to help increase buy-in and commitment. • Involve employees in the planning and implementation of any intervention; consider gender and culture. • Provide educational materials on nutrition and health, eg, leaflets, posters, workshops, workplace ‘champions’. Have nutritional information available for canteen meals and displaying this at the point of choice and purchase. • Combine an element of physical activity promotion alongside dietary interventions. • Provide adequate and functioning water taps or ‘hydration stations’ in convenient locations, consisting of a variety of hot and cold options to suit all tastes. Tea, coffee, milk and low calories drinks all count towards the recommended daily fluid intake. • Provide clean and hygienic areas for food preparation and storage, and include cupboard space, a fridge, cutlery, kettle, microwave and washing-up facilities, to facilitate meals brought in from home. • Provide products that are lower in saturated fat and salt, eg, soups, meat options, spreads, oils used in food prep and as dressings. • Provide higher fibre starchy carbohydrates, eg, breakfast cereals and breads and meal deals that include a starchy carbohydrate, vegetables and a portion of fruit. • Sell fruit cheaper than processed desserts. • Provide structured and regular breaks, with cover for lone workers. Break any historical culture that encourages working through breaks. • Secure appropriate contracts with vendors that support changes to healthier food provision and incentivisation.
snack provision, hydration facilities and effect organisational policy changes.4 A study by Warwick Medical School,18 commissioned by Public Health England, showed that using ‘nudge’ theory encourages healthy eating in hospital canteens. The researchers found that reducing the effort required to select healthy options, or increasing the effort required to select unhealthy options, improved diets. Increasing the availability of healthy options also drove healthier diets. See Table 2 for some practical measures that employers can take to promote healthier choices amongst their workforce. Cost is always going to be an important factor for any company considering a new intervention or programme to increase awareness of, or provide, healthier eating opportunities in the workplace. It can be difficult to quantify or monetise the benefits of such programmes. Nevertheless, employers should be reassured by the BDA findings that such interventions can increase productivity by 1-2%, and by the strong association between obesity and increased sick leave.4 Therefore, by promoting healthy weight maintenance amongst employees, absenteeism will reduce. Merseyrail reduced their staff sickness leave from 155 days to 35 days in one year, reducing their cost of sickness by £11,000 in the first year alone.4 An airline company achieved a 5% weight loss in men who attended an intervention, which was maintained at a two30
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and-a-half-year follow-up.4 So, with strategic implementation of a nutritional care program, the benefits can outweigh and cover the costs. Studies have suggested that companies who invest in the health and wellbeing of their workforce have a more positive corporate image, loyal employees and a higher standard of customer service.4 In the long term, organisations need to implement strategies to reinforce and sustain initial behaviour changes, provide regular update sessions and policy reviews.4 An example of this could be to provide an annual ‘health awareness day’ where employees could have a health +/weight check, access to a dietitian and obtain information on healthy eating. CONCLUSION
Employment levels in the UK are currently at the highest they’ve been in over 40 years. Nevertheless, sickness and absenteeism is a considerable cost for employers. Obesity is one of the top causes of sick leave, most likely due to its associated conditions. Optimising nutrition in the workplace, therefore, needs to be a priority in order to preserve our workforce. In order to succeed, any intervention in the workplace must involve both the individual and the surrounding environment, and employers need to take practical steps to make healthier food choices easier and more attractive to employees.
THE LOW-FODMAP DIET: AN OVERVIEW OF ITS DEVELOPMENT AND APPLICATIONS Diets involving the restriction of fermentable carbohydrates in order to provide relief from the symptoms of bloating, pain and other gastric discomfort, have been emerging for a number of years. In particular, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (low-FODMAP) diet has increased in popularity. There has been considerable interest in the low-FODMAP diet and its applications in IBS and other conditions since its conception in 2005 and it has been recommended as a second-line intervention for IBS by the BDA since 2013, for relief of symptoms of bloating, pain and diarrhoea.1,2 IBS is thought to affect between 7-10% of people worldwide3 and over 80% of those with IBS report a link with food.4 Therefore, there is a continued interest in a diet which will help in some way to alleviate these symptoms, however much they may vary between individuals. WHY WAS IT DEVELOPED?
For some time, it was recognised that though certain foods may be more ‘gas producing’ than others, ie, brassicas, dairy, beans, pulses and legumes, there had never been a recognised group classification of these foods and their components. This meant that potential dietary interventions were difficult to assess and there was no set guidance for identifying individual tolerance levels. The collective term ‘FODMAPs’ was coined in 2004 by a team of researchers at Monash University in Australia, who were keen to create a dietary intervention that included all of the problematic short-chain carbohydrates that had previously been identified. Those which were included had been recognised to cause symptoms due to malabsorption, maldigestion,
fermentation and osmotic load. Whereas previously, much research had focused on eliminating only one or two of these FODMAPs, the research team’s theory was that by removing all the FODMAPs – and carrying out a phased, carefully monitored reintroduction – dietary triggers and individual tolerance levels could be better assessed.5 The team then began to have their efforts recognised internationally through the development of further studies, initially through a hypothesis around the pathogenesis of Crohn’s disease.6 Overall, the team hypothesised that dietary restriction of these short-chain carbohydrates would reduce luminal distension (through reducing water/gas retention) and potentially bring relief to individuals with IBS who report visceral hypersensitivity. A small observational study showed improvement of symptoms following restriction of fructose.7 An exacerbation of symptoms with the reintroduction of fructose and fructan was then noted in a blinded controlled trial that re-challenged those who had previously reported improvement following restriction of fructose.8 This continued development included teaming up with international researchers in New Zealand and in the UK. Research began into the development of assessment tools, detailed food analysis, including cutoffs for high/low FODMAPs and assessment of the diet’s efficacy in other conditions.5
NUTRITION MANAGEMENT
Jessica English RD Self-employed Freelance Dietitian, founder of Level Up Nutrition Jess runs Level Up Nutrition, working with individuals on a one-to-one basis in Brighton and virtually UK-wide. She has a special interest in health communications and global public health nutrition. www.levelup nutrition.co.uk
REFERENCES Please visit the Subscriber zone at NHDmag.com
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NUTRITION MANAGEMENT WHAT IS INVOLVED IN THE DIET TODAY?
T
A low-FODMAP diet involves an exclusion of high-FODMAP foods for around four to six weeks, with a gradual, phased reintroduction in order to assess individual tolerance levels, which then results in a maintenance diet. If no improvement is seen within four weeks of starting the elimination phase, it is recommended to stop the intervention and other options should be considered.2 Due to the complex, restrictive nature of the diet, it is recommended to be carried out with supervision from a healthcare professional. There is limited research into the effectiveness of the diet when not dietitian-led. The initial, low-FODMAP elimination phase is followed by a period of food re-challenging in order to assess individual tolerance levels. When the re-challenges are complete, a maintenance diet can be devised which minimises the FODMAPs that have caused discomfort, reintroducing others at a tolerated level, but providing an otherwise varied, balanced diet. It is important that nutritional adequacy of the diet is assessed throughout all stages.
POPULARITY
The diet has increased in popularity in recent years, as more and more people seek out help for intolerances and functional gut disorders. The development of an app by Monash University and others has meant that dietary choices for many who are undertaking the intervention are somewhat clearer. This may, however, potentially lead to individuals undertaking the diet without the assistance of a trained healthcare professional, risking nutritional deficiency and lack of guidance in the reintroduction phase. Many (non-medical) websites and blogs that list the details of a low-FODMAP diet fail to explain the reintroduction phase at all, instead usually listing high and low sources of FODMAPs. Anecdotally, I’ve also spoken to many people who’ve stuck to the elimination phase for months at a time, with great reluctance to, or misunderstanding of, continuing on into the reintroduction phase. There also appears to be a lack of education or support provided by GPs and nursing staff, with recommendations being given for patients to
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The low-FODMAP diet
trial the diet seemingly with just general blanket advice, limited further support and no referral to a dietitian. This can lead to confusion and anxiety for patients, as the diet is not only very restrictive, complicated and time consuming, but also requires a higher level of cooking skills and potentially increased food costs, as many processed foods are ruled out. For those not confident with all this, or who are not computer literate, the diet will likely be daunting. EFFICACY OF A LOW-FODMAP DIET IN IBS
Various studies have been developed to investigate the efficacy if a low-FODMAP diet versus other traditional and non-traditional interventions. Continued research into a low-FODMAP diet versus NICE guidelines has shown contrasting results between different studies. In UK research from 2011, those following a low-FODMAP diet reported a 76% reduction in symptoms compared with 54% of participants who were following general NICE guidelines for IBS management. In particular, there was a significant improvement in symptoms of bloating, flatulence and abdominal pain in the low-FODMAP group.9 A US study looking into the effectiveness of a low-FODMAP diet compared with a diet following modified NICE guidelines in those with diarrhoea-predominant IBS (IBS-D), showed similar overall outcomes for symptom improvement, although improvements in specific markers of pain and bloating were more marked in the low-FODMAP group.10 A recent Swedish study also showed similar outcomes
following comparison of a low-FODMAP diet and a more traditional ‘IBS diet’.11 In 2016, a small study sought to compare the effects of a 12-week programme of Hatha yoga with a 12-week FODMAP intervention.12 This study showed no significant difference in overall symptom improvement between the two interventions at 12 and 24 weeks. However, there was a slightly higher attrition rate for the FODMAP group. Despite the relatively small sample size (n=59) of this study, it highlights the potential for more intricate gut-brain interactions in IBS and the need for continued research in this area. A recent small study (n=44) looking into the effect of a prebiotic supplement when compared with a low-FODMAP diet in a group of participants with either IBS or functional abdominal distension, has shown a prebiotic supplement to be an effective treatment.13 Both treatment groups reported statistically significant improvements to IBS symptoms, although the prebiotic group didn’t report significant improvements in borborygmi or flatulence. There was no difference in treatment effect between groups; however, post-treatment symptoms returned in a different manner for each group; with improvements generally continuing for two weeks post-treatment for the prebiotics group. Nevertheless, symptoms reappeared immediately for many in the lowFODMAP group. As many high-FODMAP foods are also prebiotics, it might seem an unlikely treatment, as prebiotics generally provide substrate www.NHDmag.com April 2019 - Issue 143
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NUTRITION MANAGEMENT
Changes to variation and proliferation of gut microbiota . . . which were assessed during this study, have led to the development of further research into prebiotics and a low-FODMAP diet.
for microbiota and increase gas production; worsening symptoms. However, longer-term administration of these prebiotics (as with food intake) seems to show an adjustment in the microbiota, eventually returning to pretreatment levels. Changes to variation and proliferation of gut microbiota (an increase in Bifidobacterium sequences in the prebiotic group and a decrease in the lowFODMAP group, alongside a decrease of Bilophila wadsworthia in the prebiotic group and an increase in the low-FODMAP group), which were assessed during this study, have led to the development of further research into prebiotics and a lowFODMAP diet. This includes a study looking into the use of a prebiotic supplement alongside a lowFODMAP diet in the treatment of IBS.14 The results showed adequate symptom relief and presented a potential method for identifying responders and non-responders to low-FODMAP treatment through stool and urine metabolite analysis, which could provide insight into mechanisms and help to individualise treatments for IBS in the future. This may also help to address any issues arising from altered gut microbiota following the elimination of a standard low-FODMAP diet. In general, there appears to be good evidence to support improvements in symptoms of pain, bloating and diarrhoea in those with IBS who fit the criteria for undertaking the diet, although it may be slightly less effective in treating symptoms associated with constipationpredominant IBS (IBS-C). 34
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OTHER APPLICATIONS OF A LOW-FODMAP DIET
Research is being conducted into the efficacy of the diet in treatment of a variety of health conditions. These include endometriosis and small intestinal bacterial overgrowth (SIBO), infant colic health and paediatric IBS. In endometriosis, dietary interventions have generally had limited success. As there is a considerable overlap with symptoms of IBS and endometriosis (including increased reported visceral hypersensitivity), researchers at Monash University have begun to investigate potential benefits of a low-FODMAP diet.13 Initial results suggest that there may be some improvement in symptoms for those with endometriosis who report gut symptoms, though further research is needed. As regards SIBO, there is a lack of consensus worldwide regarding its diagnosis and management. Again, there are many overlapping symptoms with IBS. Many variations of elemental and elimination diets are recommended from various sources and a lowFODMAP diet may potentially reduce unwanted symptoms of bloating and pain. However, due to the inherent difficulties in diagnosing and assessing efficacy of any treatments, conclusive research into this area is limited at this time. PRACTICAL CONSIDERATIONS
Those undertaking a low-FODMAP diet are recommended to do so under the supervision of a qualified healthcare professional; ideally
NUTRITION MANAGEMENT a trained registered dietitian who has the expertise needed to assess nutritional adequacy. Participants need to be assessed for their understanding of the nutritional limitations of the diet, ability to plan and prepare meals and be aware of the potentially increased financial and time burden. Education sessions will need to effectively explain the importance of the reintroduction phase and the need for assessing individual tolerance levels. Due to the restrictive nature of all elimination diets, attention also needs to be paid to the potential for links to disordered eating in those who are undertaking a low-FODMAP diet. Investigations into short-term changes to microbiota following the elimination phase of the diet suggest a negative effect, potentially reducing overall calcium intake14 and decreasing concentrations of potentially beneficial butyrateproducing bacteria.15 Research into any long-term alterations to the microbiota following the reintroduction phase of the diet is lacking and so it is unclear what effect this may have on microbiota and, potentially, on overall health. More research is needed in this area to establish any long-term effects on microbiota and gut health in general. Dietary fibre appears to be particularly important in gut health, for increasing variability of microbiota, but also for gut motility, stool bulk and consistency, which may affect IBS symptoms. It may prove difficult to achieve the recommended 30g/day of fibre,16 particularly during the elimination phase; therefore, particular attention may need to be paid to this over the longer term during the maintenance phase. It is also apparent that the implementation of this diet, education sessions and continued support is time and resource heavy. This may mean that it is unsuitable for settings within the NHS, with time-limited consultations and where dedicated provisions cannot be made. Group sessions may provide a more suitable setting for reaching more patients who would potentially benefit, although these aren’t suited to everyone. CONCLUSION
The low-FODMAP diet has been shown to be effective in alleviating symptoms of pain, bloating and increased stool satisfaction in those
with IBS in a number of well-controlled, shortterm studies. Nevertheless, due to the restrictive nature of the diet, it is not suitable for everybody. There is also only very limited evidence from observational studies which address the effectiveness of maintaining the diet over the longer term and there have been concerns raised over potential deleterious effects on microbiota, taking into consideration limited overall fruit, vegetable and fibre intake and the potential prebiotic effect of these foods. Individuals should be thoroughly assessed prior to commencing the diet, which should ideally be carried out by a qualified healthcare professional. This should ensure that the intervention is suitable and limits potential for abuse or misinterpretation of the diet. As per NICE guidance and BDA guidelines, there are first line treatments and assessments which may negate the need for an elimination diet in those with IBS. Potential benefits need to be weighed up against the practical considerations of implementing the diet and, as always, informed patient/client choice is paramount.
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Available at naturaldispensary.co.uk, bimuno.com, Holland & Barrett, Boots and Amazon For more information please contact hcp@bimuno.com *Study found that Bimuno reduced symptoms of IBS, comparable to a low-FODMAP diet www.gastrojournal.org/article/S0016-5085(18)34687-0/pdf **Scientific data shows that daily use of Bimuno increases gut bifidobacteria levels within 7 days, results may vary
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CONDITIONS & DISORDERS
Farihah Choudhury Health and Wellbeing Coordinator, University of Southampton Farihah is a Prospective Master’s student of Nutrition for Global Health. She is interested in public health nutrition, particularly in changing population health patterns as a result of dynamic food environments, food security and food waste, food poverty, food marketing and literacy.
REFERENCES Please visit the Subscriber zone at NHDmag.com
ADULT ONSET FOOD ALLERGIES Food allergy in adults is seeing a steady rise in developed countries. This article takes a look at the current understanding of food allergies and examines the reasons behind the increase in prevalence. In October 2018, NHD published a review of the current status of food allergy, in which we focused on paediatric food allergy.1a In several ways, paediatric food allergy is easier to fathom than that for adults. Many would hold late exposure to allergenic foods accountable, or poor diversification of infant diets1b,2,3 and would promote growth of beneficial gut microbiota to mitigate adverse health conditions later in life. Given this, the phrase ‘allergic reaction’ for most probably conjures up an image of a child with steadily swelling lips or irritated skin. After the recent inquest into the death of Natasha Ednan-Laperouse, the 15-yearold schoolgirl who had a fatal allergic reaction after eating a sandwich from Pret a Manger in 2016,4 an urgent reconsideration of food labelling on items sold in outlets was called to be had in the UK. However, although allergic reactions are more prevalent in children, and often more severe, adult onset food allergy is not uncommon and is seeing a steady rise in developed countries. Adult allergies present more of a conundrum, to the public and health practitioners alike: why would a food that has never caused any issue before, seemingly begin to incite an allergic reaction out of nowhere? THE ALLERGY DEBATE
The relatively sudden increase in allergy prevalence has not yet been 36
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pinned down to a single cause – many cite genetic predisposition (atopy) or epigenetic interactions with the environment.5-6 Some would argue the role of air pollution7 and others the globalisation of the food industry.8 Nearly 52% of Americans develop food allergies after the age of 18,9 and compared with infant-onset allergies, these are more likely to persist. This is in part due to the fact that allergic reactions in children are caused by poorly formed antigens that fail to respond to usually innocuous agents, whereas adult food allergies are caused by the loss of this previously well-developed defence mechanism. Adverse reactions to food can be separated into reactions which are intrinsic to the host (allergies, aversions and intolerances) and reactions intrinsic to the food (food poisoning). Immune-mediated hostintrinsic reactions, ie, food allergies, include immunoglobulin-E (IgE)mediated and non-IgE-mediated food allergy, cell-mediated food allergy, mixed reaction food allergy and coeliac disease. CURRENT UNDERSTANDING
Allergy research on the whole is a constantly developing area and much of the gaps in our understanding are yet to be filled. Much more is established about the immunology of IgE-mediated allergies than non-IgEmediated, though this is worrying, as
CONDITIONS & DISORDERS Table 1: Symptoms of food allergies IgE-mediated
Non-IgE-mediated
Gastrointestinal
Nausea, vomiting, abdominal pain and cramping, diarrhoea
Reflux, vomiting, diarrhoea, abdominal pain and distension, abnormal bowel biopsy
Dermatological
Acute rash
Rare: rash, dermatitis herpetiformis
Respiratory
Nose running and sneezing, eyes watering, swelling of lips, mouth and throat, can affect ears, wheezing/ Very rare: Heiner’s syndrome, recurrent bronchospasm, coughing, breathlessness, pneumonia inability to speak (symptoms rarely seen in isolation)
Cardiovascular
Hypotension, changes in heart rate, dizziness or faintness
Generalised
Anaphylaxis
the implication is that many people experience extreme allergic reactions and even anaphylaxis seemingly out of the blue (as non-IgE-mediated allergy symptoms have a later onset) and nobody will have assumed otherwise – neither medical professionals, nor the sufferers themselves. Recent fatalities are a testament to seemingly disproportionate allergic reactions to perceivably innocuous, or previously unproblematic, levels of exposure. Moreover, much less has been elucidated in terms of adult food allergies compared with paediatric allergy. HOW DO YOU KNOW YOU’RE ALLERGIC?
The enigmatic nature of allergy onset and diagnosis means that there has been speculation aplenty about what does or does not constitute an allergy and how best to avoid symptoms and reactions. Many err on the side of overcaution and believe they have allergies when they don’t. Others underestimate the risks and dismiss their symptoms. This understandably occurs especially amongst adults who have not previously had a food allergy. A European meta-analysis of studies conducted between 1990-2007 determined that self-reported allergy is thought to be anywhere between 3-35%10 in the UK and of the 3% of adults who are reported to have IgE-mediated food allergy, 25 have self-reported symptoms,11. However, incidence is on the increase and hospital admissions for food allergy in 1998-
Poor growth, failure to thrive, anaemia, irritability, dehydration, hypovolemic shock, anaphylaxis (less common)
2012 have shown a steady rise across most age groups.11 Furthermore, hospital admissions for anaphylaxis in the UK have risen from roughly 1.5 people per 100,000 per year, to up to eight people per 100,000 in 2012.11 In the same vein, in 2015, seven times as many people were admitted to hospital in Europe with severe allergic reactions as they were in 2005.12 This rise in incidence reporting may be partially due to limited understanding of food allergy prior to the 21st century – complications and fatalities due to what we now know as an ‘allergy’ may have been understood to be a completely separate diagnosis at the time. More likely is that a combination of the factors I mention above are in play to some extent. ADULT FOOD ALLERGY PATTERNS
Children tend to grow out of wheat, milk and egg allergies, so, whilst both adults and children can have allergies to shellfish, fish, tree nuts and peanuts, it is unusual for allergies to dairy and eggs to develop for the first time in adulthood. Shellfish is the most common allergy in adults and adults are more likely to develop oral allergy syndrome, which is caused by uncooked vegetables and apples and fruits with stones. Those who have, or have previously had, eczema, hay fever, or asthma, are more likely to have food allergies.13,14 Several cofactors may also make allergic reactions www.NHDmag.com April 2019 - Issue 143
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CONDITIONS & DISORDERS more intense, such as alcohol consumption, painkiller use, physical exercise and hormonal states, though evidence of this is currently limited.15,16 FOOD LABELLING
According to the UK’s Food Standards Agency (FSA) regulations, there are 14 foods considered to be the most important allergens17 and must be clearly labelled in any prepackaged foods and beverages: gluten, crustaceans, molluscs, eggs, fish, peanuts, nuts, soybeans, milk, celery, mustard, sesame, lupin and sulphur dioxide. Labelling ambiguities cause confusion amongst both outlets and customers, which can lead to unanticipated exposure of allergens, such as ‘flour’ being listed as an ingredient without specifying the type of flour. Terminology can also cause considerable confusion – with variations including: • ‘may contain…’ • ‘manufactured in a facility that also processes . . .’ • ‘may contain traces of . . .’ For an able adult, this can present the same dilemma when buying food whilst living with an allergy, as it would if one were buying food for a child living with an allergy. Recent improvements to labelling regulations have ensured that even non-packaged foods sold in food outlets must have allergen labelling in their immediate vicinity, visible to the customer – and this is being phased in over the next few years. ALLERGY MANAGEMENT
The current advice for those who experience symptoms of food allergy is mainly centred on total avoidance.18 When we consider that many allergies are self- or misdiagnosed, this muddies the waters considerably, as someone who may have an unrelated condition will avoid something that may be a critical food group and source of daily nutrients, such as gluten-rich foods or pulses. Furthermore, for adults who have never experienced an allergy before, it may be difficult to adjust to avoidance, as well as incite feelings of shame or inconvenience in 38
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later life. By comparison, children tend to grow to avoid and accept over a long period of time, but in adults, allergies are sometimes seen as self-proclaimed problems, or dietary fussiness, which can make it harder to adjust when in social settings. Other short-term management strategies for mitigating unanticipated or unwilling exposure to allergens include orally or intravenously administered antihistamines, bronchial dilators, steroids and epinephrine emergency injectors, such as EpiPens. However, for non-IgE-mediated allergy symptoms, the patient is restricted to using steroids and avoidance to manage their symptoms. FUTURE THERAPIES AND RESEARCH AVENUES
Whilst current recommendations for management include complete abstinence or injectors only after coming into contact with allergens, future therapies may well include immunotherapy,19 administration of antiIgE antibodies, Chinese herbal remedies (for example FAHF-2 now in clinical trials), as well as the possibility of combining immunotherapy and anti-IgE antibodies to reduce severity of adverse responses.20 Additionally, though research has been concentrated on serious allergies, such as peanut allergy, research is being conducted into the links between vitamin D and risk of anaphylaxis, as well as the role of epigenetic factors in allergy development.21 SUMMARY
Adult food allergy prevalence is on the rise, yet attention in this area is placed on paediatric food allergy, due to the severity and lack of control children have over adverse allergic reactions. The mystery surrounding exactly why we develop food allergies is, as yet, unsolved and this exacerbates the risk of misinformed selfdiagnosis, as well as underestimating risks of food allergy. Adult food allergy patterns differ to those of children and the most common food allergy in adults is from the consumption of shellfish. Current research is delving into the root of allergy and links are being made between various biological and environmental cues.
SOCIAL CARE
DYSPHAGIA: IDDSI IMPLEMENTATION IN HIGHLAND CARE HOMES Delivering safe, nutritious and appetising mealtimes is essential for care home residents, especially those who suffer from dysphagia. This article looks at how this is being successfully managed in The Highlands. Since the 1st of April 2019, NHS Highland has fully implemented the new texture classifications across all health and social care settings. The International Dysphagia Diet Standardisation Initiative (IDDSI)1 describes texture modified food and thickened liquids used for individuals of all ages, living with dysphagia. The framework allows for consistent management, production and adherence to a texture modified diet (see Figure 1 overleaf). WHAT IS IDDSI?
IDDSI is a global standardised framework that provides terminology and definitions for texture modified foods and thickened liquids. It consists of a continuum of eight level (0-7) and provides an easy-touse colour-coded model. It includes descriptors, testing methods and evidence for both drink thickness and food texture levels. FOCUSING ON SUPPORT FOR CARE STAFF
Increasing numbers of care home residents are living longer with conditions such as dementia, stroke, Parkinson’s disease and other neurological conditions. All have an increased propensity for developing dysphagia, where symptoms increase in tandem with disease progression. It is our duty, as health and social care professionals, to support these vulnerable people to access safe enjoyable nutritious meals and drinks. This requires a greater awareness
and understanding of both carers and cooks about how they can deliver this practically, in a way that ensures food is varied, tasty and well presented. Gone are the days (I hope) when a diet for swallowing problems was a liquidised, unrecognisable brown/grey mass of whatever composite meal was on offer that day. Equally, attempts at presenting food well in the kitchen were often thwarted by carers who then proceeded to mix everything together on the plate. In the Highlands, we have focused a great deal of effort on supporting care staff and cooks to deliver high quality, safe and nutritious food and fluids for people who have an identified swallowing difficulty. Support includes: • extensive opportunities for learning and development; • one-to-one support for care chefs.; • access to online and printed resources, recipes and professional expertise. Unfortunately, not all cooks have had the experience of previously working in care homes, never mind preparing texture modified diets. So, in Highland, we are currently working with the University of Highlands and Islands (UHI) to deliver a new SVQ course, which supports care cookery as a career. Investment in care chefs is also championed by the National Association of Care Caterers (NACC),2 while the Care Inspectorate Food, Fluid and Nutrition hub 3 offers practical information, YouTube demonstrations and web links for anyone looking for evidence-based information and advice.
Evelyn Newman Nutrition and dietetics advisor: care homes NHS Highland 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. @evelynnewman17
REFERENCES Please visit the Subscriber zone at NHDmag.com
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SOCIAL CARE Figure 1: The International Dysphagia Diet Standardisation Initiative (IDDSI) framework
PURCHASING SYSTEM FOR PREPREPARED MEALS
Across Highland we noticed that when care cooks went on holiday, or were absent for any reason, it was not uncommon for a general member of care staff to step in and do the cooking instead, especially in the smaller homes. The risk to residents with dysphagia has become increasingly clear in this situation, particularly when there are several different textures required. They may not have access to a suitable, safe and varied diet, which could lead to greater risk of aspiration (or worse!), malnutrition and dehydration. An alternative solution to mitigate against these risks is now more accessible for them through a Board-wide contract with a preprepared meals company. This is often only needed on a short-term basis. Following a tendering exercise, led by the procurement team, 40
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this service is offered to care homes and care home managers can, if they choose, now order a wide range of frozen texture modified meals via the internal purchasing system. This provides an assurance that food provided to people during the absence of the chef, is both nutritious and safe to meet individual needs. Of course, many care home residents and service users also struggle to eat standard meal portions and appetite is often diminished. Staff are normally encouraged to offer small, regular meals and snacks to promote increased nutritional intake. However, this requires a greater level of effort and imagination for people with dysphagia. Breakfasts can become quite monotonous if all that is offered is porridge or yoghurt (and what happens if you don’t like either?). I wonder what snacks are available to service users where you work. There are of course some great examples of well-presented,
SOCIAL CARE varied and appetising texture modified meals: you only have to look on the IDDSI website or the care inspectorate hub for examples and links to YouTube clips and recipe sites.
IDDSI posters and other resources have been widely shared and updates have been routinely provided through a quarterly social care newsletter.5
TRAINING PROGRAMME FOR CARE HOME STAFF
A MDT APPROACH TO DYSPHAGIA
Our care home training programme includes an afternoon of practical demonstrations of texture modified cooking and meal presentation from a professional chef.4 Hundreds of care staff have now attended the quarterly full-day events and evaluations of each day have been unanimously positive. There has been a transformational impact on many aspects of the meal service for people with dysphagia and a far greater awareness of nutrition as a health and safety rather than just a practical issue. Here are some of the outcomes: • More varied menus with texture modified options. • Care home managers have invested in more suitable equipment for cooks to prepare and present texture modified meals correctly. • More appropriate and timely referrals to speech therapy and dietetic staff. • Happier residents: “I like that I can still choose from a normal menu like everyone else, but have it adapted to suit my needs with the right textures.”- Resident with Parkinson’s disease.
The year-long implementation of IDDSI has been planned and led by a multidisciplinary group of health and social care staff, resulting in a gradual, risk-managed transition. A wide variety of communication methods have supported this and we plan to continue to monitor how well this has progressed. Using a small grant, speech therapy colleagues, in conjunction with care staff and myself, will be objectively assessing and reporting on the impact of the implementation process in Highland care homes. To conclude, I encourage colleagues to work with care staff and cooks to ensure that this growing group of elderly people who are living with dysphagia – or those who just prefer to have a softer diet – receive safe, well-prepared and presented texture modified food. Our residents and service users deserve the best that we can give them.
w No ers v I co DS ID
IDDSI IMPLEMENTATION BY SPEECH THERAPY STAFF
Speech therapy staff in Highland have led the transitional implementation of IDDSI and have also changed their practice, moving away from routine use of thickened drinks. There is an increasing awareness that the risk to individuals of aspirating thickened fluid is greater than if they aspirate a conventional drink. SLTs are therefore more likely to suggest that fluids are offered on teaspoons, straws or in small sips. There is a 70% chance that people with dysphagia will be at risk of dehydration, so robust person-centred care planning and proactively offering fluids is central to avoiding complications such as urinary tract infections, dizziness, confusion and constipation.
Staff training tool for health and social care teams – learn about managing dysphagia and implementing the IDDSI framework. Already using The Dysphagia Game? Order an IDDSI add-on pack. www.dysphagiagame.com
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F2F
FACE TO FACE
Director: Child-nutrition.co.uk Ltd
Ursula meets amazing people who influence nutrition policies and practices in the UK.
Judy grew up in New Zealand, but moved to Sydney, Australia to complete her higher education. She won a scholarship and completed a BSc in biochemistry and pharmacology, and then a post-graduate diploma in Nutrition and Dietetics. During her student holidays, and for the first year after graduation, she worked at the Prince Henry Hospital in Sydney. “It was a really sprawling hospital terrain, but it was on a cliff overlooking a beach, so offered great ocean views,” said Judy. She then moved to Europe and had two nutrition research jobs, firstly, to Bordeaux in France, following her husband’s career move to study oenology (the science of wine production), where she put on a white coat and worked in a laboratory studying insulin and pancreatic function. Later, at the Institute for Child Health in London, she worked on balance studies in infants, researching trace element metabolism. There was never a problem with her Australian dietetic qualifications; Judy has been UK based ever since her arrival in the late seventies. She weaved in and out of a wide variety of London hospital posts with the increasing theme of paediatrics. “I particularly enjoy working with young children and their parents, because dietetic guidance is often pivotal to the improvement of a medical condition and parents are usually very keen to follow advice,” said
Judy. She smiled when I questioned whether this was not the case for other dietetic encounters. She held one of the first specialist posts looking after infants and children who were HIV+ and described the challenges of previous drug regimens, which induced anorexia and often required nutrition support measures. One mother was most anxious about the stigma of enteral feeding for her child, but was reassured when Judy set out the wide variety of medical diagnoses (other than HIV+) that benefited from nutrition support. During a budget and staffing review of this hospital job, she was informed that the post of paediatric dietitian was counted as nonessential. Although there was never a confirmation of redundancy, she felt the insult of her post being marked as ‘not needed’, so decided to apply for a community nutrition post. In addition to supporting GP clinics and working with schools and other groups, she became increasingly involved in freelance projects, as well as writing. She claims early-adopter status for dietitian-with-a-website, setting up a consultancy to support individuals seeking advice on child nutrition issues. Other than medically complex conditions, themes are often eating behaviour difficulties, such as fussy or disordered eating. “It is great to be able to use my kitchen with children, to show and try foods, or measure out sample quantities. My usual
Ursula meets: JUDY MORE Government consultant on infant/child nutrition BDA Paediatric Group – past Chairman Ursula Arens Writer; Nutrition & Dietetics Ursula has a degree in dietetics, and currently works as a freelance nutrition writer. She has been a columnist on nutrition for more than 30 years.
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consultations are at least one hour, so there is enough time to consider all aspects in detail and find ways to give pragmatic support,” she says. Judy reports that most young children with fussy eating behaviours may be hypersensitive to the tastes and textures of some foods, and there is often some family history. Recommending nutrient supplements takes away some anxieties over inadequate intakes; she advises against discussions that are guilt-inducing or faultfinding. In many cases limited food choices are a stage in development and, provided parents model food diversity and enjoyment, most children normalise food choices. From 1999 to 2002, Judy was the chairman of the BDA Paediatric Group. It was during this time that several paediatricians reported rising rates of rickets and concerns were raised over the limited availability of suitable vitamin D supplements. Judy was invited to consult for the then Department of Health (DH), to advise on the reintroduction and promotion of the Healthy Start vitamins. “There was only one nutritionist employed at DH and it was a frustration that decisions to support this project seemed so tangled and slow. The contract to bid for the project seemed unattractive to companies and the system to distribute the vitamins from the single warehouse was unreliable. Fortunately, the Healthy Start scheme is now better supported,” she said. During that time, she also provided paediatric nutrition consultancy to DH, including website copy and amending the publication Birth to Five. In 2011, Judy wrote the book Infant, Child and Adolescent Nutrition: A Practical Handbook, and has also contributed chapters to several textbooks, including the definitive Clinical Paediatric Dietetics. As a member of the Infant
and Toddler Forum, she has authored many of their resources. Judy also provides consultancy to companies and organisations and lectures on paediatric nutrition themes to dietitians and other healthcare professionals. So, what should dietitians advise on childhood obesity? Judy feels that large portions of food have become normalised and that there should be more vigorous efforts to communicate less-is-more. “Parents need to moderate their own portions, with the sharing of regular nutritious meals rather than constant snacking and allowing more time to support eating together and eating slowly,” said Judy. “There is strong promotion and marketing of less healthy foods to young children, which should be curtailed. I am especially concerned when parents give their children (ursine shaped, flavoured, extruded) snacks, thinking that because they are not sweet, they are healthy.” Could some of the promotion of quick-and-easy foods be because consumers seem to value convenience the most, I asked? We agreed that both push and pull forces contributed to the current range of less-than-healthy foods given to children, but that many poor choices were due to confusion and mixed messages. Judy is currently supporting the development of food portion size guidance for paediatric dietitians, to address childhood obesity. Children have the least control of their diets, but suffer the greatest consequences to health, if food intakes are unbalanced and bizarre. “That is why I love paediatric dietetics so much. Because it is critical.” And I am left to wonder. Did Judy’s ‘critical’ mean very important? Or did it mean condemnatory of the many inadequate food mixtures and diets given to children in the UK? Both are true, of course.
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BOOK REVIEW
YOU HAVE THE RIGHT TO REMAIN FAT A MANIFESTO
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.
REFERENCES Please visit the Subscriber zone at NHDmag.com
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VIRGIE TOVAR MELVILLE HOUSE LTD. 2018 ISBN: 978-1911545163 PAPERBACK £7.99
Virgie Tovar is fat* and feisty and wants to fight societal rebuke of obese women. She actually wants to cheer all people who are not slim, not white, not hetero, not well-connected and not articulate. But it is only natural that her strongest motivations reflect her own person: fat, gay, Mexican-heritage and strongly feminist. She describes being always fat, but in childhood she felt cherished as queen-like by her family, and it wasn’t until school that taunts began. As self-awareness grew, anxiety and insecurity also grew. She lost some weight over a summer holiday, eating only toast and lettuce, but was disappointed that on return to school, her friends hardly noticed. Virgie has a long list of diets tried and failed that she keeps suitably vague. She also gets mightily peeved at memories of romance with young men who made snide references to her body and casually assumed her dinner-on-a-date would be a nodressing salad. But, she has now cut herself free from fretting about what individual men think of her. In fact, she now wants to be noticed for all the wrong-but-right reasons. Perceptions of beauty and worth are, of course, societal concepts, although I am sure dietitians support healthy weight for disease resistance rather than just for optical acceptance. Virgie mentions the force-feeding fattening camps that young girls in Mauritania need to endure to obtain the heft needed to be considered bride-
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worthy, but obviously this is as bad, or worse, than the slender ideals we (society) seem to cherish. She describes some fat-phobic communication attempts by American health organisations. Giant posters warning about childhood obesity were funded to appear around Atlanta, Georgia. One picture of a fat young boy bears the strapline: ‘Fat prevention begins at home and the buffet line.’ Virgie describes getting the most for your dollar as the obvious and logical behaviour of poorer families, and describes this poster as perpetuating class-based bigotry. The next picture of a fat young girl bears the strapline: ‘It’s hard to be a little girl if you’re not.’ Virgie protests most strongly at the message of being ‘more fat’ means being less feminine. The last picture shows a fat early puberty black girl with the strapline: ‘Fat may be funny to you, but it’s killing me.’ Virgie objects to the portrayal of fat black women as inherently always joking and humorous: it is a racist act of character-framing in the name of public health. There are many organisations that gather to promote awareness of
sensitive and minority issues. Virgie describes some of those supporting fat women, but I get slightly lost in the details describing fatfeminism versus body-positivism. The groups within groups surely all want the same thing: open acceptance of differences and varied life choices (as long as these don’t harm others). Virgie has a little stab at the divergent paths that fat women follow when romance wafts into the room. She laments that women partnered with men, or fat-negative mates, are more likely to return to dieting. She also vents particular annoyance at some people, mainly women, who do the public drama of, “I could only manage the tiniest sliver of birthday cake”. The noteating-in-public show is dishonest and unfair to other fat people who enjoy eating and who want to do so in a social environment, openly and for all to see. This is a small 120-page book about the big topic of social aspects of fattism. Of course we (society) must confess to being fat-phobic, in the way that people who are bald, or have
ginger hair or bad skin, who are less witty and articulate (because their first language is another), who have bad teeth or frizzy hair, who twitch or stutter, suffer unfair disregard. This is difficult terrain for dietitian readers who obviously care so much to support the physical and mental health of fat people. Nobody should be treated with disrespect because of body weight, and freedom to be foolish (in rejecting sensible dietary and lifestyle choices) is an essential libertarian principle I would defend strongly. But while you can argue against people being horrible and mean, you cannot argue the well documented data showing increased risks and adverse effects of being fat, such as Type 2 diabetes. Hopefully, Virgie has always considered dietitians as there to help. Virgie’s book is there to help dietitians who want to become more finely-tuned to the many faces of fattism. *Virgie chooses the descriptor ‘fat’ to describe people of greater body size and weight. www.NHDmag.com April 2019 - Issue 143
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EVENTS & PUBLIC HEALTH COURSES YAKULT STUDY DAY 2019 Latest insights into the gut microbiota and health: from research to practice 25th June, 8.30am to 4.30pm Venue: Wellcome Collection, London Early Bird: £60/£25 for students (before 31/03/19) Regular: £85/£50 for students (after 31/03/2019) For more information visit: www.hcp.yakult.co.uk/events/158/yakult-studyday-2019
Upcoming events and courses. You can find more by visiting NHD.mag.com
ADVANCED STATISTICS FOR NUTRITION RESEARCH 2nd May One-day workshop The Nutrition Society Training Academy, London W6 7NJ www.nutritionsociety.org/events/advanced-statistics-nutrition-research
***DIETITIAN - CHILD AND ADOLESCENT MENTAL HEALTH SERVICE - STAFFORD*** Salary: £32,350 - £35,490 pa
We are looking for a Dietitian to work in our Child and Adolescent Mental Health Service (CAMHS) at The Huntercombe Hospital Stafford nr Wolverhampton. The hospital is a 36 bed Tier 4 CAMHS hospital for young people aged 12 -18 years with a range of mental health disorders. Huntercombe can offer you a rewarding career where you will be valued as a key member of our team and every day you’ll be able to make a difference to the lives of our patients and residents, supporting and encouraging them to achieve their goals and ambitions. Working as a Dietitian you will be responsible for providing dietetic assessment, diagnosis and treatment programmes to individual patients. You will be an autonomous practitioner, holding a caseload and working without direct supervision. Most patients and residents are referred via NHS and local authorities. We play an integral part in contributing to new models of care outlined in the Five Year Forward View. Your main duties will be to provide expert advice, signposting, guidance and information to health and social care professionals, patients, carers, relatives or other non-professional contacts; plan menus with the Catering Department; use your highly developed knowledge and skills in the implementation and planning of individual dietary treatments taking into account patients’ conditions; provide education workshops with staff, patients, carers and other professionals; providing a high level of care to patients with dietetic and nutritional requirements. For full details of this post and for an informal discussion, please contact Hayley Valentine in Central Recruitment on 07540153430. Email: hayley.valentine@huntercombe.com
dieteticJOBS.co.uk To place an ad or discuss your requirements please call
01342 824 073 (local rate) 46
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WHERE ARE THE MALE DIETITIANS? Working in the specialist area of IMD means that I don’t get too involved in student training, so I am often asked to mentor the students instead, two of which, currently, are male student dietitians. This brings the amount of males to six in our 30-plus femaledominated department! Unheard of! Over the past few years, I have noticed a steady trickle of male student dietitians coming through our doors from Coventry University. Kostas, who is one of our current students and the BDA student rep, tells me that in his year of 35 students, there are four males, with similar amounts in other years. When I trained 20 years ago, there was one male dietitian on my course. Times they are a-changing . . . and for the better. I contacted the BDA, who told me that 4% of their approximate 9500 membership is male, so there are only around 400 in the UK. I asked Kostas why he thought there were very few males coming forward to train. He noted that the public perception of dietitians is of food, cooking and home economics and the public don’t realise how much science and maths is involved in the course and the job. Kostas told me that he first got interested in sports nutrition when he was playing football, but after starting the course, he found that he enjoyed the clinical side more and is especially interested in oncology and myth busting! Kostas’s colleague Chris had a different path; his family life was
Louise Robertson Specialist Dietitian
food orientated as his mum was in catering. He enjoyed food tech at school and loved science. So, when researching what he wanted to do, dietetics was suggested to him. He finds it surprising that there are not more males in the profession. Maybe dietetics isn’t being promoted as a career to males. Maybe the public doesn’t understand what dietitians do full stop. Another reason that dietetics could be female dominated is that the first dietitians in the 1920s were nurses with a specialist interest in nutrition. In the past, nursing was also a female-dominated profession, although this has changed more than dietetics has. Put dietitian into an online search engine and you mainly come up with photos of women in white coats holding fruit! I’m loving the new competition that the BDA is hosting – to create new photos that accurately highlight the diversity of the dietetic profession. We need to get our thinking caps on to ensure that there is an equal amount of men as well as women in these photos, which may help to spark more interest in male students who are thinking about what career to get into.
Louise is an experienced NHS dietitian who has been specialising in the fascinating area of Inherited Metabolic Disorders in adults for the last 10 years. In her spare time she enjoys running her blog Dietitian's Life with her colleague and good friend Sarah Howe, playing the cello and keeping up with her two little girls! www. dietitianslife.com
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FOR HEALTHCARE PROFESSIONAL USE ONLY Breastfeeding is best for babies
THE FIRST AND ONLY EHF
TO CONTAIN GOS/FOS PREBIOTICS
Aptamil Aptamil Pepti Pepti Clinically proven to REDUCE allergic manifestations for up to five years1–3
the
step st ep in the effective management of
cows’ milk allergy is extensively hydrolysed formula†
References: 1. Arslanoglu S et al. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the fi rst two years of life. J Nutr. 2008;138:1091-5. 2. Arslanoglu S et al. Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the fi rst 5 years of life. J Biol Regul Homeost Agents. 2012;26:49-59. 3. Pampura AN et al. Ros Vestn Perinatol Paediat 2014;4:96-104
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 are foods for special medical purposes for the dietary management of cows’ milk allergy. They should only be used under medical supervision, after full consideration of the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable for use as the sole source of nutrition for infants from birth, and/or as part of a balanced diet from 6-12 months. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet. † For the management of mild to moderate IgE-moderated cows’ milk allergy the iMAP guideline recommends an Extensively Hydrolysed Formula (EHF) as the fi rst step for formula feeding or mixed feeding (if symptoms only with introduction of top-up feeds) infants.
18-044 (GOS/FOS)/Date of Prep: March 2018 © Danone Nutricia Early Life Nutrition 2018
Healthcare Professional Helpline: 0800
996 1234 www.eln.nutricia.co.uk/cma