NHD Magazine March 2026 Issue

Network Health Dietitians

The magazine for dietitians, nutritionists and healthcare professionals

Evidence & guidance Weaning

Tailored strategies for diabetes patients

Managing IBS-C in practice

Spotlight on ketogenic diet therapy

Expert-led nutritional care for Lionel, when it mattered most

The UK’s No.1 preterm formula with the widest, most nutritionally tailored range1,2

Promotes feeding tolerance and helps reduce infection risk3-5*

Aligned with ESPGHAN principles on neonatal nutrition6

Nutriprem HMF supports breastfeeding during early infancy7†

Halal & Kosher

Scan the QR code to learn more about the Nutriprem range

60 years of partnership in preterm care

*Nutriprem 1 & 2 are the only preterm formulas in the UK to contain prebiotic oligosaccharides2 which have been shown to reduce the risk of infection4,5

†Nutriprem Human Milk Fortifier supports preterm infant growth and preserves breastfeeding during early infancy7

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. Nutriprem Human Milk Fortifier and Protein Supplement are not suitable for use as the sole source of nutrition. Refer to label for details.

1. IQVIA data, December 2025, Moving Annual Total (MAT), volume preterm market share (UK). 2. MIMS online. Available at www.mims.co.uk (accessed February 2026). 3. Modi, et al. Pediatr Res. 2010;68(5):440-5. 4. Arslanoglu, et al. J Nutr. 2007;137(11):2420-4. 5. Bruzzese, et al. Clin Nutr. 2009;28(2):156-61. 6. Embleton, et al. J Pediatr Gastroenterol Nutr. 2023;76(2):248-68. 7. Delsoglio, et al. J Neonatol Clin Pediatr. 2024;11(3):128.

HMF: Human Milk Fortifier; ESPGHAN: European Society for Paediatric, Gastroenterology, Hepatology and Nutrition.

Accurate at time of publication: February 2026 ©Nutricia 2026

2

Patient images shown are of real patients, using photographs of themselves as preterm infants

Weaning: evidence and best practice

Blended diet in enteral nutrition

Are calories in or out?

and hydration

Tailored strategies for diabetes patients

IBS-C in practice

FOOD FOR THOUGHT 22 The new era of disordered eating NUTRITION MANAGEMENT

Ketogenic diet therapy

DIET & LIFESTYLE 29 Nourishing longevity

STUDENT ARTICLE

Relative energy deficiency in sport SKILLS & DEVELOPMENT 35 Helping students on placement

LAST WORD 38 Ramadan and eating disorders

All references can be accessed here: www.NHDmag.co.uk/article-references.html

Copyright 2026. 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 publisher@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

Editor Emma Coates RD

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Up front

Navigating modern weaning

New UK recommendations, inequality concerns and industry change

Weaning is a significant developmental step for baby and parent, and the last year has seen important updates in this area. Our cover story this month takes a close look at the current evidence for infant weaning practices in the UK; Barira Saad, RD, examines the NHS and NICE guidelines, along with BDA and WHO recommendations, and highlights the key take-home points.

The move from milk to solid foods ensures that nutritional intake remains adequate for growth and development. It is also the start of a great journey in learning essential eating skills, developing independence and can establish healthy long-term eating habits. Introducing new foods during weaning may help reduce the risk of allergies, while also allowing parents to gradually adjust feeding routines.

Over the past 12 months there have been notable updates and developments in infant feeding guidance, recommendations and information. The new guidance includes detailed recommendations for infants under one year old, including timing and approaches to introducing solids. Early years settings will be required to consider this guidance. It is expected that the guidance will promote positive eating habits and emphasise the importance of these on shaping future eating habits and longterm health. The guidance also aims to reduce health inequalities, ensuring that all children have access to nutritious food.

A new study1 highlights that UK parents face food insecurity, struggle with formula affordability and have inconsistent feeding support. The research shows that parents/carers are going without food to ensure infants are fed. Whilst families and/or third sector organisations often provide

financial and practical support for new parents living on a low income, many report experiencing stigma or embarrassment when seeking help.

It was also found that there are limited opportunities to discuss issues and concerns regarding finances or infant formula with healthcare professionals. Socioeconomic barriers affecting weaning readiness, feeding choices and access to food have a long-term impact on health, with the prevalence of obesity being higher in children in the most deprived areas.

In England, the Better Health Start for Life weaning campaign from the Office for Health Improvement and Disparities was launched to promote NHS-aligned weaning advice. Survey data triggered the campaign, with 40% of first-time mothers introducing solids before the NHS-recommended six months and 64% receiving conflicting information about when to start weaning.

guidance is aimed at reducing early childhood overweight and obesity rates.

In another effort to tackle obesity, the UK government published voluntary industry guidelines in August 2025, which aim to reduce sugar and salt in foods marketed for babies and young children up to 36 months.

Manufacturers have 18 months to reformulate products and update labels. The beneficial implications for consumers include clearer labelling to support healthier choices of first foods and less misleading marketing claims. This move aligns with NHS recommendations for a varied, low-salt, low-sugar weaning diet. Obesity and infant feeding organisations have welcomed the change, seeing it as a step in the right direction, but further reform will certainly be welcomed in the future, with the hope that the guidance will shift from voluntary to mandatory. The true impact of this change remains to be seen, but it’s anticipated that it will start to reshape baby food aisles over the next couple of years.

The campaign advises on the signs and signals for when a baby is ready for solids and provides an NHS weaning hub containing over 120 recipes. The Emma

Thanks as always for joining us and enjoy the read.

Emma Coates RD & NHD Editor

Nutrition in the news

Karen Voas-Wootton’s digest of nutrition news with clinical relevance

Small sodium cuts lead to big heart-health gains

Modest, population-wide reductions in sodium in commonly eaten foods could translate into substantial cardiovascular benefits without requiring consumers to change their eating habits, says research in the journal Hypertension.1,2

In France, researchers evaluated national targets to lower salt in baguettes and other breads – a major contributor to daily intake. Full compliance could reduce average salt consumption by 0.35g per person per day and prevent an estimated 1186 deaths annually, alongside measurable falls in hospitalisations for ischaemic heart disease and stroke.

Men received the greatest benefits across all age groups, with 0.87% of heart disease and stroke prevented among men (compared with 0.63% in women). Among women, the avoidable proportion is highest

Takeaways top self-reward and comfort choices

Ordering a takeaway is a popular form of ‘self-gifting’ after both good and bad days at work, reveals a study in Frontiers in Psychology, 3 with potential implications for dietary health. Led by researchers at Anglia Ruskin University, the study asked 280 adults in the UK to imagine different workday scenarios and choose between several treats, including alcohol, chocolate, a bubble bath, online shopping or a takeaway.

The results reveal that participants imagining a bad day at work were significantly more likely to treat themselves to takeaway food, an alcoholic drink, a bubble bath or

a chocolate bar compared with people imagining an average day at work. Ordering a takeaway meal, however, was the only self-gifting treat that satisfied both a motivation to selfreward after a good day at work and self-console after a bad day.

“Some options in our study provide clear benefits for self-care, but others carry health risks,” warns co-lead author of the study, Dr Suzanna Forwood. “Consuming takeaways, chocolate bars and alcoholic drinks increases our intake of calories, sugar, salt and alcohol – all of which contribute to health challenges.”

in those aged 55 to 64 years.

A parallel UK analysis focused on 2024 reformulation goals for packaged and takeaway foods across more than 100 categories. Meeting these targets could cut salt intake by 17.5%, potentially preventing around 103,000 cases of ischaemic heart disease and 25,000 strokes over 20 years, while generating major gains in quality-adjusted life years and savings for the NHS.

For dietitians and nutrition professionals, the findings reinforce the impact of food-system approaches alongside individual counselling. Researchers emphasised that coordinated action between policymakers, manufacturers and health services is crucial to achieving meaningful, sustained sodium reductions and lowering population blood pressure levels worldwide.

Karen Voas-Wootton

RD

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Alzheimer’s disease: the gut’s hidden role

Emerging research challenges the longheld view that Alzheimer’s disease is confined to the brain, with new evidence suggesting that changes in the gut may play a significant role in the condition’s development. A new study in the journal Alzheimer’s & Dementia analysed colon tissue from people with Alzheimer’s and found striking differences in immune activity, metabolism and microbial communities compared with those without cognitive impairment.4

Unlike most previous human studies, which relied on stool samples, the team examined gut tissue collected at autopsy, allowing closer inspection of microbes and proteins interacting within the intestinal wall. People with Alzheimer’s showed weaker gut immune defences, reduced stress-protection proteins and altered metabolic pathways linked to fat breakdown and insulin signalling –changes that hint at wider, whole-body disruption.

Notably, proteins involved in nerve signalling were reduced in the gut’s enteric nervous system, potentially explaining why gastrointestinal symptoms can precede memory problems. Higher levels of amyloid-beta 42, a hallmark Alzheimer’s protein, were also detected in colon tissue. Distinct shifts in the microbiome were linked to disease severity, reinforcing interest in gut–brain pathways.

For nutrition professionals, the findings highlight growing interest in dietary strategies and microbiome-targeted interventions as possible tools for future prevention, diagnosis and management.

Plant-forward diet is good for the kidneys

A large UK Biobank study has found that following a plant-forward diet, such as the EAT-Lancet Planetary Health Diet, is linked to a lower risk of chronic kidney disease.5 Among 179,508 adults tracked over 12 years, greater adherence to the diet – which emphasises fruits, vegetables, legumes, nuts, moderate meat and dairy, and limits added sugars and fats – was associated with reduced CKD incidence. Protective effects were particularly strong in individuals with low green-space exposure or certain genetic profiles. The findings highlight the potential of sustainable, plant-forward diets to support kidney health and reduce future CKD risk.

NICE update streamlines weight management

NICE has updated its guidelines on overweight and obesity, incorporating the latest evidence on assessment, treatment and service delivery, while emphasising a streamlined, personalised approach for children, young people and adults (excluding pregnancy).6

KEY UPDATES

Central adiposity: Waist-to-height ratios are now clarified as a tool for assessing central adiposity in children aged five and above. This helps identify those at higher cardiometabolic risk and tailor interventions more accurately.

Anti-obesity medications: Adults with a BMI of ≥35 kg/m² and at least one related comorbidity can now be offered pharmacological treatment alongside lifestyle interventions. This integrates medication as part of a structured, multidisciplinary care plan.

Digital tools: NICE encourages full use of digital technology to deliver weight management services. Remote consultations, digital monitoring and online behavioural support are recommended to make care more flexible and patient-centred.

The update reinforces personalised, evidence-based interventions. Clinicians are now better supported to offer integrated care – combining lifestyle, medication and digital tools – for sustainable weight management.

Dietary implications of infant weaning

Current evidence and best practice

Infant weaning affects long-term health outcomes, making the clinician’s role vital in guiding families through this key stage of development. This article examines the current evidence for infant weaning practices in the UK, drawing on NHS and NICE guidelines and BDA and WHO recommendations.

In the UK, weaning is the introduction of solid foods into an infant's diet, although it is more accurately termed 'complementary feeding' internationally.1 WHO defines this as the process of introducing foods and liquids alongside breast or infant formula when milk alone is no longer sufficient to meet nutritional requirements.

OPTIMAL TIMING FOR INTRODUCTION OF SOLIDS

Current UK guidance advises exclusive breastfeeding for around the first six months, with the introduction of solid foods from six months and not before four months, alongside continued breastfeeding for as long as desired.2-4 Parents should be educated about three signs that indicate readiness for solid foods that typically appear around six months of age:

1. Postural control – The infant can sit upright in a supported position and hold their head steady.

2. Hand-eye-mouth coordination –The infant looks at food, picks it up and brings it to their mouth.

3. Swallowing ability – The infant can swallow food rather than automatically pushing it out with their tongue.

It is crucial to help parents distinguish between genuine readiness signs and behaviours commonly misinterpreted as hunger for solid foods. These behaviours, which include increased night waking, fist chewing or wanting more frequent

milk feeds, are normal developmental behaviours in infants under six months and are better addressed by offering additional milk feeds.2

NUTRITIONAL CONSIDERATIONS AND FOOD GROUPS

Once weaning begins, families should be encouraged to offer a variety of foods from the four main food groups, as this is crucial for nutritional adequacy and the development of food acceptance patterns. 5,6

Starchy carbohydrates – Include potatoes, sweet potatoes, rice, pasta, bread and other cereals for energy and dietary fibre.

Fruit and vegetables – A wide variety should be offered, including vegetables with bitter flavours (broccoli, spinach, cauliflower, green beans) from the outset. Early and repeated exposure to vegetables during the complementary feeding period increases vegetable acceptance in infancy.7

Dairy products – Full-fat dairy products are appropriate from six months. Cow's milk can be used in cooking but should not replace breast milk or infant formula as the main drink until 12 months.⁵ Protein sources – Offer a variety of protein-rich foods. This is especially important from around six months, when infants’ iron stores start to decline and requirements for iron and zinc increase.8

THE CRITICAL ROLE OF IRON

Adequate iron intake is essential for a baby’s brain development. From around six months, iron requirements rise – particularly for breastfed infants – so it’s important to provide ironrich foods to support rapid growth and prevent iron deficiency anaemia. Key sources of iron include:

• Red meat, poultry, fish

• Eggs

Barira Saad RD

• Pulses, ground seeds and nuts

• Iron-fortified infant cereals

Non-heme food sources of iron require vitamin C for absorption, so parents should be advised to offer these with fruit or vegetables.⁹

ALLERGEN INTRODUCTION: NEW EVIDENCE CHANGES GUIDANCE

Recent evidence has led to changes in guidance regarding allergen introduction, even for babies with a family history of food allergies. The BDA complementary feeding statement states that potentially allergenic foods should be introduced from around six months of age, or from the start of complementary feeding (but after four months of age), alongside other complementary foods and continued breastfeeding where possible. This includes:

• Peanuts and tree nuts (finely ground)

• Eggs (well-cooked)

• Cow's milk

• Fish and shellfish

• Wheat

• Soya

Based on evidence from landmark studies, early introduction (from six months rather than delayed introduction) is associated with a reduced risk of food allergy development. Allergens should be introduced one at a time, in small amounts and in cooked form when appropriate. Whole nuts should not be given to children under five years old due to choking risk, but smooth nut butters or ground nuts are appropriate from six months. Families with a history of food allergy, eczema or other allergic conditions should discuss allergen introduction with their HCP.10,11

APPROACHES TO WEANING

Weaning traditionally involves offering smooth purees, gradually progressing through lumpy textures to chopped foods and finger foods. Baby-led weaning is an alternative approach, where infants self-feed with appropriately sized pieces of family foods, bypassing purees.12

Current evidence suggests that by six months, many infants can manage mashed, lumpy and finger foods without needing smooth purees.2 HCPs should support families to adopt the approach that works best for them, and many adopt a combined approach. The Baby-Led Introduction to SolidS (BLISS) trial found no significant differences in growth, body composition or key nutrient intakes between a modified baby-led approach and traditional spoon-feeding.13

When discussing baby-led weaning with families, HCPs should address safety considerations:

• Infants should be seated upright and supervised during eating.

• Foods should be cut into small pieces that are easily managed by the baby.

• Hard foods, like uncooked carrots and apples, should be cooked until soft.

• Parents should understand the difference between gagging (a normal protective reflex) and choking (a medical emergency).

FOODS TO AVOID

HCPs should provide clear guidance on foods to avoid or limit:14

• Honey – This should not be given to infants under 12 months due to the risk of infant botulism.

• Salt – Infant kidneys cannot process excess sodium and those under 12 months should consume less than 1g of salt per day. Avoid high-salt foods and do not add to food or cooking water.

• Sugar – Added sugars contribute to dental caries and establish unhealthy taste preferences. Minimise sugary foods and drinks. Natural sugars in fruit and milk are acceptable.

• Certain cheeses – Avoid mouldripened cheeses or those made from unpasteurised milk as they might carry Listeria, but these can be offered when cooked.

• Whole nuts – These pose a choking risk for children under five years of age.

• Low-fat products – Infants require full-fat dairy products for adequate energy and fat-soluble vitamin intake.

• Rice drinks – These should not be given to children under five years due to high arsenic content.

• Certain fish – Shark, swordfish and marlin should be avoided due to high mercury levels.

PROGRESSION AND TEXTURE ADVANCEMENT

Once weaning is established, it is important to progress textures

appropriately. Infants not exposed to lumpy textures by around nine months may have increased feeding difficulties later.8 By seven to nine months, infants should progress to mashed, lumpy foods and finger foods with a variety of textures. By 10 to 12 months, infants should manage a wider variety of textures, tastes and bigger chunks of soft foods and finger foods.5

The progression through textures supports the development of oral motor skills necessary for effective chewing and swallowing. Delayed texture progression is associated with increased risk of feeding difficulties and limited dietary variety in later childhood.

MILK FEEDING ALONGSIDE WEANING

Breast milk or formula milk feeds continue to be the main source of nutrition in the early stages of weaning. Parents should be advised to offer food in between milk feeds. Gradually add all three meals and offer milk in between mealtimes.2

Once a baby is 12 months, cow's milk can be offered as the main drink in place of formula milk, although breastfeeding can continue for as long as mother and child wish. WHO and UNICEF recommend continued breastfeeding up to two years of age or beyond.1 However, milk requirements are reduced to 350–400mL per day with three meals and one or two snacks between mealtimes.

PLANT-BASED DIETS AND WEANING

An increasing number of families are choosing to raise their children on vegetarian or vegan diets. HCPs

should provide appropriate guidance to ensure nutritional adequacy. The BDA complementary feeding statement includes updated guidance on plantbased milk alternatives. If families use plant-based drinks as a cow's milk substitute after 12 months, these should be fortified, unsweetened and have:

• Energy – More than 45kcal

• Calcium – At least 120mg

• Iodine – Ideally 10–25mcg

• Vitamins – Added vitamin D and vitamin B12

Families following vegetarian or vegan diets require specialist dietary advice to ensure nutritional adequacy, particularly around several key nutrients:

• Vitamin B12 – Found naturally in animal products, supplementation is essential for vegan and vegetarian infants.

• Iron – Plant-based sources (nonheme iron) are less well absorbed than animal sources. Ensure ironrich foods are offered with vitamin C sources to enhance absorption.

• Zinc – Found in beans, lentils, nuts, seeds and fortified cereals. Adequate intake is challenging on plant-based diets.

• Calcium – Essential for bone development, found in fortified plant drinks, tofu, tahini and green leafy vegetables.

• Vitamin D – All infants should receive vitamin D supplementation, but this is particularly important for those on plant-based diets.

• Omega-3 fatty acids – Plant sources such as flaxseed, chia seeds and walnuts provide alpha-linolenic acid, which the body converts poorly into docosahexaenoic acid (DHA). Consider algae-based DHA supplements for vegan infants. The BDA recommends that families following a vegan diet for their infant should be referred to an RD for assessment and guidance.15

COMMERCIAL BABY FOODS

These offer convenience; however, HCPs should be aware of concerns regarding their nutritional adequacy.5,16

Commercial baby foods may have

a place for occasional use when travelling or in emergencies, rather than as the primary source of nutrition during weaning.

Key concerns:

• High sugar content, where repeated exposure may influence taste preferences and increase dental caries risk.5

• Lower energy density compared with home-prepared equivalents, potentially providing insufficient energy for rapid infant growth.

• Inadequate amounts of key nutrients.16

• Limited exposure to lumpy textures affects oral motor development.

• Misleading labelling, with products inappropriately labelled as ‘perfectly balanced’ or ‘suitable from four months’. 5,16

The UK Government published voluntary guidelines in August 2025 requiring manufacturers to reduce sugar and salt levels by February 2027.17

Benefits of home-prepared foods:

• Nutritional control ensures adequate energy density and iron-rich foods at every meal.

• Easy progression from mashed to minced to chopped textures.

• Wider variety of flavours and seasonings (excluding salt).

• More cost-effective than commercial products.

• Infants can eat modified versions of family meals, supporting social eating.

HCPs should reassure parents that home preparation need not be complicated. Simple modifications of family meals, batch cooking and freezing portions provide nutritionally superior options.

SUPPORTING FAMILIES IN PRACTICE

HCPs can support families through the weaning process by:

• providing consistent, evidencebased information aligned with current UK guidelines;

• reassuring parents that babies often need multiple exposures to accept new foods;

• encouraging family mealtimes where infants can observe and learn from others;

• promoting responsive feeding, where parents recognise and respond to infant hunger and fullness cues;

• normalising messy eating as part of learning and exploration;

• addressing parental anxiety about choking through education about safe food preparation. Building parental confidence is key to successful weaning. Many parents feel anxious about this transition, particularly about adequate nutrition, food allergies and choking risk. Providing clear, evidence-based guidance whilst acknowledging individual family circumstances can help parents navigate this period with confidence.

CONCLUSION

Infant weaning is a critical period that shapes nutrition, eating behaviours and long-term health, making evidence-based guidance from HCPs essential. By supporting families with practical advice, reassurance and personalised strategies, clinicians can help infants develop healthy dietary patterns while fostering confidence and enjoyment at mealtimes.

Myth busting with Madi

Madi Myers explores some of the claims, myths and current evidence around

fads and fashionable crazes

Are calories in or out?

Calories are everywhere: on food labels, menus, fitness trackers and smartphones. They have become one of the most recognisable and influential concepts in modern nutrition. This article explores the origins of calorie counting, the evidence behind current policies, such as menu labelling and the growing recognition of its limitations in both practice and public health.

Calorie-counting apps, first appearing in the mid-2000s, are now among the most downloaded weight-loss tools worldwide, and calorie labelling is embedded in public health policy across many countries. But how did a unit of heat measurement become such a dominant feature of dietary advice? More importantly, does our current fixation on calories actually improve health outcomes, or does it risk oversimplifying nutrition in ways that may do more harm than good?

HISTORY OF CALORIES

The calorie did not originate in nutrition science. Its roots lie in 19th-century physics, where it was first used to measure heat energy in the context of steam engines and fuel efficiency. By the early 1800s, it was being used in scientific teaching, and in 1863, it entered the English language through the translation of a French physics text, defining a calorie as the heat required to raise the temperature of one kilogram of water by one degree Celsius, which is what we now refer to as a kilocalorie (kcal).1

Then came the leap from physics to food. In 1887, American chemist Wilbur Olin Atwater popularised the idea of food as energy through his work The Potential Energy of Food 2 Atwater’s experiments laid the foundation for the calorie values still used in food

composition tables today. His system assigned fixed energy values to macronutrients – approximately 4kcal per gram of protein and carbohydrate and 9kcal per gram of fat – a framework that remains embedded in nutritional labelling more than a century later.

Since then, calories have become central to dietary guidelines, weight management strategies and public health messaging. In the UK and many other countries, energy is now listed in both kcal and kilojoules on food packaging, reinforcing the idea that food’s primary value lies in its energy content.

THE IMPACT OF CALORIE LABELLING ON MENUS

One of the most visible examples of calorie-focused policy is mandatory menu labelling. In England and Northern Ireland, large food businesses (employing more than 250 people) are required to display calorie information on menus.

Similar policies were introduced previously in countries like the US, beginning with New York City in 2008. The rationale is simple: if people are given calorie information at the point of choice, they will consume fewer calories. This is thought to operate through two main mechanisms:

1. Consumers choose lower-calorie options or smaller portions.

2. Businesses reformulate or redesign menus to reduce calorie content. Evidence suggests, however, that real-world effects are modest at best.

A recent Cochrane systematic review and meta-analysis (SRMA) found that in the US, calorie labelling was associated with an average reduction of around 11% in calories selected per meal.3 In contrast, studies from England show little consistent evidence of changes in calories ordered or consumed following the introduction of mandatory labelling. One explanation is the high ‘agentic demand’ placed on consumers. For calorie labelling to influence behaviour,

Madi Myers ANutr

individuals must first notice the information, understand it and then consciously act on it, which is a multistep process that assumes time, motivation and nutritional literacy.4

Indeed, a recent natural experiment in England found that only 26% of consumers noticed calorie labels and just 14% reported using them to guide food choices.5 Evidence from New York also suggests that attention to calorie labels has declined over time, with no sustained impact on calories consumed or frequency of fast-food visits.6 Notably, although average calorie intake in the US has fallen slightly in recent years, obesity rates have not followed suit. This evidence calls into question whether menu labelling meaningfully contributes to the policy’s core aim and why other countries have followed suit when there is little evidence for benefits.

WHAT’S THE HARM?

Calories on food labels are likely to be wrong

Calorie values on food labels appear precise, but they are inherently approximate. Atwater’s energy system, while groundbreaking, does not account for differences in how foods are digested, absorbed and metabolised. The thermic effect of food varies by macronutrient – protein, for example, requires more energy to digest than fat or carbohydrate – yet this is not reflected in standard calorie counts. Beyond this, individual variation in digestion and absorption can be substantial. One study estimates that the actual energy derived from the same food may vary between individuals by as much as 50%.7 In practice, this means that the calorie numbers we rely on are at best educated averages, not precise measures of the energy available to any one person.

Calories can be triggering for those with disordered eating

For individuals with eating disorders or a history of disordered eating, calorie labelling and tracking can be actively harmful. A survey in Scotland, where menu calorie labelling has not yet been implemented, found that 95% of people affected by eating disorders believed that displaying calories on menus would negatively impact their recovery, triggering fear, guilt and rigid

food rules.8 There is also growing evidence that calorie-counting apps are disproportionately used by individuals with eating disorders, and that these tools may reinforce pathological behaviours such as restriction, obsession with numbers and loss of internal hunger cues.9 Several studies now suggest a bidirectional relationship: people with disordered eating are more likely to use calorie-tracking apps and app use may, in turn, exacerbate symptoms.10 This raises important ethical questions about population-wide interventions that may benefit a small minority while posing real risks to vulnerable groups.

Calories alone are misleading

A calorie is a unit of energy, not a marker of nutritional quality. Focusing solely on calories can obscure the vastly different health impacts of foods with similar energy content. A cookie and an avocado may provide comparable calories, but their effects on satiety, micronutrient intake, cardiometabolic health and long-term outcomes are fundamentally different. In recognition of this, the British Nutrition Foundation introduced the concept of the ‘quality calorie’ in 2018 to encourage consumers to consider nutrient density alongside energy density. This reflects a broader shift away from reductionist thinking and towards whole-diet patterns.

Counting

calories

is not effective for weight management

Calorie counting remains one of the most commonly recommended weight-loss strategies. In the short term, tracking intake can help some individuals create an energy deficit and lose weight. However, long-term evidence paints a more sobering

picture. A recent SRMA found that only around 25% of individuals maintain weight loss over the long-term following calorie-restricted approaches, with other studies suggesting even lower rates of sustained success.11 For many, calorie counting becomes burdensome, socially limiting and psychologically draining – factors that undermine adherence over time. This does not mean that energy balance is irrelevant; it does, however, challenge the idea that meticulous calorie tracking is a necessary or sustainable route to healthy weight management for most people.

CONCLUSION

Calories have become one of the most powerful symbols in modern nutrition, embedded in policy, technology and everyday decision-making. Yet their rise from a 19th-century unit of heat measurement to the cornerstone of dietary advice has not been without consequence. While calorie information can be useful in specific contexts, the evidence suggests that population-wide calorie labelling and obsessive tracking offer limited benefits and carry meaningful risks.

Food is far more than the energy it provides; reducing it to numbers alone ignores nutritional quality and the complex relationship people have with eating. For nutrition professionals, the challenge is not to abandon calories altogether, but to put them back in their proper place: as one tool among many, not the defining feature of a healthy diet.

Nutrition & Hydration Week

Foundation of safe and effective care

Good nutrition and adequate hydration are essential to life, recovery and independence. They influence immune function, wound healing, cognition, mobility and emotional well-being.1 Yet malnutrition and dehydration still occur frequently in hospitals, care homes and the community, often developing silently and worsening clinical outcomes.2 Nutrition & Hydration Week 2026 (16–22 March) provides a call to action to move from awareness to reliable practice: screening everyone, conducting ‘food-first’ interventions promptly and escalating where required.

The Malnutrition Universal Screening Tool (‘MUST’) remains the accepted UK standard for screening adults at risk of malnutrition.3 In brief, screening follows three measurable steps:

Step 1 – Current nutritional status. Calculate BMI or use alternative measurements where BMI is unreliable (eg in the case of wheelchair users).

Step 2 – Recent unplanned weight loss expressed as a percentage over 3–6 months.

Step 3 – The acute disease effect. Has the patient had, or is it likely they will have, no nutritional intake for more than five days?

Each element scores 0–2 and combined scores classify low (0), medium (1) or high (≥2) risk.

When ‘MUST’ is used, the explanatory booklet and toolkit provide worked examples and training materials suitable for clinical teaching.4 BAPEN guidance specifies rescreening frequency by setting: weekly in hospital, at least monthly in care homes and approximately every two to three months in community services for those at low risk, with increased frequency following any clinical change.

WARDS AND CARE HOMES

When a person screens at medium or high risk, the first 48–72 hours are critical. Practical, low-cost, high-impact steps used across NHS trusts include the following:

Food-first optimisation – Offer energy- and protein-enriched meals and snacks (fortified porridges, milk-based puddings and thickened soups where appropriate), and provide small, frequent portions if appetite is poor. Document food preferences and cultural needs on the meal order and bedside board so catering staff can personalise choices.

Mealtime assistance and environment –Ensure the person has help at mealtimes if needed (cutting up food, prompting, adapted cutlery, etc). Implement protected mealtime, pausing nonurgent ward rounds and routine tasks to reduce interruptions. Many trusts have local protected mealtimes policies and practical checklists to make this routine on the wards.5 Audit these processes using simple Mealtimes Matter checklists.6

Structured hydration – Place a labelled, preferred drink within reach, schedule

regular drink rounds and use visual prompts (such as bedside hydration stickers or coloured beakers) to identify those who require prompting. Where fluid targets are needed, document agreed daily targets and use fluid balance charts for high-risk patients.

Documentation and escalation –Enter the screening result and the immediate plan in the nursing care plan and electronic systems. Set a review date and when intake remains <75% of estimated needs after 3–7 days, escalate to dietetic referral. Many NHS trusts use standardised ‘foodfirst to ONS to dietitian’ pathways embedded in electronic referral forms to ensure timely escalation.

Safe oral intake and dysphagia –Where there is suspected swallowing difficulty, request bedside swallow screening and, if indicated, a formal speech and language therapy assessment before offering textured diets or thickened fluids. Although these first-line actions are low resource, they rely on routine, reliable practice and clear responsibilities.

Ines Jabir RD

IN PRACTICE

Several practical examples from NHS trusts illustrate how to embed these steps. A typical acute trust pathway requires ‘MUST’ screening by a ward nurse at admission, with weekly rescreen and automatic escalation triggers. A ‘MUST’ score ≥2 generates an auto-referral to dietetics and a nursing checklist for immediate food-first actions.

Leicestershire Partnership NHS Trust and other trusts publish local protected mealtime policies and practical checklists that specify roles for nurses, catering and therapy teams. Trusts often appoint nutrition champions or nutrition advocates on wards to run brief training sessions, monitor compliance and lead small-scale audits during Nutrition & Hydration Week. These local approaches mirror the national 10 Key Characteristics for Good Nutritional Care and support consistent delivery across services.7

MEASURE IMPACT AND SHARE WHAT WORKS

Audit is a simple and powerful tool to measure screening results and impact. Useful process metrics include proportion of patients screened on admission, percent rescreened within the expected time frame, number of referrals to dietetics, proportion of high-risk patients who received ONS within 48 hours and completion rates for fluid balance charts. The Mealtimes Matter Audit and the Nutrition and Hydration Digest provide templates and assurance guidance suitable for local quality improvement cycles. Sharing positive results, for example, reducing dietetic referrals for preventable

malnutrition, encourages dietetic resources in different services and builds organisational commitment towards effective, timely and safe patient care.8

TRAINING AND CONTINUITY OF CARE

Sustained improvement depends on regular, role-specific training. Nursing and care staff require regular practical skill sessions on weighing/estimating height, completing ‘MUST’, recording intake and assisting at mealtimes. Allied professionals and medics should understand escalation criteria and when to initiate nutrition support. Nutrition advocates or champions act as local trainers, audit leads and the bridge to dietetics and catering services. For continuity, it is essential to include nutritional status and plan in discharge for community handovers, so community teams and GPs can continue monitoring and management.

NUTRITION & HYDRATION WEEK: HOW TO GET INVOLVED

We can join Nutrition & Hydration Week 2026 in real terms! The team has provided some fun ideas for each day of the week (and I’ve added some of my own):

• Monday: Big Breakfast – It’s the most important meal of the day.

• Tuesday: Snacky Tuesday – Share the value of snacks between meals and at suppertime.

• Wednesday: Global Afternoon Tea –Hold a tea party and share the fun on social media.

• Thursday: Thirsty Thursday –

Promote hydration with regular drink rounds, preferred drinks and hydration prompts.

• Friday: Fruity Friday – Encourage fruit intake through fruit trolleys, desserts and easy meal add-ins.

• Saturday: Smoothie Saturday – Design your own smoothie or milkshake.

• Sunday: Sundae Sunday – Celebrate energy-dense desserts that support nutrition and recovery. An array of infographics is available to highlight your commitment to delivering high-quality nutrition and hydration. Visit www.nutritionandhydrationweek.co.uk/ resources. Join your organisation’s social media page and showcase why nutrition and hydration are key for safe and effective care.

CONCLUSION

Nutrition and hydration are not optional extras in care; they are fundamental to safety, recovery and dignity. Nutrition & Hydration Week 2026 offers an opportunity to strengthen everyday practice through consistent screening, timely food-first interventions and clear escalation pathways. By embedding reliable processes, investing in staff training and sharing what works, healthcare and care settings can reduce preventable harm and ensure nutrition and hydration are treated as core components of high-quality care year-round.

Tailored strategies for diabetes patients

As healthcare professionals, our mission is to optimise outcomes. Yet, managing diabetes often involves frustrating plateaus. It's time to retire the average treatment effect and embrace strategies that reflect the patient's biological fingerprint. This isn't just better compliance; it's superior clinical efficacy, powered by personalised dietary patterning and pharmacological synchronisation.

In practice, most adults with T1D and T2D already know a lot about ‘what they should be doing’; the gap is usually around tailoring, confidence and support in the context of busy lives, comorbidities and cultural food patterns. Starting with open questions along the lines of “What does a usual day of eating look like for you?” and “What feels hardest at the moment?” allows the person to set the agenda and helps you decide whether to prioritise weight, hypoglycaemia, distress or the risk of complications.

SHARED PRINCIPLES

Despite different aetiologies, there is a substantial overlap in nutrition messaging for T1D and T2D. Emphasis is on whole, minimally processed foods, higher fibre, healthy fats and weight management where appropriate. National guidelines stress flexible, individualised nutrition care rather than one ‘diabetic diet’, highlighting that Mediterranean-style, DASH, vegetarian, lower carbohydrate and culturally adapted patterns can all be appropriate if they help the person meet glycaemic, cardiovascular and weight goals.1

T1D: MATCHING INSULIN TO REAL LIFE

Alka Pandey RD

For adults with T1D, structured education in carbohydrate counting and insulin adjustment remains central and is specifically endorsed in UK guidance, such as the Dose Adjustment for Normal Eating (DAFNE) programmes. Supporting people to estimate carbohydrate in grams or portions and to adjust insulin doses for meals, snacks and activity can improve blood glucose levels (HbA1c) and quality of life without insisting on a rigid diet.2

T2D: WEIGHT, REMISSION AND REALISTIC CHANGE

For many adults with T2D, modest weight loss and reduced energy intake improve glycaemic control and cardiovascular risk, even before substantial HbA1c changes are visible. Very low energy diets delivered in primary care, as used in the Diabetes Remission Clinical Trial (DiRECT) programme (around 800–850kcal/day for several months, with structured food reintroduction), have demonstrated remission in a significant proportion of people with recent T2D, with some remission sustained at five years in those maintaining weight loss.3

Outside formal remission programmes, flexible approaches, such as Mediterranean-style, reduced carbohydrate or intermittent energy restriction, can support weight loss and metabolic improvements when tailored to preference and cultural context. The key is focusing on an overall energy deficit, higher fibre, adequate protein and reducing UPFs, while regularly reviewing glucose, renal function and medications (particularly sulfonylureas and insulin) to minimise hypoglycaemia.4

CARDIOMETABOLIC RISK AND NEWER THERAPIES

For adults with T2D and established cardiovascular disease, heart failure or chronic kidney disease, updated NICE guidance recommends sodium-glucose co-transporter 2 (SGLT2) inhibitors alongside metformin, with GLP-1 receptor agonists considered where additional glucose and weight benefits are needed. Dietitians can help patients adjust to side effects (for example, advising on hydration, gradual fibre changes and strategies for nausea with GLP-1 agonists) while supporting continued lifestyle changes rather than viewing medication as a substitute.5

USING APPS

Digital tools, simple visual models and apps can make dayto-day diabetes self-management feel more manageable rather than more complicated. Popular options include the Carbs & Cals book and app,6 MyFitnessPal and Nutracheck. In practice, this might mean agreeing on one app that fits the person’s confidence and digital literacy and then using

it together in clinic to review a few days of meals, estimated carbohydrate, bolus doses and associated glucose readings.

THE T-PLATE APPROACH IN CLINIC

A plate-based visual model remains a powerful, low-tech tool for creating flexible, culturally adaptable meal structures. A typical ‘diabetes plate’ or T-plate approach uses a 9–10 inch plate and divides it into half non-starchy vegetables, one quarter lean protein foods and one quarter higher-fibre starchy carbohydrate or other carbohydrate-containing foods, with a small amount of healthy fats. Teaching patients to serve vegetables or salad first, followed by protein and then to ‘fit in’ the starchy component to the remaining quarter of the plate can help reduce carbohydrate portions to a level that supports weight and glucose control. This approach is easily adapted for mixed dishes by visualising the same proportions within a bowl or shared platter.⁷

HAND-BASED GUIDES

Hand-sized methods are portable, personal and widely used in diabetes education. Common cues include a palm (without fingers) as a portion of cooked meat or fish, a closed fist for a portion of starchy carbohydrate, such as rice, pasta or potato, a cupped hand for fruit or snack foods and a thumb or thumb-tip for fats like butter, cheese and spreads.8

TRANSLATE STANDARD TOOLS INTO FAMILIAR FOODS

Existing hand and plate methods can be translated into staple cultural foods using simple, pictorial examples. For example, Diabetes UK provides hand-sized guidance for chapati, naan, rice and plantain; these can be adapted by describing a small chapati or mini naan as roughly one hand-size and a portion of cooked rice as two cupped hands together.9

The same logic can be applied to other cuisines. One palmsized piece of injera or flatbread, a fist-sized fufu ball or two cupped hands of noodles or couscous can be presented as a baseline portion, with options to reduce or increase depending on glucose targets and appetite. Creating a shortlist of six to eight culturally specific examples with the patient makes the guidance feel personally relevant.10

KEEP MESSAGES SIMPLE

For people with lower health literacy or for whom English is not a first language, simple visuals and minimal text often work better than detailed numerical guidance. Pilot work in UK Black, Asian and minority ethnic communities shows that pictorial booklets using photos or drawings of traditional foods with clear portion cues can improve understanding and confidence in estimating carbohydrate content.11

Where possible, providing translated handouts or bilingual materials, and checking understanding by asking patients to explain the advice back in their own words or using their own food examples, helps ensure messages are landing. Collaborating with community workers or dietitians who share the person’s background can further refine examples and improve cultural resonance.12

EXERCISE AND ACTIVITY

Regular physical activity improves insulin sensitivity, reduces time spent in hyperglycaemia and lowers HbA1c by around 0.5–

0.7 percentage points in adults with T2D, even in the absence of major weight loss. Both aerobic and resistance training contribute, with meta-analyses showing additional benefits for blood pressure, triglycerides, total cholesterol and overall cardiovascular risk.13

Exercise also supports mental health. Studies in people with diabetes demonstrate reductions in symptoms of depression and anxiety, alongside improvements in health-related quality of life and perceived well-being with regular activity. For many individuals juggling multiple demands, emphasising mood, sleep, stress management and social connection as equal priorities alongside glucose management can make activity goals feel more relevant and motivating.13

CULTURE, COST AND DISTRESS

Dietitians are increasingly encouraged to embed cultural competence and social determinants into care, recognising that food is tied to identity, family and finances as much as to health. Diabetes UK’s nutrition guidelines recommend adapting dietary advice to ethnic background, religious practices and economic circumstances, using familiar foods and shared decision-making to enhance engagement.1

STRUCTURING FOLLOW-UP AND MEASURING WHAT MATTERS

Guidelines highlight the importance of ongoing, structured education and review rather than one-off advice. Agreeing on a small number of specific, patient-chosen goals (for example, ‘have breakfast four days a week’, ‘walk 10 minutes after dinner’, ‘reduce sugary drinks to weekends only’) and revisiting them at each contact can reinforce progress and support behaviour change.

Using patient-centred outcomes alongside HbA1c, such as fewer hypos, more energy, better sleep or feeling less restricted around food, helps people see the value of nutrition changes even when glycaemic markers shift slowly. Structured group education or digital programmes can extend the reach of dietetic support.

CONCLUSION

Effective diabetes care moves beyond generic advice towards personalised, practical strategies that fit real lives. By combining flexible dietary frameworks, culturally relevant portion tools, digital support and appropriate pharmacotherapy, clinicians can help people achieve sustainable improvements in glycaemia, cardiometabolic risk and quality of life. The focus is on achievable change, guided by biology, preferences and ongoing partnerships.

EXPERTS IN NON-INVASIVE DIAGNOSTIC AND MONITORING SOLUTIONS FOR: TYPES OF TEST: POINT OF CARE LAB HOME

Managing IBS-C in practice

What the new constipation guidelines mean for clinicians

In October 2025, the BDA published guidelines for the ‘Dietary Management of Chronic Constipation in Adults’. Here, we focus on constipationpredominant IBS (IBS-C), the differences between chronic constipation and IBS-C and how we can utilise the latest BDA guidelines in our IBS-C practice.

IBS is one of the most common causes of altered bowel habits, previously believed to have a prevalence of 10–20%.1,2 Since the Rome IV criteria for IBS were developed, this has now reduced to a 4.1% worldwide prevalence.1

In recent years, IBS has been reclassified as a disorder of the gut–brain interaction. It is a chronic gastrointestinal condition accompanied by a range of gut symptoms, where no organic or structural cause has been found. Symptoms include recurrent abdominal pain, accompanied by altered gut habits.1-3

In the absence of other conditions, and meeting the Rome IV criteria, there are three main types of IBS:

1. Diarrhoea-predominant (IBS-D)

2. Constipation-predominant (IBS-C)

3. Mixed IBS where diarrhoea and constipation are both present (IBS-M)

IBS unclassified (IBS-U) is when people meet the criteria, but do not fall into any of the first three subtypes.1-4

The Rome IV criteria for IBS are:4

• Recurrent abdominal pain on average at least one day/week in the last three months, associated with two or more of the following criteria:

- Related to defecation

- Change in frequency of stool

- Change in form (appearance) of stool

• Criteria fulfilled for the last three months with symptom onset at least six months prior to diagnosis

POSSIBLE CAUSES OF IBS DEVELOPMENT

The cause of IBS is unknown. Some people’s symptoms start suddenly, whereas others progressively worsen over time.1-3 It is thought that the following factors increase the likelihood of developing IBS:

• Genetics

• Gastrointestinal infections

• Female hormones

• Trauma, anxiety or stress1-3

Dietary influence is indicated as a possible cause of IBS development. Studies have found that people with IBS tend to have a higher intake of UPFs and a lower intake of fibre compared with healthy controls.6,7

CONSTIPATIONPREDOMINANT IBS

The Rome IV criteria state that this subtype has to include the following: 4

• 25% or more of bowel movements with Bristol stool types 1 or 2

• Less than 25% of bowel movements with Bristol stool types 6 or 7

• IBS subtypes can only be confidently established when the patient is evaluated off medications used to treat bowel habit abnormalities

Additionally, common symptoms of IBS-C include:

• Frequent bloating

• Excessive gas

• Abdominal pain

• Infrequent stools that are hard to pass (less than three per week)

• Incomplete evacuation of bowel movements (not feeling like you have finished)8

The majority of research surrounding IBS focuses on IBS-D or IBS-M, with a lack of research on IBS-C.8

Hazel Clarke RD

Symptom burden is often reduced once the bowel frequency and consistency improve

In addition to IBS causes, IBS-C pathogenesis can include colonic motility, daily behaviours and sedentary lifestyle.8 Low-fibre diets may cause IBS, especially IBS-C.6,7 Insufficient fluid intake has been linked to a higher risk of IBS-C, likely due to dehydration.8

CHRONIC CONSTIPATION VERSUS IBS-C

Chronic constipation and IBS-C share many symptoms, including infrequent bowel movements, abdominal bloating, excessive gas, straining to pass stool, Bristol stool types 1 and 2, and a sensation of incomplete evacuation. The key distinction between the two conditions lies in abdominal pain. Under the Rome IV criteria, IBS is defined by recurrent abdominal pain occurring at least once per week and associated with defecation and/or a change in stool frequency or form.

IBS-C refers to patients who meet IBS criteria and whose bowel habit is constipation-predominant. IBS-C is also subtyped based on stool form, with hard stools present in more than 25% of bowel movements and loose stools occurring in less than 25%, excluding laxative use.

In functional (chronic) constipation, abdominal discomfort or bloating may occur, but abdominal pain is not the predominant symptom, and the patient does not meet diagnostic criteria for IBS.

Rome IV diagnostic criteria for functional constipation include the following features, which are not required for IBS-C:

• Straining during more than 25% of defecations

• Sensation of incomplete evacuation

• Sensation of anorectal obstruction or blockage in more than 25% of defecations

• Manual manoeuvres to facilitate defecation (for example, digital evacuation or pelvic floor support)

• Insufficient criteria for IBS

Although patients with IBS-C may experience some of these symptoms, a diagnosis of functional constipation requires that IBS criteria – particularly pain - based criteria – are not met.

Proposed mechanisms for the two conditions overlap, but constipation is more often associated with disordered colonic transit or evacuation, whereas IBS-C is more strongly linked to visceral hypersensitivity and dysregulation of the gut- brain axis.

THE CURRENT GUIDELINES: HOW THEY RELATE TO IBS-C

The dietary treatment for IBS-C remains similar to chronic constipation and includes a dietary routine, not skipping meals and good amounts of fibre intake.2,4,8 NICE and BDA guidelines encourage the following suggestions for constipation:

• Encourage intake of six to eight glasses of non-caffeinated fluids daily to improve stool frequency and reduce laxative dependence.

• Gradually increase fibre intake to minimise gastrointestinal discomfort.

• Recommend one tablespoon of brown or golden linseeds daily, taken with approximately 150mL of fluid, and incorporated into meals as appropriate.

• Avoid additional wheat bran.2

The challenge is that the BDA and NICE guidelines are not IBS-C specific. This means that some guidance may be more applicable to IBS-D or controlling the gas production and pain of IBS, such as limiting caffeine, reducing fizzy drinks and cutting out fibres such as beans and cauliflower.2

In practice, it can be helpful in IBS-C to focus on improving stool consistency and frequency through adding foods and fibres into the diet. Symptom burden is often reduced once the bowel frequency and consistency improve, so at this point, consider if exclusion is required. Table 1 explores recommendations for chronic constipation and whether they are helpful for IBS-C.

Dietary

Fibre supplement Psyllium (10g and above)

Fruit Kiwi 2–3 daily (skin on preferable)

Prunes (if kiwi not possible)

Grains Rye bread 6–8 slices daily

Water Drink 0.5–1.5L high mineral content water daily

Water intake ~2L daily

Some current recommendations for constipation management have insufficient research to support them, for example, high-fibre diets are recommended, alongside sufficient fluid. Most evidence focuses on fibre supplementation rather than diets as a whole.

When a food is researched, it is difficult to develop a high-quality randomised controlled trial (RCT). Current recommendations are not necessarily wrong, but the research itself can be lacking. Furthermore, research exploring specific high-fibre foods (mangoes, oats, flaxseed flour) is promising but generally based on uncontrolled trials. Adequate

Yes

Yes

Yes

Rarely

Maybe

Yes

Reason

• Softens stool, improves frequency

• Reduces straining severity

• Some evidence shows it helps manage gas and bloating

• Kiwi is a low-FODMAP fibre, so it will not produce gas or pull in water to the colon

• Will not worsen bloating, gas or pain

• Helps with stool frequency

• Does not help consistency and may cause gas

• 6–8 slices of rye bread is not manageable for some patients

• Wheat contains fructan, a FODMAP that is very gasproducing, which may add to bloating and pain

• May be a preferable swap for other wheat-containing breads

• Will not worsen IBS symptoms

• Difficult to obtain and possibly expensive

• Needs to have a specific high mineral profile

• No negative IBS side effects

• Lack of evidence that additional fluid alone is beneficial

and appropriate RCTs are needed before specific recommendations can be made.5

TAKING A PRACTICAL APPROACH

The first step is to focus on regulating bowel habits. This may be achieved by the following:

1. Regular meal pattern (including breakfast)

2. Consistent toilet routine

3. Kiwi 2–3 daily (skin on if able)

4. Psyllium 10g daily or more (slow titration for nervous patients)

5. Adequate fluids

6 Gentle movement

7. Gradually increasing fibre (not specific at this point)

A regular meal pattern may be sufficient to help manage IBS-C symptoms; however, for patients whose stools have regulated and improved but who still experience underlying IBS symptoms (pain, bloating, gas), it may be worth considering:

• A low-FODMAP diet or modified lowFODMAP diet

- Acknowledge that this could worsen constipation due to reducing fibres that pull water into the gut.

• Caffeine intake

- If high, this could be dehydrating

- If within recommended limits, consider if timing intake could help stimulate bowel motions

• Gut-brain connection

CONCLUSION

Limited research looks at IBS-C as a standalone condition, which is why the new BDA chronic constipation guidelines are so helpful. We now have a strong evidence-based framework that can be adapted for people with IBS-C, rather than starting from scratch. However, IBS-C is not the same as functional constipation. Symptoms are often driven by gut sensitivity and gut-brain interactions, meaning a standard ‘constipation approach’ won’t work for everyone. In practice, management needs to be individualised and guided by symptoms, often involving a degree of trial and adjustment. For many patients, this means combining elements of the NICE and BDA chronic constipation guidance, potentially FODMAP principles and broader gut-brain strategies. Used together, these approaches allow for more personalised, effective care rather than a one-size-fits-all solution.

Protecting patients from the new era of disordered eating

Priya Tew RD

We are living in a time where weight loss has become framed as medical progress, personal responsibility and social currency all at once. In this landscape, speed and suppression are being prioritised over sustainability and self-trust. As dietitians, we need to pause and ask not just whether these interventions work, but what they cost – biologically, psychologically and culturally. Because when weight loss is treated as a prize at all costs, we risk missing the quieter harms unfolding beneath the surface.

If you have spent any time in a clinical setting lately or (let’s be honest) just scrolled through social media, you will know that we are in the middle of a weight loss gold rush. Between the headlines about GLP-1 agonists (those famous ‘skinny jabs’) and the relentless push for the next biohack, the pressure to be thin has reached fever pitch.

As healthcare professionals, we are often caught in the middle. On one hand, we have new clinical tools that we know can genuinely help some people improve their metabolic health. On the

other hand, we can see the fallout. Diet culture has moved away from diets to a harder-to-spot format that is more medicalised, more intense and frankly more dangerous than ever before.

I have two major concerns. Firstly, we will soon be in the midst of a massive rise in disordered eating. And secondly, we are losing sight of the person inside the body. We need to look at the wider issues from the ‘rebound’ to the ‘shadow market’ and think about how we can protect our patients from falling into the spiral.

THE SPIRAL AND THE MYTH OF THE QUICK FIX

We have all seen it. A patient starts a new restrictive diet or a medication, the weight drops off rapidly and everyone cheers. But what happens six months later? Or a year later?

When people lose weight past their biological set point, the body sends out an SOS and goes into warning mode. The set point is a little like an internal thermostat. When we drop below it, the body goes into unsafe mode. It spikes ghrelin and reduces leptin, to encourage us to eat.

If a patient is not supported to build long-term and sustainable behaviour changes, such as intuitive eating, finding joy in movement and managing stress, they are essentially standing on a trapdoor. The moment the medication stops, or the willpower runs out, the trapdoor opens. The weight rebounds. For someone living in a bigger body, this is devastating. It reinforces the idea that their body is broken and that they are a failure, which they have perhaps already been feeling and living out. Yet, in reality, their biology is just doing its job.

LIVING IN A BIGGER BODY: THE HIDDEN TOLL

We need to talk about the trauma of weight stigma. For our patients in larger bodies, this new era of weight loss is not just about health; it is often treated as a moral mandate. When society and sometimes the medical community present thinness as a simple choice or a prescription away, it erases the lived experience of these individuals. Weight cycling, which is that ‘yo-yo’ effect, is incredibly hard on the heart and the metabolism. It is often more damaging than just staying at a stable but higher weight. When we push for

rapid weight loss without addressing the psychological side, we are often just trading one set of health risks for another. Plus, we risk losing that patient’s trust. If an individual feels they have failed at the latest medical intervention, they might stop coming to see us altogether. They end up missing out on vital screenings because they simply cannot face another lecture about the scale.

THE SHADOW MARKET: OUR TEENS ARE WATCHING

This is the part that really keeps me awake at night. We are seeing a rise in aesthetic weight loss among teenagers who are getting hold of these drugs illegally. Whether it is through unregulated websites or pharmacies, kids are bypassing doctors to try to reach an impossible body ideal.

Think about what that does to a developing brain. Puberty is a time when we should be learning to trust our bodies. Instead, we are teaching teens to silence them. Using these drugs for aesthetic reasons during growth years can lead to bone density issues and hormonal imbalances. My biggest fear is that it will lead to a lifelong struggle with eating disorders. If a teen learns that they can just turn off their hunger, they never learn the vital skill of interoceptive awareness. We are effectively handing them a tool for anorexia and disordered eating.

IS THIS THE NEXT WAVE OF EATING DISORDERS?

In short, yes. I believe we are witnessing the birth of a new era of disordered eating. When we use medications that quieten food noise, we are not just quieting cravings, we are quieting the body’s natural communication system. For someone with a predisposition to an eating disorder, that silence is

addictive. It feels like control. But what happens when the medication wears off? The food noise returns like a shout. This often leads to binge eating episodes fuelled by both biological hunger and emotional desperation. It is a perfect storm for binge eating disorder and bulimia.

WHAT CAN WE DO?

I don’t want to be all doom and gloom. These medications can be a bridge to better health, but only if the bridge is built on solid ground. Here is how I think we, as healthcare professionals, should be approaching the situation:

• Screen and screen again –We need to ask the deep questions. Not just “What do you eat?” but “How do you feel about food? Do you feel in control? Are you afraid of weight gain?”

• Focus on function, not fashion –Let’s celebrate the non-scale victories. Is their blood pressure better? Do they have more energy to play with their kids? Can they walk further without breathlessness? These are the metrics that actually matter for quality of life.

• Ditch the weight-centric language

– Instead of saying “You need to lose weight”, let’s try to talk about ‘adding in’. We can talk about adding in more fibre, adding in more joyful movement or adding in more sleep.

• Support the whole person –If a patient is on a weight loss medication, they must have access to a dietitian and a therapist. We cannot give someone a tool that changes their biology without giving them the emotional skills to handle that change.

CONCLUSION

We have a responsibility to be the voice of reason in a world that has gone weight-loss mad. Our goal should not be to shrink our patients. It should be to help them live the fullest and healthiest lives possible in the bodies they have right now. Let’s move away from the spiral of diet culture towards a healthcare model that is compassionate, weight-inclusive and most importantly, safe.

THE 4TH KETOCOLLEGE ADVANCE EVENT

12, 13 & 14 MAY 2026

FELBRIDGE HOTEL • EAST GRINSTEAD • WEST SUSSEX • UK

AIMED AT EXISTING KETOGENIC TEAMS New Sessions for 2026

• Paris INKS Conference Update

• Gold-standard and non-standard KDT applications

• Glut1 lived experience

• The role of the pharmacist in the Ketogenic team

• Fuelling the Long Haul: Evidence-based Strategies to Boost Keto Adherence

• KDT in Migraine

• KDT in Cancer

• KDT in Type 1 Diabetes

• Beyond Seizure Control: Exploring the Non-Seizure Benefits of the Ketogenic Diet

• The end of the journey: How to wean KDT

• Managing KDT in status epilepticus

• Practical aspects of initiating patient on KD in ICU setting

• KDT pregnancy & breastfeeding

• Mitochondrial Disease & KDT

• Plant-based KDT and global warming

In addition to updates in our core topics:

• Mechanisms of the Ketogenic Diet

• Prediction of responders in paediatrics

• KDT in paediatrics, neonates to 16

• KDT Practicalities in Paediatrics

• KDT Transition Challenges

• Interesting KDT Case Studies

• KDT Practicalities in Adults

• Efficacy of Ketogenic Diet Therapies for adults with epilepsy

• Managing side-effects of KDT, short & long-term

• Blended Ketogenic Diets

• KDT in Mental Health

• KDRN update

11 MAY 2026 • 12.30-5.30PM

FELBRIDGE HOTEL • EAST GRINSTEAD • WEST SUSSEX • UK

FOUNDATIONS

Ketogenic diet therapy for adults: the challenges of transition

*Additional authors: Victoria Whiteley, ACP Dietitian, Royal Manchester Children’s Hospital, Manchester Foundation Trust; Julie Fountain, CEO, Matthew’s Friends; and Val Aldridge, Ketogenic Family Support, Matthew’s Friends.

Eva Partridge RD

Ketogenic diet therapy (KDT) is an established, evidencebased management option for children, young people and adults who have drug-resistant epilepsy (DRE).1 For most paediatric patients, KDT is used for a finite period – around two years – after which time, many return to a normal diet without deterioration in seizure control. However, for a significant number, seizure activity returns when weaning off the diet is attempted and long-term KDT becomes necessary into adolescence and adulthood.2

As paediatric ketogenic services across the UK have expanded, the number of young people reaching adulthood while still requiring KDT has grown in parallel. Unfortunately, the number of adult KDT services has not grown at the same rate.3 This mismatch has created a national gap in adult provision, leaving adults with epilepsy, those transitioning from paediatrics and those seeking KDT for the first time facing long waits, limited access or (in some cases) no service at all.

UNDERSTANDING KDT

KDT involves a carefully prescribed dietary regimen that is high in fat, low in carbohydrate and moderate in protein. When nutrition is provided in this way, the body switches from using carbohydrate as its primary energy source and begins to break down fatty acids, producing ketone bodies for energy – a metabolic state known as ketosis. This altered metabolic state has been shown to reduce seizure frequency and severity in children and adults with epilepsy.4

THE CURRENT UK LANDSCAPE

Provision for KDT for adults in the UK and Ireland is extremely limited. At present, there are only four adult KDT services collectively supporting around 150 adult patients, compared with 39 paediatric centres supporting approximately 854 patients.3 Waiting lists for adult services can exceed two years.

Adults with DRE should be offered the opportunity to consider KDT when clinically appropriate. However, many remain unaware of the therapy or are not referred because local neurology teams know that waiting lists are long or that no adult service exists in their region. Where services are available, they are often at capacity and deliver care with limited dietetic staffing.

The evidence base for adults has strengthened significantly over the last decade. Studies show that around

PATIENT PERSPECTIVE:

Leroy’s story

My son Leroy has been on keto for epilepsy since he was 14. He’s 21 now and still on keto, as when we tried to wean him off, his seizures worsened. He’s tube-fed, but has blended food through his feeding tube, using the modified ketogenic diet. It’s been life-changing for him. Although he is not seizurefree, his background seizure activity is much less, and he is so much more alert and ‘switched on’. Keto has also helped his reflux and nausea.

In our current hospital, Leroy was kept in the paediatric clinic until he was 19, as there was no alternative. He was originally referred to an adult centre, but the referral was rejected. Then he had a referral to another adult centre, but the last letter was 18 months ago, telling us that he was on a waiting list. We have heard nothing since.

He is under a neurologist here for his epilepsy and other complex medical needs, who performs annual keto bloods and checks his urine, etc, but we have no dietitian input. Fortunately, we have just been able to continue with his diet fairly easily and are able to maintain ketosis without needing changes or tweaks. I’m not sure what we would do if that became an issue. Fingers crossed it doesn’t…

40% of adults who follow a properly initiated ketogenic diet experience a reduction in seizure frequency of greater than 50%, which is a responder rate comparable to that of a new antiseizure medication (ASM).5,6 Benefits can extend beyond seizure control, including improved alertness, reduced medication burden, better mood and enhanced quality of life. The implications of uncontrolled epilepsy are severe, including the risk of sudden unexpected death in epilepsy. For adults who have exhausted multiple ASMs, access to alternative, evidence-based therapy is essential. Two groups of adults are currently disadvantaged by the limited UK provision:

• Young people established on KDT in childhood who require ongoing support into adulthood and cannot safely discontinue the diet.

• Adults who have difficult-tocontrol epilepsy and deserve the opportunity to explore alternative management options.

Without sufficient adult services, these individuals experience inequitable access to therapy.

KDT IN INTENSIVE CARE AND STATUS EPILEPTICUS

Although historically used more frequently in paediatrics, KDT is increasingly being used in adults with super-refractory status epilepticus (SE), when conventional treatments have failed. Emerging international evidence supports its use in critical care settings;7,8 guidance and standard operating procedures are available to enable safe initiation in adult intensive care units (ICU).9 However, adults stabilised in ICU frequently require ongoing dietary therapy after discharge.

In the absence of commissioned adult outpatient services, there is often no clear pathway to continue care, placing patients at risk of relapse and undermining gains made during critical illness. This is yet another example of how limited adult provision creates gaps across the epilepsy pathway.

HOW ADULTS EXPERIENCE KDT

KDT can be delivered via oral diet or enteral feeding tube and is tailored

to an individual’s preferences, lifestyle and nutritional requirements. Adults often report more nuanced subjective effects of sustained ketosis than children, such as reduced anxiety, improved concentration, greater mental clarity and improved confidence. These experiences can have important implications for employment, independence, relationships and overall well-being.

THE TRANSITION CHALLENGE

While adults hoping to trial KDT face major access barriers, an equally affected group is the young people established on KDT since childhood. These individuals typically remain on KDT because attempts to discontinue the diet result in worsening seizure activity. Ongoing support is therefore medically essential.

Across the UK and Ireland, an estimated 25 adults and 40 young people of transition age are currently ‘stuck’ in paediatric ketogenic services due to the lack of commissioned adult provision (unpublished data from Ketogenic Dietitians Research Network). These individuals remain under paediatric teams not because it is clinically appropriate, but because no safe adult pathway exists.

A recent survey of young people and their families exploring transition experiences revealed several consistent themes:

• Heightened anxiety and loss of stability, when no destination adult service is available or when the handover lacks structure.

• Reduced autonomy and independence, as young people struggle to manage their diet without access to knowledgeable and experienced clinicians.

• Pressure on paediatric teams, who are unable to discharge patients but lack caseload capacity to provide long-term adult care.

• Young adults having to discontinue KDT when no adult team exists locally, despite evidence that stopping the diet leads to increased seizure activity. These challenges not only undermine patient experience but also create a systemic strain across services.

WHAT NEEDS TO CHANGE?

Meaningful improvement will require coordinated action across commissioners, clinicians, charities and patient groups. Key priorities include:

• National recognition of the transition gap affecting young people moving from paediatric to adult KDT services.

• Clear commissioning recommendations for integrated care boards to ensure consistent funding for adult KDT.

• Standardised transition pathways modelled on other long-term conditions.

• Investment in workforce, including specialist dietitians, nurses and neurology input to support a sustainable adult service model.

• Development of regional or huband-spoke models to reduce geographic inequality and extend specialist expertise.

CONCLUSION

KDT is an effective, evidencebased therapy that can significantly improve seizures and quality of life for adults with drug-resistant epilepsy. Access to specialist adult services in the UK remains extremely limited, leaving many without the opportunity to trial a therapy endorsed by NICE and widely used in paediatric care. For young people established on KDT, the transition to adulthood is too often marked by uncertainty, prolonged waiting or loss of support.

Addressing the adult KDT provision gap is essential to ensuring equity, continuity of care and optimal long-term outcomes. With coordinated national attention, clear commissioning pathways and strengthened workforce capacity, the UK can build an adult KDT service landscape that meets the needs of this growing population.

PATIENT PERSPECTIVE:

Andrew’s story

I’m 59 and was diagnosed with epilepsy around 17 years ago. My seizures began suddenly and included several long absence episodes each week. After trying different medications, I eventually found a combination that helped manage the condition. However, I’ve never liked taking medication and always hoped to reduce it. Since starting the KDT, I’ve been able to lower the dose of both medications over time. This has made a huge difference. I’m far less drowsy in the mornings and feel more alert throughout the day. Although the diet can be challenging at times, it’s helped reduce my seizures, clear the brain fog and even improve my liver health. I’ve lost some weight too, which has brought my non-alcoholic fatty liver disease (NAFLD) readings back into the normal range.

Finger-prick tests for glucose and ketones can be a nuisance, but they’re a small price to pay for a better quality of life. I’m incredibly grateful to my KDT epilepsy specialist dietitian at my centre, the team at Matthew’s Friends, for their brilliant recipes and the wider adult epilepsy services. Their support has made a real difference to both my physical and mental well-being.

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Diet and ageing: nourishing longevity

Chronological ageing is predictable, but biological ageing is not. While life expectancy has risen over recent decades, the number of years spent in good health has not kept pace. Many individuals now live longer while spending a greater proportion of later life affected by chronic disease. This widening gap between years lived and healthy years lived has prompted research into modifiable influences of ageing, with diet being one of them. Nutrition is important throughout one’s life. Across adulthood, dietary patterns shape the body’s capacity to repair tissue, regulate metabolism, preserve skeletal muscle and maintain cognitive and immune function. Evidence consistently demonstrates that diet influences nearly every biological pathway implicated in ageing, including inflammation, insulin sensitivity, muscle preservation and gut health.1,2

The National Institute on Aging distinguishes between chronological and biological ageing.3 Chronological ageing reflects the number of years since birth, whereas biological ageing describes the functional state of cells, tissues and organs. Biological ageing is driven by the cumulative effects of

molecular and cellular damage over time and can progress independently of chronological age, helping to explain why individuals of the same age may experience markedly different quality of life.

Ageing is often framed as a simple function of time, and it is to an extent, but biologically it is driven by complex, interacting processes. Diet strongly affects how quickly we age (biologically), influencing disease risk, cellular ageing, oxidative stress and DNA damage.4 Nutrients are more than just energy sources. For example, protein intake regulates muscle protein synthesis; fibre alters gut microbiota; fat quality influences inflammation; and micronutrients support DNA repair, neurological integrity and mitochondrial function.2

Public health bodies increasingly recognise diet as central to healthy ageing. WHO defines healthy ageing as the maintenance of functional ability rather than simply the absence of disease.5 Similarly, the National Institute on Aging emphasises lifestyle factors, including nutrition, as key determinants of biological ageing trajectories.6

Zoe Reape ANutr

PROTEIN

Loss of muscle mass and strength (sarcopenia) is one of the most significant predictors of frailty, disability and disease in older age. Skeletal muscle plays a central role in glucose regulation, bone protection, immune resilience and physical independence.7 In fact, grip strength is a key determinant of mortality.

From midlife onwards, muscle tissue becomes less responsive to dietary protein (anabolic resistance). As a result, older adults require higher protein intake and exercise to achieve the same stimulation of muscle protein synthesis as seen in younger individuals.8,9 This is more pronounced for women in menopause, who lose muscle at a faster rate due to declining oestrogen.

To help preserve muscle mass, strength and function in older adults, current evidence supports both a higher total protein intake (above the existing RDA) and an even distribution of protein across meals, rather than concentrating it in a single sitting.8,10 Studies show that adequate protein intake combined with resistance training slows sarcopenia and

osteoporosis, improves strength and supports metabolic health across ageing populations.7,9 In this context, protein is not about physique or performance; it is a foundational nutrient for maintaining independence and quality of life as we age.

FIBRE AND THE GUT MICROBIOME

The gut microbiome has emerged as a central regulator of ageing biology. With age, microbial diversity often declines, a change associated with increased systemic inflammation, immune dysfunction and frailty.11

Dietary fibre is the primary lever for beneficial gut bacteria. Its fermentation produces short-chain fatty acids, such as butyrate, which strengthen gut barrier integrity, regulate immune responses and reduce chronic inflammation.12 Highfibre plant-based diets are associated with more gut diversity and a composition that promotes health and youthfulness.13 Large population studies show that higher fibre intake is associated with reduced all-cause mortality, cardiovascular disease and metabolic dysfunction.12

Importantly, research suggests that diversity of plant intake, rather than fibre from a narrow set of foods, is key to maintaining microbial resilience across the lifespan.

BLOOD SUGAR AND INSULIN

Metabolic health is one of the strongest predictors of ageing outcomes. Chronically elevated blood glucose and insulin accelerate vascular damage, oxidative stress and inflammatory signalling, increasing the risk of cardiovascular disease, obesity, dementia and frailty.14

From a dietary perspective, the goal is not carbohydrate elimination, but beneficial swaps from simple to complex carbohydrates. Meals that combine protein, fibre and fats reduce post-meal glucose spikes and insulin demand, supporting long-term metabolic health. However, with age, insulin sensitivity declines and high fasting glucose is observed. A higher amount of visceral fat and inflammation contributes to an unfavourable blood glucose profile, which in turn elevates disease risk such as T2D and Alzheimer’s.15 Diet and physical activity (alongside medication) can successfully help manage insulin and blood glucose.16

FAT QUALITY, INFLAMMATION AND BRAIN AGEING

Dietary fat quality plays a central role in shaping inflammation, vascular integrity and long-term cognitive health. While total fat intake has historically been the focus of dietary guidance, evidence points to fat type and dietary context as more relevant determinants of ageing outcomes than fat intake alone.

Omega-3 polyunsaturated fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are consistently associated with anti-inflammatory effects and protection against cardiovascular and neurological decline. These fatty acids are integral components of cell membranes, influencing membrane fluidity, receptor function and intracellular signalling pathways. In neural tissue, DHA is concentrated in synaptic membranes, where it supports neurotransmission and neuroplasticity.17

Omega-3 fatty acids modulate inflammation through multiple pathways. This is particularly relevant in the context of ageing, where chronic low-grade inflammation

contributes to endothelial dysfunction, arterial stiffness and blood-brain barrier permeability. Observational and interventional studies suggest that higher omega-3 intake is associated with slower cognitive decline, improved vascular function and reduced all-cause mortality, although effect sizes vary depending on baseline nutritional status and overall dietary pattern.18

In contrast, diets characterised by high intake of UPFs often deliver excessive amounts of industrial trans fats and saturated fats alongside refined carbohydrates and low fibre. This combination promotes oxidative stress and systemic inflammation, all of which accelerate vascular ageing. Evidence from large cohort studies and metaanalyses consistently links trans fat intake with increased cardiovascular events and mortality, leading to widespread recommendations for their elimination from the food supply.19 Importantly, the inflammatory impact of saturated fats appears to be context-dependent, with whole-food sources behaving differently, especially in foods such as milk and yoghurt.

This reframes fat guidance towards dietary pattern quality. Emphasising sources of unsaturated fats, such as oily fish, extra-virgin olive oil, nuts, seeds and avocados, while minimising UPFs, aligns fat intake with cardiovascular and cognitive ageing goals.

NOURISHMENT FOR LONGEVITY

When nutrition science examines whole dietary patterns rather than individual nutrients, clear themes emerge. Diets associated with longevity, including Mediterranean, Nordic and traditional Japanese patterns, share high fibre intake, adequate protein, healthy fats and minimal UPFs. Large trials demonstrate reduced cardiovascular events and mortality with Mediterranean dietary patterns.20 Observational studies link these patterns to better cognitive and metabolic ageing outcomes.2

Longevity observed in so-called Blue Zone populations reflects not only diet, but also social connection, movement and cultural sustainability. Nutrition is most effective when embedded in a supportive lifestyle, not pursued in isolation.

It is also worth noting what longevity nutrition is not. It is not about perfection, superfoods, detoxes or chronic restriction. It is not about eating progressively less with age. Inadequate energy, protein and micronutrient intake accelerates muscle loss, fatigue and metabolic decline, particularly in women going through or at the other side of menopause. The strongest evidence supports nourishment and consistency over dietary extremes.

CONCLUSION

Ageing well is shaped by the cumulative impact of dietary choices rather than any single nutrient. A diet rich in protein, fibre, healthy fats and micronutrients supports muscle, metabolism, gut health and cognition, creating resilience as biological demands change.

Nutrition can influence ageing at any stage, so optimising dietary patterns is a powerful tool for maintaining health, function and independence in later life.

Blended diet in enteral nutrition: expanding evidence and practice

Duncan RD

Blended diet (BD), or blenderised diet, is becoming increasingly common in dietetic practice.1,2 BD is not a new practice but is growing in popularity, and as it does so, the evidence supporting it for paediatric patients is expanding.3,4 This article discusses the benefits and concerns surrounding BD in paediatrics.

With the increase in interest and provision of BD, dietitians have been leading the development of guidelines, research into efficacy and management of patient and carer expectations.5 As dietitians, we must first consider patient safety, how to ensure nutritional adequacy of blends and ensure patients and carers are heard and their viewpoints included.2,6 BD is not suitable for all patients; however, dietitians should be able to justify recommendations to ensure patient autonomy is respected, while navigating the ever-expanding research base.7

WHY

BLENDED DIET?

There has been a significant increase in the number of paediatric families exploring BD over the past decade, despite the practice itself existing for many years.1,3 Several key factors now influence both family decision-making and professional opinion regarding this shift:

1. A push towards patient-centred care

Families frequently report that BD feels more ‘normal’ and closely aligned with typical family mealtimes, promoting inclusion and emotional well-being for both children and carers.2,8 Parents also describe feeling empowered by the ability to prepare food for their child, supporting autonomy and reducing the medicalisation of feeding.9 These perspectives align with wider movements towards patient-centred and relationshipcentred care in paediatric nutrition.7

2. Growing reports of gastrointestinal tolerance

A growing body of evidence indicates that many children receiving BD experience improved gastrointestinal symptoms, including reductions in reflux, gagging, retching and constipation.5,10 Improvements may relate to the higher viscosity, fibre content and diversity of whole foods, which can positively influence gut motility, tolerance and stool patterns.1,11 BD may also support a more favourable gut microbiota profile, contributing to reduced inflammation and improved GI function.4,9

3. Whole food trends and concerns about ultra-processed foods

Public awareness of whole food nutrition and concerns around ultra-processed foods (UPFs) has risen sharply in recent years, partly due to media coverage and social media influence. Families may therefore prefer food-based enteral options, perceiving them as more natural or healthier alternatives to commercial formulas.6,11 While not all messages circulating online are evidence-based, these influences contribute to increased interest in BD.9

4. Availability of commercial formula alternatives

Commercially produced formulas containing whole food ingredients have become more widely available and provide an option for families seeking the benefits of BD without the full preparation workload.10,11 Research suggests that these products may offer similar improvements in GI tolerance for some children.5 Additionally, companies have developed freshfood blends in preprepared pouches, offering convenience for families during travel or when kitchen access is limited.6

WHAT DOES THE MOST RECENT RESEARCH TELL US?

While randomised controlled trials remain limited, observational studies, case series and qualitative research consistently demonstrate several key themes across paediatric populations receiving BD:1,3

1. GI tolerance and symptom relief

Multiple studies report improved gastrointestinal symptoms in children with complex medical needs after transitioning to BD, including reductions in vomiting, retching, reflux and gagging.5,10 These improvements have also been observed in children with neurological impairment, severe

Hazel

Relative energy deficiency in sport But I’m not an elite athlete

When we think of under-fuelling and burnout, we picture elite athletes pushing their limits in high-pressure environments. But what if someone is not an Olympian or professional runner? That’s where relative energy deficiency in sport (RED-S) comes in.

RED-S is becoming increasingly common in recreational athletes, university students and even those who just enjoy regular exercise.1 It doesn’t require professional training volume; instead, it is a mismatch between what the body uses and what it is given.

RED-S was introduced by the International Olympic Committee (IOC) in 2014, evolving from the earlier concept of the female athlete triad, which focused on disordered eating, menstrual issues and bone health.2 RED-S recognises that anyone of any gender can be affected, and that low energy availability impacts multiple systems in the body. The 2018 IOC update recognised that RED-S can affect nearly every bodily system, including cardiovascular, gastrointestinal and psychological health, as well as reproductive or skeletal health.3

At the heart of RED-S is low energy availability, which is when the body doesn’t have enough calories left after exercise to support everyday functions like hormone production, immunity or bone maintenance, and starts cutting corners to protect its vital systems.4

While elite athletes have carefully tailored nutrition plans, recovery schedules, physiotherapy and sports science teams, most of us are doing the opposite. We squeeze in workouts between lectures or jobs, skip meals, over-caffeinate and call it ‘balance’. It’s easy to fall into low energy availability without noticing, especially when it’s praised as discipline or self-care.5

WHAT ARE THE SIGNS AND SYMPTOMS OF RED-S?

• Constant tiredness

• Missed or irregular periods

• Low libido or hormonal disruptions

• Poor workout recovery

• Mood changes

• Weakened immunity

• Digestive issues

• Plateauing performance

Over time, RED-S can lead to low bone density, stress fractures, infertility6 and metabolic issues.3,7

WHY IS RED-S OVERLOOKED?

Many people with RED-S are within normal weight ranges and appear fit and healthy.8 In some sports and fitness circles, the early warning signs – like low appetite, exhaustion or missing periods –are brushed off as ‘part of training’.9

WHAT CAN YOU DO?

The good news is that RED-S is reversible, especially when caught

early. The first step is making sure you’re eating enough to meet your body’s energy demands. This means fuelling regularly throughout the day with balanced meals that include carbohydrates, fats and protein, and not skipping snacks when you’re active or busy.10 Rest is just as important; full rest days are essential for recovery and preventing burnout.3,10

Monitor your body’s signals. For example, your menstrual cycle can be a key sign of hormonal health, and irregularities like missed periods shouldn’t be ignored.6 Question the mindset that being busy or ‘always on’ means you don’t need proper fuel. Seek support. If you notice ongoing fatigue, hormonal changes or a drop in performance, speak to a GP or registered dietitian with experience in performance nutrition. Early recognition and intervention can make a big difference and may prevent more serious health consequences.3

CONCLUSION

When trying to be our best selves, we sometimes forget to meet our body’s basic needs. Knowing about RED-S isn’t just about avoiding injury, it’s about recognising that your health, hormones and energy levels are important. You don’t need to earn your food. You don’t need to justify your rest. And you don’t need to reach burnout before taking your symptoms seriously.

A longer version of this

student-written article is available here: www.nhdmag.co.uk/student-hub

Elizabeth Turnell STUDENT