Network Health Digest April 2021 issue 162 by NH Publishing Ltd

– ED D M R NH FO R IN FO AY CH ST EA R

The Magazine for Dietitians, Nutritionists and Healthcare Professionals

RENAL DISEASE AND NUTRITION

INFANT IRON DEFICIENCY PARENTERAL NUTRITION FOOD FIRST GASTRIC DISORDERS BUSTING SOCIAL MEDIA MYTHS IMD WATCH

Public health strategies: do they work? Page 8

NHDmag.com

April 2021: Issue 162

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References: 1. Atwal K et al. An extensively hydrolysed synbiotic-containing formula improves gastrointestinal outcomes in infants with non-IgE cow’s milk protein allergy, already well-established on extensively hydrolysed formula. Poster Presentation. European Academy of Allergy and Clinical Immunology Food Allergy and Anaphylaxis Meeting 2020. 2. Van der Aa LB et al. Clin Exp Allergy. 2010;(40):795–804. 3. Browne et al. A synbiotic EHF may help improve atopic dermatitis-like symptoms and parental QOL in infants with non-IgE mediated cow’s milk allergy. Poster Presentation. European Academy of Allergy and Clinical Immunology Paediatric Allergy and Anaphylaxis Meeting 2019. 4. Browne et al. A new synbiotic EHF for infants with cow’s milk protein allergy is well tolerated, highly acceptable and supports good growth and intake over 28 days. Poster Presentation. British Society Allergy and Clinical Immunology Meeting 2019. 5. Van der Aa LB et al. Allergy. 2011;66:170–177. 6. Martin R et al. Benef Microbes. 2010;1(4):367–82. 7. Wopereis H et al. Pediatr Allergy Immunol. 2014;25:428–38. 8. Harvey BM et al. Pediatr Res. 2014;75:343–51.

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UP FRONT Welcome to this April issue of NHD. As we move into spring, we start to see flashes of colour and new life pop up all around us. Those cheerful yellow daffodils have given way to tulips and divine scented bluebells. With the clocks having moved forward last month, we may have lost an hour of precious sleep, but we gain those longer, brighter days. Nevertheless, despite the new lease of life we’re enjoying in nature, there has been a tough pill to swallow from the government over recent weeks, with just a 1% pay increase for NHS staff recommended to the NHS Pay Review Body last month. After an extraordinarily challenging year battling against the coronavirus and the lack of substantial pay increase over the last decade, this announcement has certainly left a bad taste in the mouths of many. Let’s face it, after we take into consideration the expected rise in inflation, a 1% pay rise isn’t even a pay rise. The BDA Trade Union has condemned the recommendation, with BDA Trade Union Director, Annette MansellGreen, commenting, “Dietitians, along with other dedicated and hard-working NHS staff, have been subjected to realterm pay cuts for over 10 years. To have this cynical and measly recommendation made at a time when they have been going above and beyond during the pandemic is an insult.” Whilst the 1% pay increase is insulting to most, some also believe that the government has missed a great opportunity to invest in the NHS. UNISON has expressed concerns that this latest thump from the government is potentially damaging beyond the here and now for the NHS, its hardworking staff and its patients. In a recent blog, UNISON explained that the government is not only failing

to recognise the efforts of staff and reward them for all they’ve done over the past year in a satisfactory way, but it also expects the insulting reaction to result in ‘the exodus of those same staff’ due to the government’s failure to demonstrate that they’re valued. UNISON also feels that the recent payrise recommendation does nothing to attract much-needed new recruits. The BDA and UNISON will continue to fight as part of a group of 14 health trade unions for a real and meaningful deal for their members. The Pay Review Body will consider the evidence from the government, along with that already submitted by the joint NHS trade unions. Its findings will be presented with recommendations in May. In the meantime, we carry on as normal, with nutrition professionals never stinting in their care of patients and clients in all fields. We, at NHD continue to provide you with resources and information, articles and news for your interest, learning and CPD. Our Cover Story this month, from Danielle Nott RD, discusses the current recommendations and approach to nutrition in renal disease, whilst topics from across the dietetic spectrum include iron deficiency anaemia, a food-first approach to malnutrition, parenteral nutrition, public health strategies, social media myth busting and gastric disorders, PLUS a whole lot more. Spring is sprung! Emma

Emma Coates RD Editor Emma has been a Registered Dietitian for 14 years, with experience of adult and paediatric dietetics. coatesyRD

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13 COVER STORY Renal disease and nutrition 6

News

34 BUSTING SOCIAL MEDIA MYTHS

Latest industry and product updates

8 Public health strategies Do they work?

37 IMD watch Shining a spotlight

11 Meet the charity Alexandra Rose Charity

17 INFANT IRON DEFICIENCY

on metabolic dietitians

42 In Cooke’s Corner Charlie considers perceptions

of nutrition professionals

New mn

colu

45 F2F Interview with Elsie Widdowson 23 Food first Managing

48 DAY IN THE LIFE OF . . .

malnutrition

27 PARENTERAL NUTRITION

50 Dates for your diary Details of upcoming events 51 Dietitian's life ’Niche down’ your social profile

31 Gastric disorders In dietetic practice

Copyright 2021. 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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WE’RE MOTIVATED TO GET HEALTHIER IN 2021 A new survey from Public Health England (PHE) of more than 5000 adults has found that 80% of people have made the decision to make healthier lifestyle changes this year. The majority of adults (70%) say they are motivated to make these changes as a result of COVID-19. The survey revealed that in 2020, the pandemic led to less healthful behaviours: • 35% of people reported unhealthy snacking at least once a day. • 30% said they were exercising less in the latter half of the year. • 29% of smokers stated they smoked more in the second lockdown. • 23% of drinkers claimed their alcohol intake increased following the second lockdown. Approximately six million adults aged between 40 and 60 now want to eat healthier (40%), lose weight (39%) and exercise more (41%). This is likely to be linked to the evidence showing an increase in intensive care admissions for COVID-19 for those living with obesity, compared with those with a healthy BMI. Dr Alison Tedstone, Chief Nutritionist at Public Health England (PHE), said: “Our survey shows the vast majority of us want to do something positive this year to improve our health and now is a good time for a reset, whether it be eating more healthily, being a healthier weight, getting more active, stopping smoking or doing more to look after our mental health.” View the survey here: www.gov.uk/government/news/seven-in-10-adults-are-motivated-to-get-healthier-in2021-due-to-covid-19. For more on the PHE’s ‘Better Health’ campaign, go to: www.nhs.uk/better-health

HIGH INTAKE OF REFINED GRAINS ASSOCIATED WITH CVD A prospective cohort study published in The British Medical Journal has found an association between intakes of refined grains and adverse health outcomes. The Prospective Urban Rural Epidemiology (PURE) study was conducted in low-, middle- and high-income countries around the world. The study analysed 137,130 participants in 21 different countries. Researchers used country validated food frequency questionnaires to assess intakes of refined grains, wholegrains and white rice. Results showed that intakes of refined grains and added sugars have increased over the years and having more than seven servings of refined grains per day was associated with a 27% greater risk of early death, 33% greater risk of heart disease and 47% greater risk of stroke. No significant associations were found between intakes of wholegrains or white rice and health outcomes. The study suggests that globally, we should be eating more wholegrain foods and less cereal grains and refined wheat products in order to optimise health outcomes. For full details, visit: https://www.bmj.com/content/372/bmj.m4948

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DRUG FOR TREATING OBESITY LEADS TO REDUCTION IN BODY WEIGHT A new drug has shown a reduction in body weight by more than 20% in adults, according to a study recently published in The New England Journal of Medicine. The study looked at nearly 2000 adults with a BMI of 30 or more, or ≥27 in adults with ≥1 weight-related coexisting condition. It took place at 129 sites in 16 countries across Asia, Europe, North America and South America. Participants received either 68 weeks of once-weekly subcutaneous semaglutide injections (dose of 2.4mg), or a matching placebo. Both groups received lifestyle intervention. Results showed an average weight loss of 15.3kg in the semaglutide group compared with 2.6kg in the placebo group, and 35% of participants who took the drug lost more than 20% of their body weight and showed a greater improvement in cardiometabolic risk factors. The drug group also reported improvements in their overall quality of life. Semaglutide is already approved and used clinically at a lower dose for treatment of diabetes. Now, with the evidence from this trial, the drug has been submitted for regulatory approval as a treatment for obesity to the National Institute of Clinical Excellence (NICE), the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA). For more information, go to: https://www.nejm.org/doi/10.1056/NEJMoa2032183

EATING OILY FISH COULD REDUCE THE RISK OF ASTHMA IN CHILDREN A recent study, published in The European Respiratory Journal, has found an association between oily fish consumption and risk of asthma in mid-adolescence. The researchers used food frequency questionnaires to assess dietary intakes of EPA and DHA from fish at seven years of age up until the age of 14 in children in both England and Sweden. They then analysed associations between intake of EPA and DHA and incidence of doctordiagnosed asthma at age 11-14 years and looked at potential effect modification by a fatty acid desaturase (FADS) polymorphism. Results showed that in children with a common FADS variant, eating at least two portions of fish a week showed a 50% reduction in the risk of developing asthma between the ages of 1114. Researchers suspect that higher levels of omega-3 may be protective against asthma through reduced inflammation of the airways. However, these results were only shown in children with a particular genetic make-up (FADS variant). The study could not prove cause and effect, but it provides insight into how genetic screening could be used to provide personalised nutrition advice. Professor Shaheen, a clinical professor of respiratory epidemiology in London, said, “Whilst we cannot say for certain that eating more fish will prevent asthma in children, based on our findings, it would nevertheless be sensible for children in the UK to consume more fish, as few currently achieve recommended intake.” Visit: https://erj.ersjournals.com/content/early/2021/01/21/13993003.03633-2020

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PUBLIC HEALTH

Farihah Choudhury ANutr Farihah is a Public Health Nutritionist within Hampshire County Council. She is particularly interested in food policy, noncommunicable diseases as a result of changing food environments, sustainable diets and food culture, and anthropology. www. easypeasysustainability nutrition.co.uk easypeasy sustainability farihahchdhry

REFERENCES Please visit: nhdmag.com/ references.html

PUBLIC HEALTH STRATEGIES: DO THEY WORK? In the UK, we have had 30 years of public health strategies on obesity, the latest being the Government’s ‘Better Health’ campaign. This article hones in on the last 30 years of public health strategies targeting obesity, in response to some newly published research from the Centre for Diet and Activity Research and MRC Epidemiology Unit at the University of Cambridge.3 Public health strategies can take many forms. Usually, they are an ongoing response to long-term population health issues, or a reactive response to emerging issues. From a historical perspective, public health campaigns tell an illuminating tale. WHEN DO WE NEED PUBLIC HEALTH STRATEGIES?

As we have witnessed with the COVID-19 pandemic, public health campaigns as part of a strategy response, traverse all of the undulating motions, from beginning to end (which may be decades later). The motions of population panic, rapid response scientific and healthcare innovation, misinformation, mixed messaging, interventions with various degrees of success, dissenters and the residual ebb and flow of the responsible agent as part of ‘business-as-usual’ society – whether that is tobacco or an airborne virus – are etched into public health history for the rest of time. Devastating and global reaching public health disruptors requiring quick and reactive responses tend to take the form of viruses, causing some scale of epidemic. Public health strategies to contain viral agents usually take the same trajectory, ending in containment and then eventual vaccination, with a view to achieving complete eradication

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when enough of the population are vaccinated, imbuing herd immunity and hence minimising transmission to almost zero. In August 2020, in the midst of the COVID-19 pandemic, for example, Africa declared they were polio-free after over a century in response.1 Communicable diseases understandably take the spotlight when talking about public health strategies, due to how they are transmitted. Other major public health problems we have experienced of the non-communicable type are tobacco smoking, alcohol consumption and high prevalence of obesity. The UK Government has a list on its website of all the issues they currently consider as requiring an ongoing public health response.2 Over the last 50 or so years (depending on the part of the world in question), we have seen a steady rise in prevalence of obesity as a consequence of a rapidly changing global food environment. An issue is considered a public health problem when it is causing significant morbidity or mortality in the population, and consequently puts a strain on health services, both operationally and fiscally. By pure happy coincidence for this feature, very recently, academics Dolly Theis and Martin White of the Centre for Diet and Activity Research and MRC Epidemiology Unit, University of

PUBLIC HEALTH Figure 1: England’s obesity and overweight prevalence 1990-2020

Cambridge, published a research analysis of just shy of 700 UK obesity policies from over the last 30 or so years, assessing their effectiveness.3 This feature will explore the findings of this paper, tied in with the wider picture. WHY IS OBESITY A PUBLIC HEALTH PROBLEM?

The first time obesity was formally recognised as a public health problem was in 1991.4 The changing food environment, alongside societal shifts in how we work, study and relax, have engendered what some describe as an obesogenic environment. The current architecture of living in a technology-powered world is such that it allows for many citizens to participate in virtually all aspects of their life through a screen. Entire degrees and school lessons can be completed online (whether voluntarily or virusinduced) and there are even remote-controlled vacuum cleaners. Perhaps more insidiously, the globalisation of the food industry has shifted food habits to convenience meals, cheap snacks and drivethroughs aplenty – not to mention the targeting of low-income neighbourhoods with fast food outlets, encouraging stark health disparities. Whilst technological and food-related innovation

is perhaps a strategy in itself to increase convenience in a busy world, it has given rise to a now not so new public health problem, which is requiring stringent and effective strategising (see Table 1 overleaf). But how well are these strategies working? The majority of adults and over a quarter of children aged 2-15 in England are either overweight or obese.5 Although we sometimes see a plateau in prevalence, between 1992 and 2020, despite government putting forward 14 strategies for reducing obesity, the prevalence remains vastly unchanged. EFFECTIVENESS OF OBESITY STRATEGIES

Theis and White3 outline a clear timeline of overarching obesity policies since 1992 (see Figure 1), using Health Survey for England data. We can see that this was pioneered with the 1992 ‘Health of the Nation’ strategy, feeding through to ‘Tackling Obesity’ in 2020, which forms Boris Johnson’s ‘Better Health’ campaign. The target of the very first strategy was to reduce the proportion of obese men to 6% and obese women to 8%, by 2005. Given that obesity prevalence today sits at 26.2% for men, and 29.2% for women,5 the goalposts have now drastically www.NHDmag.com April 2021 - Issue 162

PUBLIC HEALTH Table 1: Steps to successful strategising Clear, measurable targets. Including and honouring the most recent and relevant evidence at all stages: pre- and post-delivery. Shifting the onus from policies focusing on individual agency to structural policies targeting food industries, retailers and, above all, food environments. Robust monitoring and evaluation procedures. Ensuring policies are equipped to reduce health inequalities as a first priority.

moved. Interestingly, the very first target did not include one for children or for overweight, decoupled with obesity. Without specifying the exact wording for each of the subsequent 11 strategies from 1999 to 2018, no single strategy specified a clear target for reduction, other than vague targets relating to decreasing prevalence of obesity and overweight. This begs the question whether these strategies were set up to fail. Is it possible to achieve an outcome when there is no clear goal from the outset? Encouragingly, however, since 2018, there have been clear timeframes and percentage reductions set. June 2018’s ‘Childhood Obesity: a plan for action, Chapter 2’ sets a goal: ‘By 2030, halve childhood obesity rates and significantly reduce the health inequalities that persist.’ This recognises both the extent of childhood obesity and, importantly too, the role of health inequalities. The subsequent strategies published in 2019 and 2020 echo the same targets and timeframes, packaged in slightly different methods. The authors highlight the issue of strategies not referring back to previous strategies, or creating a cohesive narrative to outline progress made since previous manifestations. This exposes the vulnerability of the strategies put forward since 1992, insofar as confirming that none have made the appropriate progress to be able to be a point of reference for subsequent strategies. The lack of measurable targets has been pointed out previously by food policy experts.6 Instead, it appears that each strategy ‘refresh’ is an attempt to start from scratch and fix the growing problems that are not being tackled. Theis and White also note that despite beginning with a blank slate with each new strategy, the policies proposed were similar or exactly the same as prior proposed policies.3 10

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TYPES OF POLICIES PROPOSED

The authors note3 that the biggest proportion of policies (20%) fell under the umbrella of ‘Enable’ policies. An example of this is the Healthy Start Voucher scheme. Sixteen percent of policies were also ‘Guidance-’ or ‘Standards-’ related, aimed at the public sector, educational settings and the NHS. The ‘5-A-Day’ campaign falls under the ‘Inform’ category, under which 12% of policies fell. Very few policies were ‘Fiscal disincentive’, ‘Nonfiscal-disincentive’, ‘Fiscal incentive’ or ‘Eliminate’ and ‘Restrict’ choice-based. Extensive research, including a review of the evidence by Public Health England, suggests it is these genres of policies that have the greatest benefit in reducing poor health,7 yet these are the policies least frequently adapted by the UK Government. Furthermore, only 24% of the policies enclosed details of plans for monitoring and evaluation; only 19% cited evidence to support the policies being proposed; and a meagre 9% offered information regarding the financial cost of the strategy. The failure to detail robust methods of monitoring and evaluation alongside expected costs, suggests that these strategies were ill-prepared from their inception. ‘Implementation viability’ is a measure of how well a policy can be taken up in the population – this metric is measured with seven variables, including having a timeframe, a cost or budget and evidence. Only 8% (59) of policies across the 30 years have fulfilled all seven variables. From this analysis then, it is clear to see these strategies were not adequately planned, leading to their subsequent failure, signalling a need for subsequent strategy refreshing. Moreover, we must constantly consider the battle, or maybe the delicate balance, between public health strategies that place burden upon the individual’s agency, and strategies that are more upstream and structural, directly affecting

PUBLIC HEALTH environments without placing the emphasis on individuals to change their behaviours. Within the confines of central government, the difficulty is understandable, as actions seen as removing choice gain criticism as promoting the ‘nanny state’ (removal of individual liberty and market freedoms), yet those relying on individuals to adjust lifestyles are seen as unrealistic and unfair. So how does Westminster win? We know obesity is a structural issue – which is clearly exacerbated with widening of health inequalities – and hence the evidence base suggests the solutions should also be structural. Despite this, the largest proportion of strategies were found to put the onus on individual agency (43%). Secondly, despite the majority of strategies acknowledging that health inequalities need to be addressed, only 19% of these were set up to reduce these very inequalities from the beginning. POSITIVE POLICYMAKING GOING FORWARD

The analysis that formed the basis for this article gives good insight into what it is reasonable to

expect future government policies on obesity should include. Already, since 2018, evidencebased effective steps are being taken to improve the food environment for consumers. The SDIL (Sugary Drinks Industry Levy) is a successful example of this. An evaluation of SDIL, published in February 2020, found that the percentage of drinks with sugar over 5g per 100ml fell from an expected level of 49% to 15% over the 2015-2019 time period.8 The most recent strategy, published in July 2020, although reiterative of the previous two manifestations of strategy, provides a measurable goal with clear target audiences. It also includes a greater proportion of structural interventions than we have seen previously: the restriction of junk food advertising, removal of buy-one-get-one-free offers on high fat, sugar and salt (HFSS) products, and more. Going forward with the 2020 Tackling Obesity strategy, in order to achieve positive outcomes, this Government must avoid repeating the mistakes of the past.

MEET THE CHARITY

Alexandra Rose Charity’s mission is to give families on low incomes access to fresh fruit and vegetables in their local communities, through their Rose Vouchers for Fruit & Veg Project. Many of the families supported by the project struggle to provide healthy and nutritious meals for their children. One mum from Southwark shares how: “Before I had the Rose Vouchers, I didn’t have enough fruit and veg for everyone in my family. Now I do.” Families with children under the age of five receive £3 worth of Rose Vouchers per child, (or £6 if the child is under one year of age). Vouchers can be redeemed at local markets and independent greengrocers. This means that the project also supports markets, maintaining their position as sources of healthy low-cost food, and providing the community with vital access to fruit and veg. For more information about Alexandra Rose Charity please visit www.alexandrarose.org.uk

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COVER STORY

RENAL DISEASE AND NUTRITION This article examines dietary approaches to the prevention and management of chronic kidney disease (CKD). CKD is a progressive long-term condition, which describes abnormal kidney function and/or structure present for three months or more. It is classified in five stages relating to the severity of the disease, with stage 5 being classed as end stage renal disease (ESRD). CKD can progress to ESRD in a small but significant number of people. For these individuals, regular dialysis or transplantation is required to sustain life.1 Uncontrolled diabetes and hypertension remain two of the greatest risk factors for the development of CKD. The prevalence of CKD has also been found to increase with age, obesity, cardiovascular risk and in some ethnic minority groups.2 For those individuals who do progress to ESRD and start dialysis, mortality rates are significantly high at around 50-73% for those >65 years of age.3 With the growing incidence of CKD in the UK and around the world, there is now an increasing focus on the early identification and prevention of CKD. When CKD is detected early, its progression and complications can be delayed or prevented with the implementation of appropriate interventions. International guidelines now recommend that individuals are identified early to address cardiovascular risk and other risk factors, aiming to slow progression of CKD and reduce the number of patients reaching ESRD.4 DISEASE CONSEQUENCES

The kidneys have a key role in maintaining homeostasis. They also have other important functions, including maintenance of fluid and

electrolyte balance, removal of waste products, regulation of acid-base balance, hormone production and activation of vitamin D. There are two main consequences of CKD: the loss of kidney function resulting in complications and kidney failure, and the development of cardiovascular disease (CVD). Individuals with CKD are more likely to die from CVD than they are from progression to ESRD.5 NUTRITIONAL AIMS

In the earlier stages of CKD, nutritional management aims to reduce the progression of CKD and to reduce the risk of cardiovascular events. There is evidence that good glycaemic control in diabetes, weight reduction in those with obesity and nutrition support in those with protein energy wasting (PEW) can improve patient outcomes.5 Healthy lifestyle advice should be offered to help control blood pressure, achieve good glycaemic control, achieve blood lipids within acceptable ranges and to achieve a healthy weight.4 Most individuals will be asymptomatic in the earlier stages of CKD. Complications such as fluid or electrolyte imbalances, metabolic acidosis and uraemia are more common from stage 4 onwards as residual renal function declines. Therefore, most individuals with CKD stages 1-3 will not be required to limit their fluid, potassium or phosphate intake.

Danielle Nott RD Danielle currently works for Airedale NHS Trust and Leeds Teaching Hospitals NHS Trust as a Specialist Diabetes and Cystic Fibrosis Dietitian. Prior to this, she specialised in Renal for a number of years, gaining a variety of experience with all stages of CKD and posttransplantation.

REFERENCES Please visit: nhdmag.com/ references.html

CVD RISK REDUCTION

Given that hypertension is one of the greatest risk factors for CKD, it is understandable that lowering blood www.NHDmag.com April 2021 - Issue 162

COVER STORY

High-protein diets have also been found to increase hyperfiltration, worsen proteinuria and increase the rate of decline in kidney function.

pressure will have favourable outcomes on CKD progression and cardiovascular outcomes. Individuals are advised to limit their salt intake to <5g/day.4 The majority of salt consumed comes from processed foods, therefore education may be needed on interpreting food labels. Salt substitutes are not recommended as they contain potassium additives that can increase the risk of hyperkalemia. Evidence relating to weight loss interventions in CKD have been found to reduce blood pressure, proteinuria and rate of renal function decline.6 Other benefits associated with weight loss include improved insulin resistance, diabetes, dyslipidaemia and left ventricular hypertrophy.7 It is recommended that individuals with a BMI of >30kg/m2 should receive advice to help them lose weight.8 Weight reduction advice may also be given to help improve glycaemic control in individuals with or at risk of diabetes. A target HbA1c of 53mmol/mol is suggested to prevent or delay progression of the microvascular complications of diabetes.4 PROTEIN INTAKE

Approximately 250g of protein is catabolised by the body on a daily basis. The breakdown of protein leads to the development of urea and other compounds, which, in a healthy functioning 14

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individual, would normally be cleared by the kidney and excreted in the urine. However, in CKD these by-products can accumulate in the blood and can lead to uraemic symptoms.9 Highprotein diets have also been found to increase hyperfiltration, worsen proteinuria and increase the rate of decline in kidney function.10 There is insufficient evidence to support the use of low-protein diets in CKD stages 1-3; however, high-protein intakes (>1.3g/kg/day) are not recommended in those with CKD at risk of progression. Previous guidelines have suggested intakes of 0.8-1.0g/kg in stages 4-5 to be acceptable.4 However, more recent guidelines have suggested lower protein diets in stages 3-5 may offer benefits, such as postponing the need for dialysis and improving quality of life through the reduction of uraemic toxins. These guidelines have suggested 0.55-0.60g/kg body weight per day may be considered for individuals without diabetes who are metabolically stable.9 There are some safety concerns associated with lower protein diets. Previously, NICE has advised against low-protein diets (<0.6-0.8g/ kg/day) in CKD, partly due to the risk of PEW.1 PEW is a major problem in the later stages of CKD. Its onset and severity is related to the glomerular filtration rate (GFR), becoming more common with GFR <60ml/min and affecting 2040% of patients with stages 4-5 CKD.11 Energy

COVER STORY

There is currently limited evidence in relation to the type of protein that is consumed. However, there is increasing interest in the use of plant-based diets in CKD.

metabolism may also be impaired in CKD, therefore adequate energy is essential to reduce the risk of PEW. This becomes more important with lower protein intakes in order to promote protein sparing. However, it has been suggested that nitrogen balance and nutritional status can be maintained with energy intake in the range of 30-35kcal/kg with appropriate surveillance and nutrition education.9 Lower protein diets may not be suitable for all individuals, such as those at significant risk of malnutrition. Similarly, energy requirements are influenced by a multitude of factors and may vary depending on treatment goals. Therefore, dietary advice should always be individualised as there is no ‘one-size-fits-all’ approach. There is currently limited evidence in relation to the type of protein that is consumed. However, there is increasing interest in the use of plant-based diets in CKD. Plant proteins are less likely to result in hyperphosphataemia, as this type of phosphate is less bioavailable than in animal sources. DIETARY PATTERNS

Historically, nutritional intervention has focused on individual nutrients such as potassium, phosphate and sodium. However, evidence suggests that certain dietary patterns, such as those with a focus on the quality and diversity

of the diet, with liberal consumption of plant foods, may be relevant for the prevention and management of CKD. As there is no widely accepted definition of the term ‘plant-based’, there are no guidelines to suggest the minimum amount of meat a diet requires in order to qualify as plant-based. However, in individuals with CKD, a diet with a higher proportion of plant sources (emphasising fruit, vegetables, nuts, seeds, oils, wholegrains, legumes and beans) has been associated with improved outcomes, including reduced mortality and delayed progression of CKD.12 There may also be additional benefits in preventing and managing some of the metabolic complications of CKD. Proposed benefits of this diet include the increased fibre content, which can shift the gut microbiota towards increased production of anti-inflammatory compounds and reduced production of uraemic toxins.13 As previously discussed, this may help to improve quality of life and delay the need for renal replacement therapy. Higher fibre diets may also increase stool volume and decrease transit time which can increase faecal potassium excretion.14 Metabolic acidosis is a common complication of advanced CKD and is associated with an increased risk of muscle wasting, progression of renal failure and mortality.15 The reduced net endogenous acid production of plant-based diets www.NHDmag.com April 2021 - Issue 162

COVER STORY may have favourable outcomes on acid-base balance. One recent RCT in patients with CKD not on dialysis found that increasing alkali-rich plant foods resulted in improved metabolic acidosis and reduced decline in kidney function when compared with oral bicarbonate supplementation. Those following the plant-based diet were also found to have lower blood pressure, improved lipid profile and better body weight control than those receiving the bicarbonate supplementation or usual care.16 There is the concern that following a plantbased diet may lead to higher incidences of hyperkalemia due to the increase in potassiumrich foods such as fruit, vegetables, nuts and seeds. However, electrolyte disturbances are more common in the later stages of CKD as kidney function declines. Compensatory mechanisms are said to maintain potassium homeostasis until the very late stages of CKD.13 In addition, nondietary factors, such as uncontrolled diabetes, metabolic acidosis and constipation, can have a significant impact on potassium levels. Where possible, these should be addressed before considering dietary modification. Only a well-balanced plant-based diet is likely to offer the above benefits. Not all plantbased diets are of high quality, as some may contain lower intakes of fruit and vegetables and higher intakes of processed foods. Therefore, this approach may not be suitable for all individuals and may require extensive dietary education and support. As with all successful dietary interventions, advice should be patient-centred

allowing flexibility and considering, for example, the patient’s ability to implement changes, their cooking skills, finances and access to food. CONCLUSION

Nutrition plays a key role in the prevention and management of CKD. In order to prevent and delay progression to ESRD as well as risk of CVD, dietary advice should focus on salt reduction, achieving good glycaemic control in those with diabetes, reduction of blood lipids to optimal levels and weight reduction to achieve a healthy BMI. Optimal protein intake is debated, but highprotein intakes are not advised in those with CKD at risk of progression. Lower protein intakes may have a place in delaying the need for dialysis and reducing production of uraemic toxins, though close monitoring and dietary counselling would be needed to ensure nutritional adequacy and to reduce the risk of PEW. Re-emerging evidence supports the use of plant-based diets in delaying progression of CKD and its metabolic complications. Caution should be taken in those with advanced CKD stages 4-5, as the evidence for their safety is not yet well established. However, in the earlier stages of CKD, well-balanced plant-based diets may be beneficial, as they have been associated with lower cholesterol levels, blood pressure levels, rates of Type 2 diabetes and BMI, all of which are key recommendations in the prevention and management of CKD.

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PAEDIATRIC

INFANT IRON DEFICIENCY ANAEMIA: A PREVENTATIVE APPROACH Iron deficiency is the most common nutritional disorder in the world, affecting around 42% of children under five globally.1,2 In the UK alone, research has found that up to 60% of infants aged 6-12 months have inadequate dietary iron intake.1 Infant iron deficiency anaemia (IDA) in the developed world is a serious issue. This is particularly concerning when we consider that infants are easily accessible to primary care services and IDA is a preventable condition.3 Research spanning the last 20 years does not show a reduction in the prevalence of IDA, despite advances in healthcare provision.1,4 Early screening and nutrition education are imperative in reducing the risk of infants developing IDA.5 Adequate nutrition can be achieved in infancy by using breast milk, first infant formula milk and iron-enriched foods.6 IDA IN INFANTS

Iron is essential for fundamental cellular processes. Studies show that inadequate iron leads to developmental delays, cognitive impairment and increased infant mortality rates.1,3,4,7 Infants often exhibit no symptoms in the early stages of iron deficiency, so IDA commonly goes undiagnosed.8 Left untreated, the cognitive impairments caused by IDA can remain present at all stages of life and are unlikely to be corrected by subsequent iron supplementation.3 Therefore, preventative programmes are essential for improving public health in the long term.3

Jessica Paradine ANutr

IRON REQUIREMENTS DURING INFANCY

As nutritional requirements increase throughout infancy, so does the risk of developing IDA.8 In early infancy (0-6 months), IDA is rare because endogenous iron stores from the perinatal stage are sufficient to support growth during this time.3 Between 6-12 months, iron requirements are higher than at any other stage of development.1,5 Neonatal iron stores reduce by 50% and exogenous iron is required to maintain the optimal haemoglobin concentration during this phase of rapid growth.4 Maternal nutrition status, the timing of cord clamping, birth weight and growth rate, all influence infant iron requirements.5 The Department of Health recommends specific requirements for each stage of life.9 However, primary care practitioners should identify whether any adjustments are required on a case-by-case basis, as preterm infants and those born to mothers with anaemia need extra consideration. Notably, the SACN Iron and Health Report (2010) considers that dietary reference values from 0-6 months may be redundant due to endogenous iron supplies being sufficient during this period of development.5 Providing guidelines for infant iron intake at this age may cause confusion and added

Jessica is a Freelance Nutritionist who recently graduated from Bath Spa University with a degree in Human Nutrition. She is working towards Registered Nutritionist accreditation and has a specific interest in paediatric nutrition and public health.

REFERENCES Please visit: nhdmag.com/ references.html

www.NHDmag.com April 2021 - Issue 162

THIS INFORMATION IS INTENDED FOR HEALTHCARE PROFESSIONALS ONLY.

Supporting immune system development for long-term health.

Spotlight on immunity The immune system is of vital importance to protect us from a wide variety of invading organisms, and public interest in immunity is gaining momentum. It is therefore helpful to build an understanding of factors that affect immune system development.

The developing immune system Although the immune system starts to develop in utero, in newborn infants it is immature. There are a number of factors that influence the development of the immune system: the mode of birth, skinskin contact, human milk factors and environmental exposures to antigens are all important.1 Additionally, evidence suggests a healthy gut and a healthy gut microbiome are essential for normal immune system development and function in infants.2

Nutritional factors affecting immunity Nutrition plays a significant role in influencing the development of a healthy immune system.3 Human milk is the best source of nutrition for infants and provides numerous protective factors, such as Ig*G antibodies, secretory Ig*A and leukocytes (leukocytes are especially abundant in colostrum).4 Human milk also provides several other components that have anti-microbial effects such as lysosome and lactoferrin5, as well as oligosaccharides that support the microbiota.6 Additionally, human milk supplies Omega-6 Arachidonic Acid (AA) and Omega-3 Docosahexaenoic Acid (DHA) which are long chain polyunsaturated fatty acids (LCPs) that are vital micronutrients for infancy, shown to assist in immune development.7 AA initiates inflammatory responses whilst DHA resolves inflammation.8 *immunoglobulin

The microbiome and the developing immune system Around 70% of all immune cells are located in the gut. The microbiota plays a vital role in assisting immune system development by communicating with gut immune cells.9,10 Nutritional factors that encourage microbiome development include oligosaccharides (either human milk oligosaccharides or prebiotic fibres), small quantities of live bacteria that pass through in human milk (probiotics) and their metabolites (postbiotics).11,12,13 Supporting the maturation, diversity and condition of the gut microbiota through optimal nutrition is fundamental for the development of a healthy immune system.14,15 As a quick reminder, here are some biotics definitions: Prebiotics are substrates that pass to the gut where they stimulate the growth or activity of beneficial bacteria16 Probiotics are beneficial bacteria that affect the host microbiome when ingested in adequate amounts17 Synbiotics are a combination of prebiotics and probiotics17 Postbiotics are bioactive compounds produced by beneficial bacteria, which have biological activity in the host17 Human milk oligosaccharides (HMOs) are a complex pool of carbohydrates that exist in high levels in human milk, with prebiotic and other important benefits18

References 1. Simon AK et al. Evolution of the immune system in humans from infancy to old age. Proc Biol Sci. 2015;282. 2. Wopereis H et al. The first thousand days – intestinal microbiology of early life: establishing a symbiosis. Am J Physiol 2014;25:428-438. 3. Lozupone CA et al. Nature, 2012;489(7415):220-230. 4. Jackson KM, Nazar AM. Breastfeeding, the Immune Response, and Long-term Health. J Am Osteopath Assoc 2006;106(4):203–207. 5. Hanson LA et al. The immunological role of breast feeding [review]. Pediatr Allergy Immunol. 2001;12(suppl 14):15–19. 6. Andreeas NJ et al. Human breast milk: A review on its composition and bioactivity. Early Hum Dev. 2015;91:629-635. 7. Carlson SE, Colombo J. Docosahexaenoic Acid and Arachidonic Acid Nutrition in Early Development. Adv Pediatr. 2016;63(1):453-471. 8. Calder PC. Omega 3 Fatty Acids and Inflammatory Processes. Nutrients 2010;2(3):355–374. 9. Koenig J et al. Proc Natl Acad Sci U S A, 2010;108(Suppl 1)4578-4585. 10. Furness JB et al. Gut Am J Physiol, 1999;277(5 Pt 1):G922–8. 11. Hunt KM et al. PLoS One, 2011;6(6). 12. Jost T et al. Nutr Res, 2015;73(7):426-437. 13. Patel RM and Denning PW. Clin Perinatol, 2013;40(1):11-25. 14. Wu HJ, Wu E. The role of gut microbiota in immune homeostasis and autoimmunity. Gut Microbes. 2012;3(1):4-14. 15. Belkaid Y, Hand TW. Role of the microbiota in immunity and inflammation. Cell. 2014;157(1):121-141. 16. Gibson GR, et al. Nat Rev Gastroenterol Hepatol 2017;14(8): 491–502. 17. Schrezenmeir J, et al. Am J Clin Nutr. 2001;73(Suppl 2):361S–364S. 18. Bode L. Glycobiology. 2012;22:1147–6212 Job code: 21-008 Date of preparation: January 2021.

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Special immunity edition of the Nutricia magazine

PAEDIATRIC Table 1: Department of Health dietary reference values for iron9 Age (months)

Iron (mg/day)

0-3

1.7

4-6

4.3

7-12

7.8

13-36

6.9

needless stress for new parents, leading to unnecessary supplementation in the first few months of life. IRON SOURCES AND ABSORPTION

Iron absorption varies depending on the source. Breast milk contains a relatively low iron concentration (0.2-0.4mg/L); however, absorption levels are optimal, so breastfed babies are at low risk of IDA in their first months of life.3,5 In sources other than breast milk, the bioavailability of iron is low, therefore diet needs to be optimised with ascorbic acid to promote higher absorption.3 The consumption of cow’s milk in the first year of life is considered the greatest dietary risk factor for developing IDA.10-11 Cow’s milk contains around 0.5-0.6mg/L of iron.5 This is more than breast milk, but it is well established that iron in cow’s milk is poorly absorbed.5 The high bioavailability of iron in breast milk compensates for the lower concentration.5 Iron in infant formula milk is only absorbed in moderate amounts, but it can be added at higher concentrations to make up for this.6 This makes formula milk a reliable source of iron when breast milk is unavailable or in short supply. It can also provide additional nutrition after six months. Although the exact data is uncertain, it is estimated that around 95% of UK adults have adequate iron in their diet.5 These overall healthy levels are partially due to the introduction of iron-fortified foods.5 Iron content is lost during the processing of wheat flour, so the Bread and Flour Regulations Act of 1998 was introduced to ensure that all wheat flour is fortified to contain at least 1.65mg iron/100g.5 During the infant weaning process, fortified cereals can help to ensure that infants are getting adequate levels of iron in their diet.1,4

EDUCATION AS A METHOD OF PREVENTION

With simple nutrition education and supplementation, IDA and associated developmental delays are both preventable and correctable.4 Nevertheless, the general approach to IDA must be preventative rather than reactive. Many infants do not show any symptoms of IDA until it has progressed to stages where the effects are potentially long term and more serious than if treated sooner.3-4 Breast milk has been established as the ideal feeding method for a variety of reasons, including reducing the risk of IDA.5 From 0-6 months, the risk of IDA in exclusively breastfed babies is minimal unless the infant has complex needs. However, infants who are not breastfed should be given iron-enriched first infant formula milk.12 The Infant Formula and Followon Formula Regulations Act (England) 2007, requires all infant milk to have an iron content of 0.3-1.3mg/100kcal.6 For infants with additional needs, there are other types of formulas available. These include high-energy, easy-to-digest, anti-reflux, lactosefree, soy-based and hypoallergenic formulations. However, these formulas are not necessarily appropriate unless specifically instructed by a healthcare professional or health visitor.6 From six months, it is agreed that breastfed infants should also be introduced to foods to help meet increased iron requirements, whereas infants fed with formula should continue on infant milk alongside the standard weaning process.6 To encourage the exclusive use of breast milk, advertising infant formulas to the general public is illegal in the UK.6 However, follow-on milk is not subject to the same stringent regulation. Follow-on milk has minor nutritional differences that reflect the increased nutritional requirements of infants after six months. However, the WHO and the UK Department of Health advise against the use of follow-on milk.6 www.NHDmag.com April 2021 - Issue 162

FOR HEALTHCARE PROFESSIONAL USE ONLY

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Important notice: Breastfeeding is best. Nutriprem human milk fortifier, nutriprem protein supplement, hydrolysed nutriprem, nutriprem 1 and 2 are foods for special medical purposes for the dietary management of preterm and low birthweight infants. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed nutriprem, nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low birthweight infants. Refer to labels for details. References: 1. Boehm G et al. Arch Dis Child Fetal Neonatal Ed. 2002;86:F178–81. 2. Knol J et al. Acta Paediatr. 2005;94(449):31–3. 3. Mihatsch W et al. Acta Paediatr. 2006;95(7):843–8. 4. Bar-Yoseph F et al. Prostaglandins Leukot. Essent. Fatty Acids. 2013;89(4):139–43. 5. Carnielli et al. Am J Clin Nutr. 1995;61(5):1037–1042. 6. Carnielli et al. J Pediatr Gastroenterol Nutr. 1996;23(5):553–560. 7. Kennedy et al. Am J Clin Nutr. 1999;70(5):920–7. 8. Quinlan et al. Pediatr Gastroenterol Nutr. 1995;20(1):81–90. 21-001. January 2021

PAEDIATRIC Advertising of follow-on milk has caused controversy in the media and amongst healthcare professionals.6 Parents of young children will sometimes feel pressured to make the switch to follow-on milk, while healthcare professionals will attempt to educate about the guidance issued by the WHO and the UK Department of Health. With conflicting information from all angles, it can be difficult for new parents to fully understand what the best way is to prevent iron deficiency in weaning infants. Although a switch to follow-on milk is not generally recommended, exclusive breastfeeding beyond six months can actually increase the risk of IDA.4 In later infancy, it is advised that a combination approach of breast milk, infant formulas and/or iron-enriched foods should be used to achieve and maintain optimal iron levels.4 THE ROLE OF PRIMARY CARE FOR PREVENTION

Primary care has a significant role to play in preventing IDA. However, a multidisciplinary approach must be taken to identify the ongoing potential risk of IDA in infants.8 For optimal preventative results, comprehensive overviews of maternal iron status, infant diet, birth weight and any other medical history must be taken into account with every primary care contact.8 Educating parents about infant nutrition is undoubtedly the single most influential thing that can be done to prevent IDA in the early stages.3,10 Wherever possible, we must encourage parents to breastfeed exclusively up to six months of age.6 However, it is important to raise awareness of the increased nutritional requirements after six months, and the various methods available for iron supplementation.6 It is advised that infants with IDA risk factors or presenting with symptoms be screened regularly, including tracking haematological and biochemical markers to identify any changes in nutritional status that may lead to IDA. Once diagnosed, treatment should commence immediately with regular follow-ups to monitor progress.10 THERAPEUTIC SUPPLEMENTATION OF IRON

It is important to distinguish between preventative supplementation and therapeutic supplementation. Preventative supplementation through enriched food and infant formula is

recommended on a population level, whereas therapeutic supplementation is only used to correct diagnosed IDA.3 The WHO has published guidelines for iron consumption for high-risk infants and for correcting established IDA. Between 2-23 months, it is advised that infants with a low birth weight should be given 2mg/kg.3 In high prevalence areas, or in the absence of enriched foods, 6-23 month infants should also be given 2mg/kg.3 In diagnosed IDA, these requirements increase to 3mg/kg, up to a maximum of 60mg per day. This is a significant increase from the usual recommendation in the first year (1.7-7.8mg daily).3 However, as a therapeutic dose, this is considered appropriate and aims to correct the long-term adverse effects of IDA.3,10 AN URGENT CALL TO ACTION

The prevalence of infant IDA is unacceptably high. IDA is preventable with adequate nutrition and infants are one of the most accessible patient groups to primary care services.3 Instead of correcting IDA, a multidisciplinary and preventative approach is needed to identify risk factors for developing IDA at all stages of infant development. This involves: making education on the importance of iron status more accessible to parents and all women of childbearing age who may become pregnant;1,3 prioritising early recognition of IDA in infancy;5,10 and regular screening of infants with risk factors for IDA as standard practice.5,10 Evidence is lacking regarding the true prevalence of IDA, the effectiveness of regular supplementation and alternative methods of delivering iron at an absorption rate comparable to breast milk. More research is required to understand the full effects of the current burden of IDA and to evaluate the benefits of reducing prevalence. Furthermore, to implement the best preventative strategies, the cost-effectiveness of public health iron supplementation interventions needs to be assessed.3 The responsibility lies with healthcare professionals, parents, educators and researchers, to increase awareness of IDA. As healthcare professionals, our role is vital in educating the public about the importance of iron status in infancy and providing simple, accessible solutions to combating infant IDA. www.NHDmag.com April 2021 - Issue 162

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NUTRITION SUPPORT

FOOD FIRST AND BEYOND Managing malnutrition is through evidence-based nutrition and hydration care. Food first is championed by dietitians as an effective form of intervention and the first-line approach to managing malnutrition. Beyond the food-first approach, other methods of nutrition support may be considered by a clinical dietitian, such as oral nutritional supplements (ONS) and enteral feeding. Numerous clinical guidelines exist to support the use of the food-first approach in clinical practice, including NICE clinical guidelines on nutrition support in adults.1,2 THE ROLE OF FOOD FIRST IN MALNUTRITION

Malnutrition is a state of nutrition in which a deficiency, excess, or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome.3 The consequences of malnutrition have significant impacts on health outcomes and the costs associated with malnutrition are shown in Figure 1. Malnutrition in adults can present in every type of care setting (see Table 1 overleaf). It is important, therefore, that malnutrition is identified and managed

effectively in each of these settings. Using the Malnutrition Universal Screening Tool, ‘MUST’, to identify those at risk of malnutrition and implementing appropriate pathways of nutritional support for medium- and high-risk people, could produce an annual net saving to the UK of up to £229 million. This cost saving would be due to a combination of reduced hospital admissions, reduced length of stay and implementation of nutrition support.5

Caroline Hill RD Caroline is a Freelance Dietitian and runs Caroline Hill Nutrition, providing private dietetic consultations and nutrition consultancy services to businesses. www.carolinehillnutrition. co.uk carolinehill_nutrition

THE PRINCIPLES OF FOOD FIRST

Food first is a form of nutrition support using real food in combination with other methods to increase the amount of energy and protein an individual consumes. It takes into consideration factors such as a reduced appetite, early satiety and barriers to oral intake. Real food – high energy/high protein Choosing foods that are energy dense and rich in protein helps to increase nutritional intake, usually in a way

carolinehillrd

REFERENCES Please visit: nhdmag.com/ references.html

Figure 1: UK health and social care system costs of malnutrition4

More than £23 billion annually

Equates to 15% of total health and social care costs

UK costs of malnutrition Approx. £370 per capita of the population

Older people (>65 yrs) account for 52% of total costs www.NHDmag.com April 2021 - Issue 162

NUTRITION SUPPORT Table 1: UK malnutrition statistics6 Care setting

% of risk of malnutrition

Admission to hospital

25-34%

Admission to care homes

30-42%

Admission to mental health units

18-20%

Living in sheltered housing

14%

Community living (over 65 years of age)

93%

Table 2: Food fortification nutritional changes7 Energy before (kcal)

Energy after (kcal)

% change

Add 4 tablespoons of dried skimmed milk powder to 1 pint of whole milk.

375

583

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream to 125ml of custard.

148

349

135

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream to 125ml of milk-based soup.

280

250

Add 1 tablespoon of dried skimmed milk powder and 2 tablespoons of double cream to porridge made with whole milk (200g).

226

426

Add 1 tablespoon of butter and 1 tablespoon of double cream to 1 scoop of mashed potato.

183

161

Add 1 teaspoon of butter to 2 tablespoons of vegetables.

246

Add 1 tablespoon of dried skimmed milk powder, 2 tablespoons of double cream and 2 teaspoons of jam to 125g of rice pudding.

106

332

213

Food fortification

that doesn’t rely on an expectation of the individual to consume larger portion sizes. A small appetite and early satiety are common and usually contributing factors in malnutrition, so it is important to account for this when making recommendations. Examples of foods which are energy dense and high in protein include whole milk, full-fat dairy foods (such as cheese and yoghurt) and eggs. Food fortification Another method of increasing nutritional intake whilst taking into account a small appetite and early satiety, is using food fortification. This involves the addition of high energy/protein food ingredients into meals, which can increase the energy and protein content of a meal without increasing the portion size. Table 2 shows how 24

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food fortification can change the energy and protein content of common foods/meals. Little and often Again, due to changes in appetite and satiety which are common in people who are malnourished or at risk of malnutrition, having a little-and-often approach with foods can be beneficial to increasing nutritional intake aiming for three small meals, plus two or three nourishing snacks and eating every two to three hours. Examples of nourishing snacks include: • Cheese and crackers • Dried fruit and nuts • Popcorn • Fruit and custard/cream • Milk jelly • Full fat yoghurts

NUTRITION SUPPORT Figure 2: Recipe for homemade milkshake7 Ingredients: 40ml double cream 80ml whole milk 1 teaspoon sugar 80ml vanilla ice cream 24g skimmed milk powder Nutritional information (per 180ml portion): 400kcal and 13g protein Table 3: Barriers to oral intake and possible solutions Barrier

Possible solution

Poor dentition, i.e. loose dentures due to weight loss, or poor oral hygiene

If loose dentures, seek input from a dentist. For poor oral hygiene, dental input or GP input may be required and appropriate treatment commenced, eg, medication for oral thrush.

Dysphagia

Referral to a speech and language therapist for assessment and advice. Alteration of diet and fluids in line with the IDDSI framework may be recommended.

Taste changes

This could be due to medication or poor oral hygiene. Ask advice from a GP or pharmacist if medicationrelated.

Environmental, eg, lack of cooking facilities, problems with shopping and cooking

Social services input may be required. Access to a Meals on Wheels service or advice on purchasing home-delivered frozen ready meals.

Nourishing drinks Nourishing drinks can be a simple way of increasing energy intake, such as milky hot drinks (made with whole milk), hot chocolate (made with whole milk and served with cream), milkshakes and smoothies. Homemade milkshakes are also a great way of increasing energy and protein intake in a tasty way. Figure 2 gives a recipe for a homemade milkshake. Where it is not possible for an individual to make their own homemade milkshake, there are a range of over-the-counter supplements which may be a suitable alternative. Examples include Complan, Meritene and Aymes. These are commonly powder-based and usually mixed with milk. They are not intended to be a nutritionally complete solution. Multivitamins In individuals with a reduced nutritional intake and where there is concern about the adequacy of micronutrient intake, a complete oral vitamin and mineral supplement should be considered.1

OVERCOMING POTENTIAL BARRIERS TO ORAL INTAKE

In addition to changes around the type of food eaten, it is also important to look at other barriers and reasons for a reduced oral intake. Table 3 shows some examples of these barriers and how to overcome them. THE APPROPRIATE USE OF NUTRITIONAL SUPPLEMENTS

Once the principles of food first have been implemented and outcomes reviewed, further levels of nutrition support may need to be considered. This may include the consideration of the use of prescribed ONS, which should only be used in the following scenarios: • where diet alone is insufficient to meet daily nutritional requirements; • where the Advisory Committee for Borderline Substances (ACBS) criteria for the prescribing of ONS is met (see Table 4 overleaf). www.NHDmag.com April 2021 - Issue 162

NUTRITION SUPPORT

Malnutrition is an ongoing issue in the UK . . . Using effective nutrition support methods starting with the food-first approach can help to manage this cohort of patients. Table 4: ACBS prescribing indications8 Disease-related malnutrition

Proven inflammatory bowel disease (IBD)

Short bowel syndrome

Following total gastrectomy

Intractable malabsorption

Dysphagia

Preoperative preparation of malnourished patients

Bowel fistulae

Evidence from systematic reviews demonstrates that ONS are a clinically cost-effective way to manage malnutrition, particularly amongst those with a low Body Mass Index (BMI).9,10 In 2018/19, the NHS spent £357.9 million on prescribing medical nutrition products (£150.1 million on ONS alone) in primary care.11 BAPEN estimates that appropriate ONS prescribing could save the NHS £101.8 million per year due to reduced use of healthcare resources.12 It is, therefore, important and within the role of a dietitian to ensure that the different steps of oral nutrition support are followed, allowing for effective implementation of an appropriate nutrition care plan and the appropriate use of prescribed ONS. There are now newer dietetic roles within primary care, such as prescribing support dietitians, focusing on appropriate prescribing of ONS. A dietetic-led study evaluating inappropriate prescribing in primary care found that 61% of ONS prescribed in two clinical commissioning 26

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groups (CCGs) were no longer clinically indicated and could be stopped or switched to a more costeffective product.13 Not only would this lead to cost savings but also has other benefits such as reducing waste and ensuring continuation of appropriate medical intervention. CONCLUSION

Malnutrition is an ongoing issue in the UK and ensuring that the appropriate and necessary steps are taken to identify and effectively manage it, is ever more important. The consequences of malnutrition range from poorer clinical outcomes and increased hospital stays, to poor health-related quality of life.14 Using effective nutrition support methods starting with the food-first approach can help to manage this cohort of patients. As dietitians, we have an important role in addressing the challenges of managing malnutrition, such as developing care pathways, delivering training to key healthcare staff and promoting early and effective intervention.

CLINICAL

PARENTERAL NUTRITION EXPLAINED Before its initial development in the 1960s, the concept of intravenous nutrition, or total parenteral nutrition (TPN) as we know it, was considered a fanciful dream by most clinicians. Feeding entirely by a vein was considered impossible, impractical and too expensive.1 We have come a long way since then. TPN is now widely used in primary and secondary care, and is considered a safe and potentially life-saving treatment for patients with acute and chronic intestinal failure. It is, however, not without its risks and requires careful monitoring and specialist input. HISTORY OF TPN

The first uses of TPN in a clinical setting were in the late 1960s and early 1970s in preterm infants to help improve outcomes for these children who would otherwise have not survived.2 The formulations were then revised and improved and used more widely in the 1980s and 1990s, along with a better appreciation of the importance of nutrition support in acute illness and reduced length of starvation periods. It was around this time that nutrition teams were becoming more established in acute hospitals to oversee TPN administration and ensure safe practice.2 The components of TPN include macronutrients (protein as amino acids, carbohydrates as glucose, fat as lipid emulsions) and micronutrients (vitamins and minerals), electrolytes and fluid. Early TPN (1980s to 1990s) was given as separate infusions of amino acids, lipids and glucose, which was time-consuming and problematic. Now, TPN is available as ‘all-inone’ bags, allowing administration of all nutrients in one infusion.3,4 The use of this all-in-one system prevents component manipulation, thereby reducing the probability of contamination and requires only one

intravenous access, lowering the risk of infection.5 There is an argument, however, that there is now an overreliance on standard bags being prescribed in a ‘best-fit’ approach to meeting nutritional requirements, as many acute hospitals lack the resources to prepare TPN bags from scratch, which would allow for more tailoring of contents to individual nutritional needs. The standard bags when unmixed have a relatively long shelf life, whereas mixed ‘off-the-shelf’ bags normally have a shelf life of three to six months depending on the manufacturer (and if stored at the correct temperature). Bags prepared in hospital aseptic units normally have a 24- to 48-hour expiry date due to the type of aseptic unit used compared with the commercial manufacturing units.

Katy Stuart RD Katy is a Specialist Dietitian with 17 years’ experience, working in the United Lincolnshire Hospitals NHS Trust in Boston, Lincs. She mainly works in critical care, renal and complex nutrition support, including TPN. petaltheunicorn katystuart16

REFERENCES Please visit: nhdmag.com/ references.html

WHEN AND HOW IS TPN USED?

TPN is designed to meet a patient’s nutritional and fluid requirements when oral/enteral feeding is not possible or limited. It’s required when a patient cannot tolerate nutrition via either route usually due to gastrointestinal failure such as obstruction, perforation, ileus, malabsorption, short bowel syndrome, pancreatitis and upper gastrointestinal obstruction. Due to its high osmolality, TPN should only be administered via central venous access either via a central venous catheter (CVC) or a peripherally inserted central catheter (PICC). Tunnelled venous lines for longer term access are required for home TPN www.NHDmag.com April 2021 - Issue 162

CLINICAL

TPN is now a common medical and nutritional therapy across the world and has come a long way since its first development over 40 years ago.

Dr Dudrick who invented TPN in the 1960s

patients and can be in situ for years if properly cared for.4,6 Lower osmolality TPN bags can be given peripherally, but these have the increased risk of thrombophlebitis and the peripheral cannula should be changed every 24 hours, making it more impractical and uncomfortable for the patient. The peripheral TPN bags contain lower amounts of electrolytes and nutrients, so it is often difficult to meet a patient’s requirements.7 There is a risk of some nutrient deficiencies (eg, copper) for long-term TPN patients, as there is only a certain amount of some nutrients that can be added to the TPN mixture without it affecting the stability. Due to the potentially complex nature of TPN prescribing, working with a TPN-trained pharmacist is vital to ensure correct calculations of nutritional content in order to meet a patient’s needs.7 There is a reasonable amount of flexibility within the TPN formulations and electrolyte content. Sodium and potassium (monovalent) can be added in greater quantities to meet losses (in high output stomas for example), whereas only limited amounts of calcium, magnesium and phosphate can be added (as they are divalent and can cause precipitation). Following a number of incidents of patient deaths in the 1980s from infection after TPN administration, the standards and quality control of NHS aseptic units became more stringent and additions are now made strictly aseptically by appropriately trained and experienced staff and never at ward level.8,9 28

www.NHDmag.com April 2021 - Issue 162

There has been debate over the past 10 years about when to start TPN, after the EPaNIC trial in 2011 showed reduced rates of infection when delaying parenteral nutrition (PN) initiation.10 Data gathered from Nutrition Day (2016) by ESPEN showed a dramatic decrease in the use of PN and a delay in worldwide PN initiation since 2011 after the EPaNIC trial publication.5 In recent years, however, the use of PN has progressively increased again and the early use is much more common.5 The CALORIES trial (2014) was a randomised controlled trial (RCT) comparing enteral nutrition (EN) with PN in critically ill patients, in which nutritional support was initiated within 36 hours of admission. The data showed no difference in the 30-day mortality rates.5,11 It is perfectly acceptable to use PN as supplementary nutrition when the oral/enteral route is not meeting requirements, eg, poor gastrointestinal absorption in critical care and surgical patients.12,19 MANAGING AND MONITORING

Nowadays, with the newer formulations, TPN is considered a relatively safe treatment, but only with specialist input and stringent monitoring.13 The main risks are vascular access issues, such as pneumothorax, infection, bleeding and fluid and electrolyte abnormalities.4,14 For longer term TPN (i.e. >1 month), there is a risk of liver impairment and cholestasis, which can be reduced by ‘cycling’, i.e. having a break from the

CLINICAL TPN and running it over less hours (as long as the maximum infusion rate is not exceeded), or using fat-free bags intermittently.4,15,16 The mainstays of TPN treatment are biochemical monitoring, hydration status, electrolyte levels, fluid balance and supplementary intravenous fluid use if required. These should be reviewed daily as part of the nutrition team round (PENG, 2019). It is important to consider the indication and duration of PN and have a plan in place for when oral/enteral feeding will be trialled. If PN is to be longer term, referral for assessment for home TPN at a specialist centre will be required.4,17 When estimating nutritional requirements, it is important to consider the breakdown of glucose, lipids and nitrogen. Historically, only non-nitrogen energy requirements were calculated, but nitrogen contributes to total energy intake, so it needs to be taken into account to avoid overfeeding.15,18 NEW DEVELOPMENTS

There have been significant improvements in lipid emulsion compositions of TPN to reduce the risk of associated liver complications. Soybean oils (long-chain triglycerides) were first used in its initial development and then medium-chain triglycerides were introduced, followed by olive oil and saturated lipid emulsions.5 More recently, there has been the introduction of fish oils, marketed as having

more benefits over other lipid emulsions.5 Most commercially available bags use a mixture of oils and triglycerides. Olive oil has been deemed safe, with no significant differences in liver function tests and, although fish oil emulsions (omega-3s) have shown some benefit in the postop immune response, this was not found to be clinically significant.5,19 There have been studies in the use of omega-3 lipids in ICU patients and there is evidence to show it may reduce infection rates, decrease duration of stay and reduce mortality. The ESPEN guidelines concluded that fish oil lipid emulsions can be given to patients receiving TPN.19,20 CONCLUSION

TPN is now a common medical and nutritional therapy across the world and has come a long way since its first development over 40 years ago. It is an essential treatment in the management of intestinal failure, without which these patients would likely suffer malnutrition and even death. Although it has its risks, TPN when used appropriately, initiated carefully and monitored closely by a team of specialists with adequate training, will continue to help those patients who need it to achieve a successful recovery. It is important that those of us who work in the field of complex nutrition support and TPN stay up to date with national guidance and make sure our local policies are up to date too, ensuring continuing safe practice.

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NATIONAL AWARENESS EVENTS IN APRIL IBS AWARENESS MONTH Full information and downloadable toolkits from: https://aboutibs.org/living-with-ibsmain/ibs-awareness-month.html BOWEL CANCER AWARENESS MONTH Sign up to ‘Step up for 30’ at: www.bowel canceruk.org.uk STRESS AWARENESS MONTH Healthcare professionals and health promotion experts join forces to increase public awareness about both the causes and cures for our modern stress epidemic. www.stress.org.uk/ national-stress-awareness-month-2018 NATIONAL STOP SNORING WEEK 20th to 23rd April Sleep deprivation can have a negative impact on body systems such as hormonal release, glucose regulation and cardiovascular function, leading to overall poor health. Evidence has shown that the louder the noise, the worse the sleep. Find out more at: www.britishsnoring.co.uk NATIONAL ALLERGY WEEK 26th to 30th April This year the focus is on childhood food allergy: the weaning journey for parents of babies with food allergies. www.allergyuk.org/allergy-awarenessweek-2021

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www.NHDmag.com April 2021 - Issue 162

CONDITIONS & DISORDERS

GASTRIC DISORDERS This article discusses the different gastrointestinal conditions we may see within our practice as dietitians and how we can contribute towards the management of these. Ten percent or more of a GP’s work involves patients with digestive disorders1 and approximately 14% of the medicine’s budget is spent on managing these conditions.2 The most common gastrointestinal symptoms patients discuss with their GPs are constipation, diarrhoea, abdominal discomfort and indigestion.3 Gastrointestinal disorders can have similar symptoms, so patients presenting to GPs should be assessed for ‘red flag’ indicators and, if any are present, should be referred into secondary care for further investigation.4 Patients aged 50 or over may need further consideration and a variety of symptoms indicate a need for possible onward referral into secondary care (see Table 1).5 If a patient meets the IBS diagnostic criteria, NICE guidelines recommend that the following tests are undertaken: • Full blood count (FBC) • Erythrocyte sedimentation rate (ESR) or plasma viscosity • C-reactive protein (CRP) • Antibody testing for coeliac disease (endomysial antibodies [EMA] or tissue transglutaminase [TTG]) Faecal calprotectin stool samples are also often taken to rule out inflammation,

depending on local guidelines. If these tests are negative, patients are often diagnosed with irritable bowel syndrome (IBS) and treated according to local pathways. Other disorders that may have similar symptoms to IBS are not always ruled out as first line, and other diagnoses can often be missed. In this article I will talk about IBS and other conditions that need to be looked out for when assessing a patient to ensure that we are giving the correct dietary treatment.

Chloe Hall RD Chloe is a Community Dietitian with Dorset Healthcare. She has a particular interest in gut health. Chloe is also a Media Spokesperson for the British Dietetic Association. chloeindiahall

IBS

IBS is a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits. It may present as constipation, diarrhoea, or a mix of both, as well as symptoms of abdominal bloating/distention. Symptom onset should occur at least six months before diagnosis and symptoms should be present during the last three months.6 Dietary treatment may include first-line dietary advice, such as having regular meals, adequate fluid intake, restricting caffeine, reducing alcohol and assessing fibre intake. If first-line advice isn’t beneficial, then the low-FODMAP diet should be a consideration. One study found symptom improvement with

REFERENCES Please visit: nhdmag.com/ references.html

Table 1: Gastrointestinal symptoms indicating a need for referral into secondary care5 Blood in stools

Nocturnal symptoms

Unintended weight loss

Fever

Abdominal mass

Family history of coeliac disease

Ascites

Inflammatory bowel disease (IBD)

Elevated white blood cell count

Colon cancer

Loss of appetite

Unexplained anaemia www.NHDmag.com April 2021 - Issue 162

CONDITIONS & DISORDERS licensed for the treatment of the condition in the UK. There is also some evidence that probiotics may be beneficial; however, further evidence in the form of randomised control trials is required for this evidence to be conclusive.17 DIVERTICULAR DISEASE

both strategies, but more patients in the lowFODMAP group reported satisfaction with their symptom response (76%) compared with the standard group (54%).7 Patients who do not get satisfactory symptom relief from dietary changes may require drugs or psychological treatments and many patients may try a combination of all three of these strategies in order to manage their condition.8 It has been demonstrated that various psychological interventions may improve IBS symptoms, the most commonly recommended being cognitive behavioural therapy (CBT) and gut-directed hypnotherapy.9 SMALL INTESTINAL BOWEL OVERGROWTH (SIBO)

There is no accepted definition for SIBO; however, it is characterised by excessive bacteria in the small intestine and the most common symptoms can appear to be very similar to those of IBS and include bloating, diarrhoea and nausea.10 Weight loss and vitamin and mineral deficiencies, such as fat soluble vitamins, B12 and iron, may also be present.11 Some conditions are associated with the development of SIBO such as coeliac disease,13 gastroparesis14 and many others. The use of proton-pump inhibitors can also be associated.12 In clinical practice, the two most commonly used methods to diagnose the condition are breath testing using carbohydrates such as lactulose or glucose, or a trial of antibiotics to assess any benefit to symptom control.15 If diagnosed with SIBO, dietary treatment alone is unable to treat it. The first-line treatment involves the use of antibiotics. Rifaximin has a proven efficacy in clinical trials for SIBO,16 but is not 32

www.NHDmag.com April 2021 - Issue 162

Three terms are used in relation to diverticular in the large bowel: 1 Diverticulosis refers to the presence of pouches in the wall of the colon that aren’t causing any symptoms. 2 Diverticular disease is the presentation of symptoms in relation to these pouches, i.e. abdominal pain and altered bowel habits. 3 Diverticulitis is when the pouches become infected or inflamed.18 Often, patients are referred for dietary treatment of the symptoms that may come alongside a diagnosis of diverticular disease, such as constipation, diarrhoea, bloating and cramping. Fibre modification may play a role in symptom management, for example, if a patient ‘has constipation and a low-fibre diet, increasing their fibre intake gradually may minimise flatulence and bloating’.19 Adequate fluid intake should also be advised. Historically, patients have been told to avoid nuts, corn, popcorn and fruit with small seeds (eg, strawberries and blueberries). However, this is now not recommended as there is a lack of evidence for this.20 There is some evidence that low vitamin D levels can be linked to a higher risk of diverticulitis occurrence, so this should also be considered.21 One journal article uses the hypothesis that a low-FODMAP diet may be beneficial in symptom management given the conflicting evidence on whether a high-fibre diet is beneficial; however, further studies are needed to see whether a lowFODMAP diet would help.22 Some patients who have diverticular disease also have a diagnosis of IBS and, therefore, the low-FODMAP diet may be practically used in these cases. BILE ACID DIARRHOEA

A third of patients diagnosed with diarrhoeapredominant IBS actually have undiagnosed bile acid diarrhoea (BAD) and this condition

CONDITIONS & DISORDERS is often overlooked.23,24 One survey of patients has shown that there is poor recognition by healthcare professionals, with diagnoses often exceeding five years and, therefore, symptoms go untreated.25 Excess bile acids in the colon can cause diarrhoea (which may be unusually coloured) and symptoms often associated with IBS, such as bloating, pain and cramping.26 The condition may be more common in those who have had: • a right hemicolectomy • an ileal resection • active Crohn’s disease • chemotherapy • a cholecystectomy27

It can, also, be idiopathic.28

The main diagnostic tool for BAD is a SeHCAT scan, or sometimes in clinical practice an empirical trial of a bile acid sequestrant such as cholestyramine is used.29 Patients with a diagnosis of BAD and who have been prescribed bile acid sequestrants may not have satisfactory relief of their symptoms. In these cases, gastroenterologists suggest strategies such as increasing the dose, changing to an alternative sequestrant, using loperamide, or a low-fat diet.30 EXOCRINE PANCREATIC INSUFFICIENCY

This condition can cause symptoms such as diarrhoea, steatorrhea and weight loss, due to impairment of pancreatic enzymes and bicarbonate secretion. Symptoms usually develop when secretion of lipase and other pancreatic enzymes are reduced to less than 10% of normal values31 and, therefore, steatorrhea can be a late onset symptom and pancreatic secretion may have already reduced significantly prior to the presentation of symptoms.32 Patients may also develop micronutrient deficiencies and deficiencies of lipid-soluble vitamins.33 Exocrine pancreatic insufficiency can be related to chronic pancreatitis, pancreatic carcinoma, pancreatic surgery, or by upper gastrointestinal surgery.34 Some evidence also suggests it may be present in patients with diabetes,35,36 IBD37 and coeliac disease.38 Pancreatic enzyme replacement therapy is the main treatment for exocrine pancreatic

insufficiency. Many patients who have exocrine pancreatic insufficiency as a result of chronic pancreatitis suffer from malnutrition, so nutrition counselling is a vital part of treatment.39 COELIAC DISEASE

Although coeliac serology should be undertaken prior to a patient being diagnosed with IBS, it is estimated that 6-22% of all diagnosed cases have negative serology.40,41 NICE guidance states that, ‘those with negative serological test results are referred to a gastrointestinal specialist for further assessment if coeliac disease is still clinically suspected’.42 In addition to this, some patients have not been eating gluten at the time of serological testing, which may produce false negative results. Those at increased risk of coeliac disease include first-degree relatives43 and those with autoimmune conditions such as Type 1 diabetes and thyroid disorders.44 Classic symptoms such as diarrhoea and weight loss are often investigated,45 but other symptoms, such as fatigue, headaches and neurological conditions, are often overlooked.46 NON-COELIAC WHEAT OR GLUTEN SENSITIVITY

Several components of wheat are thought to be involved in this condition47 and individuals may suffer with diarrhoea, abdominal pain and bloating,48 as well as headaches and a foggy mind.49 There are no biomarkers to diagnose this condition, but obviously it is important to rule out coeliac disease and wheat allergy.44 It is unclear whether it is the removal of gluten in the diet that may result in symptom improvement or whether it is because a glutenfree diet reduces fructan intake and other components, such as wheat amylase trypsin inhibitors.50 CONCLUSION

Although patients are often referred with a diagnosis of IBS, many other conditions with similar symptoms are not ruled out as first line. Therefore, it is important to be aware of other conditions in order to make an evidencebased decision on whether dietary treatment is appropriate, or whether onward referrals/ investigations are needed. www.NHDmag.com April 2021 - Issue 162

DIET & LIFESTYLE

Priya Tew RD Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, and private patient work. www.dietitianuk.co.uk DietitianUK Priya_Tew Priya_Tew

SOCIAL MEDIA MYTHS Social media is always buzzing with diets, weight loss advice and exercise programmes. As nutritional professionals, we need to stay on top of the latest trends and shout out nutritional common sense. This article aims to debunk some of the myths surrounding those all-too-familiar fad diets. JUICING, GREEN SMOOTHIES, CELERY JUICE AND JUICE PLUS There are so many ‘green’ smoothie and juice recipes on Instagram right now, all selling weight loss. Whilst I have nothing against juicing a mound of kale, this isn’t teaching a sustainable way to eat. Programmes such as Juice Plus or ‘green powders’, sell the idea that all you have to do to be healthy is have one magical drink a day. Whereas, as we all know, the rest of the day counts too. I think we can all agree that juicing as a diet fix is going to give short-term weight loss but no long-term gains. Can these products be used as part of a healthy way to eat? I’d say yes, but are they necessary? No. Eating your fruit and vegetables would be far more beneficial and cheaper. Pros: A quick way to get extra fruit and vegetables into someone’s diet. Cons: Expensive powders and juicing alone will not result in long-lasting results. VEGANUARY Always a huge campaign, which certainly has plus points. It is great to see people trying out new foods, being inventive with meat-free meals and choosing more sustainable options. However, whilst some people will plan, research and use this as an opportunity to find a new way of eating, for others it is another detox fad. As nutrition professionals I think we need to be educating the public on the nutritional pitfalls, so veganism is not seen as an easy choice of just not eating animal products. Top nutrients to ensure you get enough of include calcium, iron, omega-3, protein and iodine. Supplements will be needed for B12 and vitamin D and, potentially, for omega-3 too. Eating vegan foods requires planning, meal prep and commitment. Many of the shop-bought convenience products are higher in fat, sugar and salt, so are not suitable for everyday eating. Pros: Encourages more sustainable eating and more plant foods. Cons: Can be oversimplified and lead to an unbalanced diet. LEMON WATER Lemon water has been around the block a few times and, thanks to the wellness bloggers, it’s back. Claims are it can kickstart your metabolism and digestion, aid weight loss, wake up your liver, detox your body and boost immunity. Obviously, those claims are not correct. Whilst it does contain some vitamin C and will hydrate you, the citric acid can degrade your tooth enamel and there are plenty of ways to get your vitamin C without damaging your teeth. Like most things, if you like it, drink it responsibly, not daily – and know it is not a magical cure. Pros: Hydration Cons: Damage to the teeth and does not do what it claims.

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DIET & LIFESTYLE COVID-19 DIETS There is so much out there about how to eat to either protect us from COVID-19 by boosting our immune system, or to help with recovery. (See NHD February, issue 160 for more on nutrition and the immune system.) A lot of this is anecdotal evidence shared on Facebook group pages and there are certainly companies looking to profit from this. Things like detoxing, or taking mega doses of supplements, or even restricting your diet, are not likely to help and could be harmful. Vitamin D and probiotics are areas with some research, but right now the emphasis needs to be on a really well-balanced diet with vitamin D supplementation. Long COVID has been linked to Mast Cell Activation Syndrome, with lots of talk about the role of a lowhistamine diet (see NHD March, issue 161). We do not yet have research to support this, but it may well help and is definitely something to look into. Pros: It is great that people want to focus on nutrition as a way to heal their bodies and look after themselves. It could lead to a focus on balanced eating, more fruit and veg, wholegrains and generally eating well. Cons: This also leads to marketing unresearched ‘remedies’ and anecdotal information being shared. Fearmongering is rife and people will try anything. INTUITIVE FASTING One of the latest new trends to be endorsed by Goop and Gwyneth Paltrow, this is anything but intuitive. The diet takes you through a process of trying different fasting time periods, starting with 12 hours (7pm-7am) then 14-18 hours of fasting, followed by 22-24 hours, every other day. I think we can see why weight loss occurs! Then it is back to the 12-hour fasting, with an idea that this process has helped develop your metabolic flexibility and resilience. This is being sold as combining intuitive eating with intermittent fasting and a keto diet. As apparent as it may be that this is the latest fad diet, it will nevertheless be tried and believed by many. For more on the clinical side of intuitive eating in relation to Type 1 diabetes, read the article in NHD March, issue 161. Pros: Nope, none. Cons: This is anything but intuitive eating! It involves a restrictive diet with fasting, cleverly packaged up to try and ride on the coat-tails of intuitive eating. MAGIC COFFEE A new to me weight loss product, this is a coffee that claims to shut off the cravings and metabolise fat to energy, helping you lose weight. It includes coffee, green tea extract and extra caffeine, so that’s caffeine with caffeine and caffeine! A definite marketing product that will not work.

Pros: It will wake you up! Cons: Expensive sales ploy. MEAL REPLACEMENT SCHEMES People are looking for ease and the “your meal is in a box” schemes deliver just that. These certainly can have their uses, but surely need to be used alongside professional advice and support, or it will turn into a yo-yo diet situation. Pros: Could help in the short term. Cons: Expensive, not sustainable and could trigger disordered eating in some people. VOLUMETRIC DIET This is a weight-loss diet where you focus on eating low-calorie, high-water foods such as soup, fruit, veggies, jelly and low-fat yoghurt both with no added sugar. Nuts, seeds and oils are frowned upon. Foods are categorised on density, dividing the calories in a food-per-serving size by the weight in grammes. 1400kcals is the starting point and 30 to 60 minutes of exercise a day is encouraged. Pros: Nope, none! Cons: A definite restrictive way of eating that reinforces diet culture and can’t be sustained long term. www.NHDmag.com April 2021 - Issue 162

DIET & LIFESTYLE THE DASH DIET Set to be a big one for 2021, this is already trending on Instagram, as it is hugely popular in the USA, ranked Best Diet Overall for several years now by the US media company News and World Report. The DASH diet (Dietary Approaches to Stop Hypertension) is a lifestyle change to help treat high blood pressure and heart health. Based on large-scale research, it focuses on eating 10 portions of fruit and veggies, low-fat dairy, wholegrains, nuts, fish and less meat. Priya’s first book is on the Dash diet in which she explains the science behind why the diet is a way to be eating for life: www.dietitianuk.co.uk/dash-diet-book Pros: A way of eating that makes sense and has science to show us it works. Cons: It can feel overwhelming when you start out, so helping people plan and break it down into smaller steps is helpful. THE SIRTFOOD DIET Partially made famous by singer Adele, this diet is all about consuming foods high in polyphenols. The premise is that a small group of these foods, known as sirtfoods, can activate your sirtuin genes, leading to fat burning. Sirtfoods include certain fruit and vegetables, some nuts and seeds, a limited range of wholegrains, wine and tea. No food is off limits, however, so meat and fish are allowed within the calorie limits. Whilst this diet leads to you eating a high amount of plant foods, it restricts calories to 1000kcals for the first phase (three days) using green juices and one main meal, then to 1500kcals (for the next four days). So it is hardly surprising people lose weight... then it is onto the maintenance phase with three meals and green juice on the side. The diet has been put together by Aidan Goggins (Masters in Nutritional Medicine and a pharmacist) and Glen Matten (a nutritional therapist) who tried it on 40 people, testing their metabolic health as well as their body composition. Pros: Encourages plant foods and says no food is off limits. Cons: Restrictive calorie limits that are bound to lead to weight loss, but can the maintenance phase be followed long term? CONCLUSION As nutrition professionals, it is key we stay abreast of the latest trends in diets, dieting and the far-fetched nutrition claims floating around social media. Yes, it can be frustrating, but it is important for us to stay current in order to help and encourage people to debunk the myths, whilst highlighting any positives there might be.

A wealth of useful dietetic resources for all dietitians and nutritionists

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IMD WATCH

WORKING IN INHERITED METABOLIC DISEASES (IMDs) In this issue, IMD Watch turns the tables and shines the spotlight on the people who practice metabolic dietetics: who, what, where and more importantly why! Suzanne Ford RD Suzanne is a Metabolic Dietitian working with adults at North Bristol NHS Trust. She is Dietary Advisor to the National National Society of Phenylketonuria (NSPKU).

Members of the British Inherited Metabolic Diseases Group met (together, in real life!) in November 2019 to discuss projects and common interests.

I asked some enthusiastic and committed metabolic dietitians who work in a range of settings, why they chose this career path, how they came to do metabolics and what their job entails. Working with metabolic patients could involve the manipulation of carbohydrate, fat, or protein intakes and sometimes in various contexts of tube feeding, pregnancy, learning difficulties, supporting sporty lifestyles or just getting safely through a day at school. Often in metabolic disorders, there is no other treatment, only diet, so the work is intense and detailed – and the role of the dietitian is highly significant. People with inherited metabolic diseases (IMDs) are born with a defect in a metabolic pathway, which could be a deficient or less functioning enzyme, transporter protein, or cofactor. The defect could be complete, i.e. the genetic mutation leads to no enzyme activity. In contrast, some mutations

are milder, resulting in residual enzyme activity, so the biochemical pathway is compromised only occasionally, such as during metabolic stress. Knowledge of IMDs is relatively newly developed. Children and adults may be diagnosed through presentation with symptoms, whilst others are diagnosed through sibling screens and six disorders are diagnosed through the national universal newborn screening programme. Disorder rarity ranges from 1 in 10,000 to 1 in 1,000,000,000, or a disorder with less than 50 cases identified globally. IMD dietitians work closely with physicians and clinical chemists to treat, monitor and manage infants, children, adults, pregnant women and those with learning difficulties, to achieve the best outcomes. The variety in IMDs is wide as is the dietary treatment – from patients who are on complex regimens to those needing a simple vitamin cofactor or occasional glucose polymer use. www.NHDmag.com April 2021 - Issue 162

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IMD WATCH BARBARA COCHRANE, PAEDIATRIC METABOLIC DIETITIAN, IMD SCOTLAND, BASED AT ROYAL HOSPITAL FOR CHILDREN, GLASGOW

“Being a Paediatric Metabolic Dietitian is a privilege when you consider the impact you have on the lives of parents and children. Having drifted into the role almost by accident, I had been the person around when our metabolic dietitian retired, so this quickly became the job I had always wanted. “No day is the same. Most of my time is spent either at clinic or dealing with phone calls, discussing blood results or solving problems. Very rarely, there is nothing in the calendar that needs immediate attention, giving an opportunity to catch up on paperwork and those things on the to-do list. Inevitably though, this is the day that Newborn Screening call with a new diagnosis. Any frustration of having your “catch-up” day going out the window is tempered by the knowledge that what you are about to tell parents of their perfect new baby will change their lives forever. “Primarily, the skills needed in this role are listening and being able to give families your

time when they need it. The best part is knowing that your advice, support and knowledge will enable a baby who has been born with a potentially damaging inherited condition to grow and fulfil their potential. Many of the diets used in the management of IMD are complex and restrictive, but also a miracle. “Due to COVID-19, our day-to-day interaction with families has changed enormously. We have moved quickly to video consultations, meaning our families do not have to travel long distances to appointments and we also get to see children in the backdrop of their own homes. We are tentatively experimenting with online educational events; our IT skills are improving and working from home is becoming the norm. We realise that not everything we do has to be face to face, although this has its place. “New treatments may change our input, but at the end of the day, there will always be inherited disorders needing a Paediatric Metabolic Dietitian.”

CLARE DALE, METABOLIC DIETITIAN, ADULT INHERITED METABOLIC DISEASES SERVICE, UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST – WORKING IN TRANSITION AND RESEARCH

“The main aspects of my job include leading on transition of patients with IMD from Birmingham Children’s Hospital (BCH) to Queen Elizabeth (QE) Hospital (adult IMD service). This involves working closely with BCH IMD dietitians, particularly Catherine who leads on transition there. This takes the form of joint transition clinics on a monthly basis. With particularly complicated patients, I will work closely with their lead paediatric IMD dietitian and this may involve joint home and/or school visits to help both the patient to feel comfortable with aspects of the adult service and also for us to understand their particular needs as best as possible – to allow for as smooth a transition as possible. “Teenage patients are typically in transition with us for two years with the support of BCH as required, before they enter the adult IMD service. During this time our aim, where appropriate, is

to foster further independence of the teenager in taking responsibility for their own health. This can take varying steps and is always led by the patient and their family. “As well as transition, I work one day a week with the IMD research team – this is a new role and there is a lot to learn. We are currently involved with PKU gene therapy. Due to COVID-19, many of the other studies have been put on hold at present, but this looks to be a very interesting role for IMD dietetics at QE. The rest of my time is spent supporting my metabolic dietetic colleagues in caring for our IMD patients under QE Hospital services. “I fell into this job about three years ago, having been involved in renal dietetics for 20+ years previously, with a particular interest in home haemodialysis. I love home visits; seeing patients in their own environment seems to help my ability to support them as best as I can www.NHDmag.com April 2021 - Issue 162

IMD WATCH and to understand their particular challenges. Surprisingly, there are many similarities between my current job and my previous home haemodialysis role. “I don’t think there are any skills needed for this job that are particularly different to the skills all other dietitians have, such as the ability to listen and communicate well. I’m sure that having teenagers myself helps me empathise more with my transition patients and

their parents. I particularly love this part of my role, but all aspects are both super interesting and challenging – never dull! I miss doing home visits though, due to the current COVID climate. “In the future, I hope to continue to foster/ evolve our transition service and learn lots through the research role; but who knows what lasting effects the pandemic will have on how we work!”

LOUISE ROBERTSON, GALACTOSAEMIA SUPPORT GROUP (GSG) DIETITIAN AND NHD COLUMNIST

“Galactosaemia is a rare inborn error of carbohydrate metabolism. It is one of the IMDs that is not screened for in the UK, so it is usually diagnosed within the first few weeks of life when the infant develops a life-threatening illness (feeding difficulties, liver failure and bilateral cataracts). Once galactose has been removed from the diet, then symptoms quickly resolve. Unfortunately, despite a galactose restriction, some people develop longterm problems. “I have been an adult metabolic dietitian for nearly 12 years, a role that includes looking after adults with galactosaemia. I was invited to join the Medical Advisory Panel of the GSG around six years ago, then 2 years ago the previous dietitian was retiring so I applied for the job! My role as the GSG dietitian is to be a port of call for dietitians and healthcare professionals working with galactosaemia. I also produce

and update dietary literature, answer queries from members and promote galactosaemia awareness. “What skills do I need in my role? Most importantly, experience of the disorder I’m working with and a passion for translating clinical information into understandable literature for patients. I also find it advantageous that I perform the role alongside my NHS job, which is in the same field. “I really enjoy creating graphics, literature and social media posts for my work. I like the contrast of working from home on projects compared with the clinical patient work at the hospital. Social media is the way forward, so I would like to try and work on being more constant with social media posts on the GSG channels and start creating videos alongside the literature. Check out the blog page on the GSG website: www.galactosaemia.org and contact me at: louise@galactosaemia.org.”

SARAH RIPLEY, COUNTRY MANAGER FOR CAMBROOKE UK, SUPPLIERS OF PROTEIN SUBSTITUTES TO PATIENTS WITH PKU

“I have the responsibility for the day-to-day running of the business. This involves many varied duties such as developing the sales and marketing strategy, managing Cambrooke UK employees, stock management and ordering, liaising with dietitians and patients to explain the key features and benefits of the Cambrooke range of products and facilitating customer ordering. 40

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“I met the team from Cambrooke at the NSPKU conference in Cheltenham in March 2016, and was impressed with their innovative products and passion for improving the lives of PKU patients. The position of Country Manager UK had just been created and it offered an opportunity to use my dietetic knowledge and experience in a brand-new role. I was successful in my application and started in July 2016. “In my job, I need good listening and communication skills in a number of different

IMD WATCH areas, such as science, nutrition and business, as I speak to many different people with different specialities daily. A willingness to learn and the ability to problem solve whilst remaining calm are essential. “The role is so varied, as every day presents new challenges and learning opportunities. I love the interaction with patients at events, which links to my previous role as an Adult Metabolic Dietitian.

“The expansion of the UK team this year and the exciting acquisition of Nualtra by our parent company Ajinomoto, will allow the sharing of ideas and resources. Collaboration with the PKU community on existing projects has been very successful and this will continue in the future. Hopefully, the COVID-19 situation will be resolved and patient events will restart later this year, as these are important for the PKU community as a whole.”

END NOTE

What do metabolic dietitians have in common with each other? They are passionate about their work and our caseloads are growing. If you see metabolic jobs advertised in the future, please remember these first-hand accounts and know that this is one of the most fascinating and rewarding branches of clinical dietetics you could choose. I hope you enjoyed reading about some of our IMD dietitians. If you want to know more about IMDs, here are some useful links. www.bimdg.org.uk

In particular, ‘Temple’ tools which provide excellent introductory information on 20 different IMDs. Go to the homepage and choose Education/Temple.

www.metabolicsupportuk.org

www.nspku.org www.galactosaemia.org

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OPINION

CGR Cooke, ANutr CGR Cooke has qualifications in nutrition and a history in fitness, varying from coaching boxing to international marketing. www.cgrcooke.com cgr_cooke cgr_cooke

REFERENCES Please visit: nhdmag.com/ references.html

In cooke’s corner “Never trust a skinny chef.” One of those funny phrases touted by the classically-trained old-guard to showcase that a good chef must be overweight in order to demonstrate their love and passion for the art. Here, Charlie considers perceptions on perfection and asks whether nutrition professionals should be flaunting their flaws. “Never trust an unfit personal trainer” or “Never trust an overweight dietitian”? These surely must mean the opposite, i.e. no person adequately qualified and passionate about food, fitness and nutrition can be anything but the absolute personification of health perfection. This is the question I wish to discuss in this month’s issue: do we have to hide our flaws and demonstrate a perfectly fit physique in order to be seen as reliable sources of health information in the eyes of ourselves, our peers, our patients and the public? Now, let’s consider I was within an average range of 6.5% to 8% body fat in my time as a personal trainer and boxer, training two to four hours per day, consisting typically of two to three sessions. I had spent two years at university studying a nutrition sciences diploma and running an online health blog based around teaching the biochemistry and physiology of nutrition, alongside my studying of countless textbooks for my qualifications as a personal trainer. I then did another degree in nutrition while running a boxing fitness service, which required studying for my coaching certifications. All of the above, I hope, showcases a person with a keen knowledge, passion and pursuit of health and fitness. Yet why do I fight the feeling to this day, that all

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my qualifications and experience could be entirely disregarded by my clients if they ever knew that I occasionally drink and eat too much, or can be partial to a cigarette? I used to feel dishonest in not disclosing such behaviours, as although I truly understand my personal flaws to be completely understandable and reasonable, I would not reveal them for fear of being perceived as, “all talk without the ability to practice what he preaches”. But, as the public perception around health begins to shift, it makes me wonder whether we can showcase our own ‘bad’ habits to our patients, both in person and especially online as, yes, we all have flaws. HARMFUL HABITS TO HEALTH

If we are the know-it-all experts, why do we still participate in habits harmful to health? Well, according to research published back in 2008, the factors for following high-risk behaviours were listed by the Centre for Disease Control (CDC)1 as: • innate human defiance • need for social acceptance • inability to truly understand the nature of risk • individualistic view of the world and the ability to rationalise unhealthy habits • genetic predisposition to addiction

OPINION According to Dr Cindy Jardine, Assistant Professor of Rural Sociology at the University of Alberta in the US, who conducted this research: “The results showed that in fact, people have a very realistic understanding of the various risks in their lives. We, as risk communicators (scientists, academics, government agencies), have to get beyond the thought of ‘If they only understood the facts, they’d change’. They do understand the facts, but we need to look at other factors we haven’t been looking at before.”2 Here lies the balance of talking the talk and walking the walk; we know the information, but what factors have we not been looking at before? What if we struggle to follow these factors ourselves? WHAT DO OUR PATIENTS THINK?

A fantastic piece in Today’s Dietitian asked their reader base of RDs and RNs whether they believed they can be effective nutrition counsellors if they are overweight. The responses were, of course, mixed, though overwhelmingly in support of the idea that a person’s external appearance alone cannot be used as an accurate predictor of health or knowledge. This was a very insightful article demonstrating how we may be perceived by our peers – but what do our patients think? Research published in The International Journal of Obesity assessed 358 participants on their likelihood to adhere to medical advice by physicians of varying weight descriptions and found: “Respondents reported more mistrust of physicians who are overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physician was perceived to be overweight or obese.”4 I can understand why this was the case; almost four years ago my very first article for NHD was published: a review of ‘Big Fit Girl, Embrace the Body You Have’ by Louise Green.5 At the time there were large changes happening in the ‘plus-size’ movement and Louise Green was a figurehead for the ‘This Girl Can’ campaign running at the time.

HEALTH AT EVERY SIZE

Louise Green found popularity due to her status as a plus-size individual with a BMI of 35+ who still participated in regular exercise, proposed eating a balanced diet, worked with a personal trainer who didn’t focus on losing weight. She went onto become a trainer herself and became popular with clients for the very reason that she was “like them”. She owned what is considered, as discussed above, to be the base of rejecting an advisor and made it her USP. This continued rise of the plus-size movement was further demonstrated in the ‘This is Healthy’ tagline on the cover of Cosmopolitan back in January of this year, in which women of varying body shapes were featured to showcase that health is ‘not one size fits all’.6 Of course, this caused quite a media frenzy, intended or otherwise, about our considerations of bodyweight and shape in its relation to public health. So, if patients will reject obese physicians, then why is there such a rise in plus-size and diverse voices for health? And where does this leave us in finding a conclusion to whether we need to be perfect in the eyes of our patients? Yes, we are walking billboards, but we are also talking billboards, so although first impressions seemingly still do matter, we at least can have confidence in that as long as we are able to demonstrate control over our habits and own the fact that we are imperfect then the public are seemingly still all ears. Maybe we need to be a little more honest about all of the meals we post on social media, the number of glasses of wine of an evening, and that being an ex-smoker doesn’t mean you are to be avoided at all costs. We all follow incorrect behaviours. We all have vices. Everyone is aware. Perhaps it is our responsibility to own our dietary and fitness flaws in order to demonstrate to our patients and clients that health is more than how we suffer from dietary weaknesses and instead how we control and mitigate for them. As always, honesty is the best policy, and being real is far more relatable and reliable than always being right. www.NHDmag.com April 2021 - Issue 162

COMING IN THE MAY 2021 ISSUE: • • • • • • • •

Preterm infant feeding Enhanced recovery after surgery Types of dysphagia explained The immune system and nutrition Ketogenic diet therapy Community dietetics Mental health & depression Palliative care pathways

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F2F

FACE TO FACE Ursula meets: ELSIE WIDDOWSON Dietitian Nutrition researcher Apple lover

Time travel offers so many exciting insights and opportunities. The stinging post-travel headaches are awful, but worth it again for a chance to meet Elsie Widdowson. Bam! I was in the kitchen of her home, called Orchard House because the garden was nothing but a military parade of apple trees. Elsie made tea. “I have a big crop of apples this year and you are welcome to as many as you like,” she said. She completed her BSc in chemistry in 1928 and her doctorate in 1931 (on methods for measuring carbohydrates in apples). “Research jobs were difficult to come by and nobody wanted me. In any case, much as I enjoyed my time with the apples, I did not want to devote my life to plants. Somebody told me that Dietetics was the up-andcoming profession, and so I enrolled on the first postgraduate diploma course at King’s College of Household and Social Science under Professor Mottram.” The researcher, Dr McCance, came into the hospital kitchen and young Elsie plucked up the courage to speak to him. Mac had been researching the measurement of available carbohydrates in foods. But his description set off alarm bells in Elsie. “I realised from my experience with apples, that the figures in fruit were too low (because some of the fructose must have been destroyed during acid hydrolysis).” So, Mac spotted a bright young research assistant and got Elsie a grant from the Medical Research Council. “It

Ursula Arens

was easier to do in those days, than it is now,” Elsie said, commenting that the Dietetics course served her well. “It aroused my interest in nutrition and I spent six weeks in the diet kitchen at St Bart’s Hospital. At the time, the composition of patients’ diets was calculated from American tables, which gave values only for raw foods, and gave calculated rather than directly measured data. This convinced me that we badly needed comprehensive tables showing the composition of British foods.” The first edition of The Chemical Composition of Foods was published in 1940. There were 15,000 separate values that had to be rechecked many times; even so, a single mistake did creep through. A decimal point error gave blackcurrants a tenfold magnification of nitrogen content. “Certain people never let us forget that one!” But Elsie strongly advises: “Don’t be afraid of owning up to a mistake, even if your results have already been published. It is better than giving someone else the pleasure of correction.” With fresh accurate data on food composition, Elsie carried out dietary surveys. Data from more than 120 adults and 1000 children allowed detailed calculations of energy and nutrient intakes. “We were surprised by the large variation in the intake of energy and nutrients between one individual and another of the same sex and age.” Elsie and Mac moved to the Department of Medicine in Cambridge

Ursula has a degree in dietetics and currently works as a freelance writer in Nutrition and Dietetics She enjoys the gifts of Aspergers.

Our F2F interviews feature people who influence nutrition policies and practices in the UK.

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7 TH GLOBAL SYMPOSIUM

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25TH – 27TH MAY 2021 WE ARE PLANNING A COVID -19 SECURE EVENT PLEASE CHECK THE WEBSITE FOR DETAILS An advanced CPD course for new and refresher Ketogenic Dietary Therapy learning and networking For the full programme and registration details, please visit www.mfclinics.com/keto-college or to register your interest please email: ketocollege@mfclinics.com

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F2F

“I realised from my experience with apples, that the figures in fruit were too low (because some of the fructose must have been destroyed during acid hydrolysis).”

and did lots of self-experimentation studies looking at the metabolic effects of minimal diets, or white vs brown bread diets. “There was great camaraderie and competition between researchers. Who could get most energy proportion from bread? (always Mac, at over 90% energy vs others at 80%.) Who could get carmine marker through our bodies the quickest? It was funny to be able to recognise the faeces of colleagues.” The bread metabolism studies led to UK fortification regulations requiring the addition of calcium and vitamins to breads, which are still in place today. Elsie and Mac advised the Ministry of Food on rationing, and after the War, they went to Germany to study undernutrition. Elsie led a study looking at five different kinds of bread fed to stunted underweight orphans. Bread provided 75% of energy for 18 months. “All the children improved physically, and it was impossible for the outsider to tell which kind of bread the child had eaten.” Another orphan study provided confusing and alarming outcomes. Extra bread with margarine and jam was given to children in one orphanage whilst only the basic rations at another. After six months there was a swap, with basic rations vs the extra allowance. The astonishing outcome was greater weight gains in the basic rations’ groups. Food intakes were tightly monitored by a dietitian, so there could not have been more or less foods consumed. Only a chance observation that a most unkind and unpleasant housemother had been in the extra foods home first, and then switched homes when the extra foods system switched, gave clue to the mystery. “We concluded that unkindness and unhappiness could delay growth in children in spite of extra food. We

showed the importance of tender loving care. So advice to researchers is, if your results seem impossible, think and think again.” “I have always had a great interest in growth, and the similarities and differences between species,” said Elsie. Human infants are exceptionally fat (16%) at birth: only the guinea pig and seal pup come close. In 1968, Elsie moved to the Dunn Nutrition Laboratory and became head of the Infant Nutrition Research division. Many subsequent improvements in the formulation of infant milks link directly to her research and observations. Parallel to Elsie’s academic and research activities, she has always been active in professional groups. She was President of the Nutrition Society, the British Nutrition Foundation and the Neonatal Society. And in 1993, she received the highest UK recognition for national achievement: the Companion of Honour award. But there is a common thread to observations made about Elsie, beyond her intellectual sharpness and scientific curiosity. She was always supportive of younger researchers: inspiring in her ideas and pragmatic in her help. The word everyone who knew her uses is “kind”. As I leave Elsie, I take some of the apples from the bowl on her kitchen table. I wished I could have given her the apple (computer) on mine: she would have loved the deep dives into the exploding feast of science data that we have all become so addicted to. Elsie with pen and paper was great. But Elsie with the internet would have been amazing! Many thanks, again and again, to Margaret Ashwell, for Elsie gossip. Her book is excellent: McCance & Widdowson; A Scientific Partnership of 60 Years (British Nutrition Foundation). www.NHDmag.com April 2021 - Issue 162

A DAY IN THE LIVE OF . . .

Danielle Timmins Student Danielle is a fourth-year Nutrition and Dietetics student studying at the University of Chester. She is interested in clinical research and promoting diversity and inclusion in dietetics. Dieteticswithdanni Dannitimmins

A STUDENT DIETITIAN ON PLACEMENT: ACUTE AND COMMUNITY I am currently on week four out of 12 of my final placement, which is split between two hospitals in Lancashire. So far, I am loving the experience of being on C placement, as my clinical knowledge and practical skills are finally coming together! Every student has a different placement experience and will work in different areas of dietetics across acute and community settings. This makes it hard to capture the entire student experience in one day, but in this Day in the Life column, I describe a typical day for me in an acute and a community setting. ACUTE HOSPITAL PLACEMENT

I spend three days per week at one hospital, mainly seeing patients on the wards and doing a telephone paediatric clinic. Typically, placement hours will be 8am-4pm or 9am-5pm Monday to Friday for students, so it is a full-time commitment. I get my uniform ready in a bag to take to work as we now change into our uniforms at the hospital to follow new infection control guidelines. I walk to the hospital along the canal with a travel mug of tea. I definitely appreciate the shorter commuting time at this placement. During my B placement, the commute was around 90 minutes each way, including driving, taking the train and walking, which was quite draining.

8.00 am – Paediatrics clinic

One morning per week I do a telephone clinic for paediatrics with my supervisor. Although this was the subject area I knew least about when beginning my

www.NHDmag.com April 2021 - Issue 162

placement, I am enjoying it so much. I start the morning by reading the referral details of the patients who are due in for the morning’s clinic. I start filling in the consultation templates with any information available (height, weight, past medical history, medications and biochemistry). However, the amount of information available for some patients can be quite limited, which means you have to gather this information from speaking to the patient or their parent. There are about six or seven patients to ring for each clinic. Each call is completely different and could be anything from suspected allergies in infants to weight management in adolescents. Today’s patients include infants and toddlers who are experiencing common symptoms of non-IgE cow’s milk protein allergy or allergies to multiple foods and one adolescent who needs weight management and healthy eating advice.

12.30 pm – Wards On a Monday after lunch, I join the dietitians to look at the referrals list and allocate patients to see. This Monday I review three patients. The first patient is at risk of refeeding syndrome due to a low BMI, negligible intake and a history of drug and alcohol use, with additional factors

A DAY IN THE LIFE OF . . .

I love e-learning webinars and think they’re a great way to learn about different areas of dietetics from experts. to consider such as upper gastrointestinal bleeding. The second patient needs nutrition support advice due to chemotherapy-induced taste changes and mouth pain. The third review patient has had a stroke and is nil by mouth. Based on the doctor’s recommendations, I put together an enteral feeding regime that meets the patient’s energy and protein requirements. I spend part of the afternoon reading through the medical notes system, looking at GP records, biochemistry results, anthropometric data, referral information and ward notes. Then, after preparing a form with all the information needed, I head up to the wards and speak to nurses and healthcare assistants to get additional information about patient intakes. Before heading back to finish writing up the plan onto the medical notes, I hand over any important details or changes to the nursing staff, or write this onto the online handover sheets for staff to see. After seeing the patients with my list of questions prepped, it’s time to write up the assessments in full onto the electronic patient notes system and discuss the patients with my supervisors.

4.00 pm – Heading home 7.00 pm – Online webinar e-learning I love e-learning webinars and think they’re a great way to learn about different areas of dietetics from experts. It is also something you can reflect on whilst you are on placement, so I try to watch online webinars whenever they are available. COMMUNITY HOSPITAL PLACEMENT

8.30 am – Telephone clinics

Due to the current infection control measures, our outpatient clinics are held via telephone. This is my first experience of these and I find it surprisingly difficult to begin with. There is no non-verbal communication, so it is important to focus on tone of voice and make sure that you are speaking slowly and clearly, especially for patients with hearing difficulties.

The experience I have had so far with community dietetics has been diverse and exciting, with every day bringing new challenges and learning opportunities. I am currently dealing with around four patients in the telephone clinic per day, but as I am only part way through my placement, I hope by the end I will be seeing more. The clinics can vary massively in topic. So far, I have seen patients with diabetes looking to manage their blood sugars, patients with IBS who needed advice on symptom management and patients at home and in care homes who lost weight and needed nutrition support. Although you may get referred for one specific reason, I have quickly found that what the patient is referred for is not always the main priority of the appointment. Speaking to a patient allows you to find out about their main concerns.

12.30 pm – Telephone clinic continues

After lunch, the first patient I speak to has Type 2 diabetes and IBS and wants advice on managing both conditions simultaneously. I find this consultation quite tricky, as some of the advice for managing Type 2 diabetes contradicts that for managing symptoms of IBS. However, this is a great appointment to reflect on and I learn a lot from it. The next appointment involves giving weight management advice and revolves around discussing patient expectations, identifying motivations and choosing achievable goals to focus on before the next review appointment. In the final appointment of the afternoon, I shadow the dietitian, as this is a specialist subject, giving advice to someone who is struggling with undiagnosed dysphagia. At the end of the day’s clinic, I try to make sure all the notes are written up and uploaded onto the notes system, letters are sent to GPs, outcomes are documented and information leaflets are posted. I try to refresh my knowledge by reading up on conditions and their treatment pathways for the patients I am seeing in the next www.NHDmag.com April 2021 - Issue 162

A DAY IN THE LIFE OF . . . day’s clinic. This helps me to feel more confident when tailoring nutritional care plans, as I then have treatment options fresh in my mind. There are also lots of forms to fill out, including daily and weekly feedback forms, observation forms, witness statements and reflections to consider, alongside seeing patients to make sure you are documenting your progress throughout placement.

4.30 pm – Time to head home! Every day I try to go for a short walk on the beach or in the local park (even when it’s cold!), as I find it’s really important to relax during evenings and weekends to avoid burning out. 8.00 pm – Additional work

If I have spare time and energy in the evening, I will do some work towards my portfolio, such as adding to my index of evidence and

the competencies these are meeting. I currently have a presentation to work on too. This is a malnutrition and food fortification education session, which I am planning to deliver to a group of carers who work at a local care home. This is such a great opportunity to talk about the importance of nutrition and simple ways to support patients’ intakes. When I complete this, it will also contribute to my teaching competencies, which I am very excited about, as I love public speaking. This Day in the Life is just a snippet of my own experience on placement, but every day is different and every student has a slightly different placement experience, as dietetics is such a diverse and interesting career pathway. Learning in acute and community settings and across lots of different conditions is challenging, but I am learning so much and can’t wait to see what the next eight weeks bring.

EVENTS & COURSES RECIPE ANALYSIS: MAXIMISING ACCURACY ON BEHALF OF NUTRITION AND WELLBEING, SUSAN CHURCH 23rd April - Central London

susan@susanchurchnutrition.co.uk Tel: 07719 381949 www.susanchurchnutrition.co.uk/recipeanalysis-training NICE ANNUAL CONFERENCE 13th May - Hilton Manchester Deansgate

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10TH ERAS UK CONFERENCE: OPTIMISING CARE AFTER TREATMENT 21st May - Leeds

www.erasuk.net/10th-eras-uk-conference.html KETOCOLLEGE 2021 - For medical Ketogenic Dietary Therapy CPD learning and networking 25th to 27th May - Crowne Plaza, East Grinstead

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TO NICHE OR NOT TO NICHE? Using social media can be a great tool to get yourself known and to grow your business. One of the ways to grow your account is to ‘niche down’ into one specialist subject. Some of the successful dietitians on social media have specialised in particular fields, enabling them to grow their Instagram following. For example, Megan Rossi (@theguthealthdoctor) specialises in gut health, Kirsten Jackson (@the.ibsdietitian) in IBS, Paula Hallam (@tinytotsnutrition) in cow’s milk protein allergy, and Sarah Almond Bushell (@thechildrensnutritionist) in weaning and fussy eating. To learn more about this, I had a chat with Sarah Almond Bushell, experienced paediatric dietitian, business mentor and coach. Sarah has created such a successful online business that she has now set up a dietitians’ mastermind to help other nutritional professionals grow their online businesses. I asked Sarah what ‘niching’ was and if we should all be doing it. 1 What is ‘niching down’? Niching is being a specialist in one subject and setting yourself up as a leader in that field. It’s important if you want to grow your social media account and then go onto make money. You should aim to be seen as ‘the expert’. For example, if a parent is looking for help with fussy eating, then they are more likely to seek the help of a specialist dietitian in fussy eating rather than a general paediatric dietitian. 2 Why is niching important? If you have more of a general nutrition or dietetic social media account then you will attract other nutrition professionals, and that’s fine if that’s your intention. If you are running a

Louise Robertson RD

business, however, you need to get to know your ideal customer and write as if you are speaking directly to them. If you don’t do this, then you are not resonating with anyone and only likeminded people will look at your content (i.e. other nutrition professionals). 3 How do you find what speaks to the ideal customer in your niche? Do your research first. For example, you could join a variety of Facebook groups on the topic you want to specialise in and see what people are chatting about. Are the same questions coming up? You could also look at book reviews in your specialism online, check the 3-star or below reviews and see what people think is missing.

Louise is an experienced NHS dietitian who specialises in the fascinating area of inherited metabolic disorders in adults. 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

4 Is niching too restrictive? Don’t be frightened of choosing a niche. People worry they will be deskilled, but often this is the opposite. Once you become known as the go-to expert, people often come to you with other questions. Make sure you choose something you love as your specialism, as you will be talking about it all the time! 5 Is niching important for NHS dietitians as well? Yes, as it promotes you as a specialist and a leader in your field. You may find opportunities arise from this. If it is your specialist field then you should have the knowledge and papers at your fingertips! For more useful tips, go and check Sarah out on Instagram: @dietitiansinbusiness. www.NHDmag.com April 2021 - Issue 162

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ONLY NEOCATE SYNEO CONTAINS SYNBIOTICS, BRINGING IT CLOSER TO BREAST MILK THAN ANY OTHER AAF 1 • Restores gut microbiota,1-3 supporting long-term health and immunity4,5 • Research shows that infants exhibit a reduction in infections as well as antibiotic use1-3 10 YEARS OF RESEARCH IN INFANTS WITH CMA HAVE GONE INTO EVERY TIN 1. Candy et al. Pediatr Res. 2018;83(3):677-86. 2. Fox et al. Clin Transl Allergy. 2019;9:5. 3. Burks et al. Ped Allergy Immunol. 2015;26:316-22. 4. Martin R et al. Benef Microbes. 2010;1(4):367-82. 5. Wopereis H et al. Pediatr Allergy Immunol. 2014;25:428-38. 6. Harvey BM et al. Pediatr Res. 2014;75:343-51.

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