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

NHDmag.com

Dec 2017/Jan 2018: Issue 130

FREELANCE PRACTICE: ADVICE ON MOVING FORWARD

ERAS BREASTFEEDING UPDATE IMD WATCH IRRITABLE BOWEL SYNDROME

Saturated fat & heart disease pages 16-18


FROM THE EDITOR

WELCOME Emma Coates Editor

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

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

Welcome to this final issue of 2017. Another year almost done and dusted… like watching Usain Bolt blasting his way down the 100m straight, it seems this year has passed us by in record-breaking speed, but we’ve had plenty of time to enjoy ourselves in the process. The team here at NHD are incredibly proud to have put together another fine set of issues throughout this year, uncovering many new contributors and continuing to work with valued regular writers, to record the ongoing development of nutrition and dietetics. And this kind of ‘happily ever after’ is one to finish the year on, rather than a cliffhanger and there’s no twist in the plot to confuse you! Our Cover Story focuses on freelance practice, a career path for dietitians to consider. It can be daunting and confusing with big questions as to how and where to start. However, we asked Priya Tew, a successful freelance dietitian, to share her advice for anyone stepping in to freelance working or existing freelancers who need a bit of an update. Perhaps a new direction for the new year starts here . . . Maeve Hanan provides an overview of breastfeeding, reviewing the current situation and the public health strategies in place to improve uptake and maintenance of this important start to infant feeding. Maeve also contributes an article on saturated fats and the debate around whether or not they are the culprits in the development of heart disease. We welcome Naomi Johnson from the BSNA who guides us through the importance of ERAS (Enhanced Recovery After Surgery), looking at the positive impact of optimising nutritional status both pre- and post-operatively. The FODMAP diet has become a regular dietary treatment option for IBS over the last (almost) 10 years, from its development at Monash University,

Melbourne in 2008, to its adaption for the UK and BDA recognition in 200910 and it is now widely available. Rebecca Gasche RD discusses the diet and its role in the management of IBS symptoms, with a review of current evidence for its use. We have a duo of metabolic articles this month as part of our IMD Watch feature. Lisa Gaff and Nicole Mills share their experience of following a low protein diet for seven days. A challenging diet, which is achievable with a great deal of effort and commitment. Anita MacDonald, Karen Van Wyk, Rachel Skeath and Pat Portnoi talk us through their collaborative work to develop a range of teaching materials for use with parents who have children living with an inherited metabolic disease. TEMPLE (Tools Enabling Metabolic Parents LEarning) is available via the BIMDG website (for details see page 34). Throughout 2017, there was no escaping the unfolding saga of Brexit in the media and there’ll be much more to come in 2018; it’s really not too far away now! Michele Sadler discusses the implication of this epic political shift on the UK’s food industry and regulation. Don’t’ forget we also have our regular features from Ursula Arens and Dietitian’s Life, alongside more from Professor Simon Langley-Evans, who tells us about the Future Dietitian 2025 programme. So, all that remains to say is, Goodbye 2017, Hello 2018. We wish you all a Merry Christmas and best wishes for a healthy New Year! Emma

www.NHDmag.com December 2017/January 2018 - Issue 130

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11 COVER STORY

CONTENTS

Freelance Practice: advice for moving forward 6

News

8

Face to face

Latest industry and product updates

With Farhat Hamid

16 Saturated fat and heart disease Are they linked?

19 ENHANCED RECOVERY AFTER SURGERY The role of nutrition

37 BREXIT & FOOD REGULATIONS The potential impact 41 Irritable bowel syndrome The low FODMAP diet 45 Energy foods How best to fuel the active 48 Prof Blog The future dietitian

23 Breastfeeding An update on public health strategies

49 Book review Hunger: A Memoir of

29 to 36 IMD WATCH

(My) Body

50 Events and courses Dates for your diary

- PKU diet challenge - The TEMPLE teaching project

51 Dietitian's life by Louise Robertson

Copyright 2017. All rights reserved. NH Publishing Ltd. Errors and omissions are not the responsibility of the publishers or the editorial staff. Opinions expressed are not necessarily those of the publisher or the editorial staff. Unless specifically stated, goods and/or services are not formally endorsed by NH Publishing Ltd which does not guarantee or endorse or accept any liability for any goods, services and/or job roles featured in this publication. Contributions and letters are welcome. Please email only to info@networkhealthgroup.co.uk and include daytime contact phone number for verification purposes. Unless previously agreed all unsolicited contributions will not receive payment if published. All paid and unpaid submissions may be edited for space, taste and style reasons.

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

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Advertising Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk Phone 0845 450 2125 (local call rate) Fax 0844 774 7514 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

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@NHDmagazine ISSN 2398-8754


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NEWS

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Dr Emma Derbyshire Independent Consultant Emma heads Nutritional Insight Ltd, an independent consultancy to industry, government and PR agencies. An avid writer for academic journals and media, her specialist areas are maternal nutrition, child nutrition and functional foods. www.nutritionalinsight.co.uk @DrDerbyshire

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LATEST INSIGHTS: A FOCUS ON IRON The American Journal of Human Nutrition has recently published a special supplements and symposia edition focusing on iron and health. I read this with much interest, as I did some research in this area a few years ago. High rates of iron deficiency, particularly amongst women, poor compliance with iron supplements and the need to develop accurate but cost-effective biomarkers of iron status were the main areas that needed driving forward. So, let’s take a look and see how the field has come along . . . Iron Deficiency - who is most affected? Latest data from 15 European countries shows that more than half of women in their childbearing years have small or depleted iron stores.1 This, in turn, has a domino effect on pregnancy, infants and the very young. For example, it was calculated that only a third of women have enough iron ‘stocked up’ to complete a pregnancy without the need for an iron supplement.1 So, new research also showing that about half of all infants born in Europe (up to 48%) are also iron deficient, is really not that surprising.2 Iron intakes in children aged six to 36 months still tend to be below the recommended dietary allowance, which does not help the problem. Young children are also less able to regulate iron.3 Whilst a degree of iron homeostasis kicks in at around nine months into infancy, the question about how effective this is remains largely unanswered.3 Biomarker progressions When it comes to markers of iron status the science has moved forward a few steps, but much remains to be done. It is clear that aligned definitions of iron deficiency, anaemia, iron repletion and excess are still needed. Cut-offs for markers of iron stores, such as serum ferritin, also need to be re-evaluated. These are not particularly accurate, as they were derived around 30 years ago and do not take ethnic or genetic factors on board.4 One thing that we do now know is that ethnicity and genotype can influence iron status.5 The movement towards measuring ‘total body iron’ does, however, seem to be a promising way forward. This involves the application of an algorithm that uses serum transferrin receptor levels and serum ferritin, thus covering the full range of iron status. Roundup This was a really interesting edition and of great value for anyone interested in the field of iron and health. What is clear is that we need to keep going with the research. Ongoing interventions are needed to test the efficacy of ways in which iron status can be improved. Aligned definitions and revised cut-offs also need to pave their way into the field and be consistently engrained across new research. References 1 Milman N et al (2017). Iron status in pregnant women and women of reproductive age in Europe. Am J Clin Nutr doi:10.3945/ ajcn.117.156000 2 van der Merwe LF and Eussen SR (2017). Iron status of young children in Europe. Am J Clin Nutr. doi:10.3945/ajcn.117.156018 3 Lönnerdal B (2017). Development of iron homeostasis in infants and young children. Am J Clin Nutr doi:10.3945/ ajcn.117.155820 4 Daru J et al (2017). Serum ferritin as an indicator of iron status: what do we need to know? Am J Clin Nutr doi:10.3945/ ajcn.117.155960 5 Gordeuk VR and Brannon PM (2017). Ethnic and genetic factors of iron status in women of reproductive age. Am J Clin Nutr doi:10.3945/ajcn.117.155853

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www.NHDmag.com December 2017/January 2018 - Issue 130


NEWS COWS’ MILK ALLERGY: IMPROVEMENT IN DIAGNOSIS STILL NEEDED The largest online survey1 of parents of children with cows’ milk allergy (CMA) in the UK, conducted by Allergy UK, confirms that there has been little improvement in the time it takes to get a diagnosis in the last five years.1 Comparative parent data from 2017 and 2012 shows that despite healthcare professionals (HCPs) demonstrating improved awareness and confidence, there is still work to be done to identify CMA sooner. 15% of parents had visited their GP 10 times or more between presenting their child’s problem and diagnosis of CMA, and 43% of cases waited between three months and a year.1 Despite this, there are some positive signs of improvement, with GPs now diagnosing nearly a third of cases (32%),1 more than double the 2012 figure,2 with the remainder diagnosed in secondary care.1 New iMAP guidelines3 (International Milk Allergy in Primary Care) provide GPs with clear and definitive support to help identify and manage this complex and distressing condition. Combining the essential advice within the recent UK NICE guidance, it has been created to facilitate accurate diagnosis and treatment pathway for suspected or diagnosed CMA. For the new iMAP guidelines and to find out more about the

issues facing parents of children diagnosed with CMA, visit www. allergyuk.org/CMAparentfeedback References 1 Survey of 2,852 parents of children diagnosed with CMA conducted in July 2017. Data on file 2 Survey of 328 parents of children diagnosed with CMA conducted in May 2012. Data on file 3 Venter, C et al (2017). Better recognition, diagnosis and management of non-IgE-mediated cows’ milk allergy in infancy: iMap - an international interpretation of the MAP (Milk Allergy in Primary Care) guideline. Clin Transl Allergy. August, Vol 7, no 26

INFANT & TODDLER FORUM (ITF) LAUNCHES CHAT CHAT is a new online educational programme from leading health and nutrition experts. Offering online and face-to-face training, CHAT aims to increase practitioner confidence in engaging and supporting families in order for them to make improvements to their lifestyles. Combining the ‘knowledge of healthy behaviours in early life’ with Healthy Conversation Skills (HCS), this unique, scalable and transferable intervention will help achieve current government targets to combat maternal and childhood obesity through the MECC mandate. CHAT has already delivered positive results in a recent pilot with the Pre-school Learning Alliance. Of the 70 respondents, the majority (80%) reported a significant increase in confidence when giving advice on nutrition and lifestyle post training. Dr Wendy Lawrence, Associate Professor of Health Psychology at the University of Southampton leads the development and delivery of HCS training. She explains the value of HCS: “This programme aids implementation of the MECC mandate by providing practitioners with the skills to initiate difficult conversations on sensitive health-related topics and more effectively support individuals to make meaningful and long-lasting changes.”

For more information on the face-to-face training: www.infantand toddlerforum.org/health-childcare-professionals/healthy-conversation

GUT FLORA FLOURISHES AT DIFFERENT TIMES OF DAY A new article published in The American Journal of Clinical Nutrition has found that the time of day and our eating behavior can affect how bacterial flora flourishes in our gut. The research analysed 77 samples of poop from 28 healthy men and women. Data on eating frequency, timing of meals and length of overnight fasting were also collected. It was found that gut microbiota is in fact highly variable throughout the day. The timing of eating and length of overnight fasting, in particular, determine how bacterial populations accumulate in the gut. So, it seems that we need to be looking at the ‘bigger picture’ when it comes to our gut flora and how our general lifestyle habits can affect this.

For more information, see: Kaczmarek JL et al (2017). Time of day and eating behaviors are associated with the composition and function of the human gastrointestinal microbiota. American Journal of Clinical Nutrition; 10.3945/ajcn.117.156380 www.NHDmag.com December 2017/January 2018 - Issue 130

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F2F

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

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

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FARHAT HAMID Head of Nutrition and Dietetics, Brent Public Health Advocate

There are many reasons to eat cake: to share celebration; because it tastes wonderful; to self-comfort after exertion or stress; or, in my meeting with dietitian Farhat Hamid, because the café was deserted and we needed to push the order up beyond cups of tea, as a way of paying table rent. And it was delicious warm apple strudel with custard: just the thing to sweeten our discussions about dietetics. Farhat is the Head of Nutrition and Dietetics for Brent, at London North West Healthcare NHS Trust, and clearly enjoys grabbing every opportunity to promote the work of the dietetic profession. You could describe her as pushy, or you could choose other descriptions with the letter ‘P’: pro-active, persuasive and passionate. Getting things done is clearly what drives Farhat and she shares her long career of achievements with me. She came from Pakistan to the UK as a young teenager and had the dual challenges of learning a new culture and language. Her hard work led to four great A-levels and a careers teacher’s random suggestion led Farhat to choose to study Dietetics. She really enjoyed her student days at the University or Surrey. “I particularly loved my placement with the infant formula company Milupa. They not only gave me some opportunities to travel across the UK, but also to lead on various creative projects,” said Farhat. Her first job was at Sandwell Hospital in the Midlands, followed by a job in

www.NHDmag.com December 2017/January 2018 - Issue 130

the London borough of Haringey. The latter was a community post, so involved health education, and support for diverse specialist services such as mental health, infant nutrition or the then early days of HIV care. “Public health projects have always excited me the most, and my interest was sparked then,” said Farhat. In 1989, Farhat became Chief Dietitian at Parkside Health NHS Trust. This remains her geographical patch, but, of course, much has changed, not least that the number of dietitians employed has grown from three to 46. She lists many additional managerial responsibilities, such as being General Manager for Long Term Conditions, Chair of a Practice Based Commissioning Cluster and Chair of the Professional Executive Committee: not being familiar with NHS decision structures, I try to clasp these many roles, but they all escape my mind like released birds. But the pattern is very clear: Farhat always seeks to step into challenging roles to seize greater influence and recognition for the dietetic profession. “Some of these roles were new and seemed scary. It was comforting to find that other Board members felt the same and we all faced a learning curve whilst working with multi-million pound budgets. However, you always come out stronger and ready to face even more difficult challenges,” said Farhat.


Had she had any time-out in her 28-year period at Brent? Aside from three maternity breaks, the answer is, “No. I did consider going part-time, but decided that I would just be doing the same work load in fewer days, so that did not seem sensible. I did have an 18-month secondment at the Department of Health, as part of The Top Talent NHS Leadership programme. I was particularly involved with projects supporting NHS-wide equality and diversity policies, and really enjoyed getting nationwide perspectives on difficult issues.” She is one of 13 national advocates under a scheme to increase the participation of allied health professionals in public health (captured as AHP4PH; no doubt someone will claim this as a car number plate). She applied by submitting a project describing a community-based course for black and minority ethnic participants diagnosed with prediabetes. Data of excellent attendance and improved health evaluations impressed the AHP4PH project team, and Farhat is keen to continue these lifestyle courses. Her only frustration is that many such projects are occasional events when small funding amounts become available, rather than becoming firm longer-term commitments built into core NHS services. In fact, she has declined some projects where there is an imbalance between settingup costs and recruitment efforts and small oneoff funds offered. But Farhat is not the first NHS manager facing high service demands with finite resources. Another achievement is her prize as ‘Innovator of the Year 2017’ at the Trust Excellence Awards. She constantly seeks diverse funding sources and has clearly mastered the arts of tendering and writing business plans. She won all of the four bids she submitted in recent years, which brought in sufficient funding to pay for 13 additional dietetic posts. Of course, this is a great success for northwest Londoners, who now have greater access to dietetic services. But the projects also led to a series

of publications resulting in a clinically effective intensive lifestyle programme that Farhat has mainstreamed in her local dietetic service. Farhat feels that the British Dietetic Association is currently better and stronger at supporting its members, and she is a member of the steering group of the Future Dietitian 2025 project (turn to our Prof Blog on page 48 for more on this project). This is an exciting opportunity to consider possibilities as well as threats to the profession and find ways to raise our visibility amongst medical colleagues and in the media. The issues she particularly supports are greater diversity within the profession: ethnically, culturally and in attracting more men into dietetics. “Dietitians can sometimes be a bit demure and passive and a greater mix of people would support the vigour of the whole profession,” said Fahrat. She is also keen to pull more dietetic services out of hospitals and into more accessible and familiar community settings supporting the national policy of the Five Year Forward View. This is especially important at providing care for hard-to-reach population groups. She supports better training for student dietitians: to think laterally and to think outside of boxes; to become more entrepreneurial and risk taking. She is all of these things, but I query whether these skills and attributes can be taught. She laughs because I am being obtuse and insists that she does much to push and support her students and staff into greater actions and participation. But she agrees that perhaps these are not solely curriculum items. She hints that two great role models in her life - her ever-supportive father and her husband - may have been her greatest teachers (but they are not available to other dietitians!). As I walked back to the underground, I noticed graffiti sprayed on the wall. It proclaimed, ‘carpe diem’. This was more likely to have been done by some teenager; had it been Farhat, it would have been, carpe diem dietetica.

If you would like to suggest a F2F date

(someone who is a ‘shaker and mover’ in UK nutrition) for Ursula, please contact:

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COVER STORY

FREELANCE PRACTICE: ADVICE FOR MOVING FORWARDS Priya Tew Freelance Dietitian and Specialist in Eating Disorders

Priya runs Dietitian UK, a freelance dietetic service that specialises in social media and media work, consultancy for food companies, eating disorder support, IBS and Chronic Fatigue. She works with NHS services, The Priory Hospital group and private clinics as well as providing Skype support to clients nationwide.

The numbers of dietitian’s moving into freelance practice seems to be everincreasing. As someone who has always done some freelance work, but also had an NHS role, I know the highs and lows of working for yourself. Here is my advice for making your freelance role a success. JOINT WORKING WITH OTHER DIETITIANS

When I started out, a lot of the work I cut my teeth on was for other dietitians. There were a few dietitians who would subcontract parts of projects out to me; in fact, I still do this type of work now. I actually love it, it is safe and just like working within a department. You can ask for advice and get your work checked afterwards to see if you have missed anything. This style of working also means that you yourself could take on a larger project and subcontract it out to others; for example, if a local student approaches you asking for work experience, could you offer them some tasks that would help you out? BUILD YOUR OWN VIRTUAL DEPARTMENT

One of the big low points of freelance work for me has been the lone working. If

you suddenly have a question to ask, you want to double-check something, need to borrow a diet sheet or pick someone’s brains, you just can’t nip into the next door office. I’m someone who loves working on my own, but I also thrive when connected with others who inspire me, encourage me and do what I do. Until recently it hasn’t been easy to have access to a supportive network. Bring on social media and this has been created for us overnight. Back in my early days on Twitter, I remember being so excited to suddenly find other dietitians, to chat to them and get a response, to meet GPs and physiotherapists. Now there is no end to this, there are groups on LinkedIn, Facebook, Instagram and a constant presence on Twitter. Join in Twitter chats to meet others; if you can’t make them at the right time, then

Table 1: Social media groups for dietitians Facebook

LinkedIn

Twitter chats

Freelance/Private Practice Dietitians Group: www.facebook. com/groups/freelancedietitianssup portandclinicalsupervision/?fref=nf Great for chatter, asking questions and sharing resources

British Dietetic Association: members only: www.linkedin.com/ groups/1968119

Look for your local hours, these can be good for connecting with local businesses, building your profile and meeting others who you could work with, e.g. #hampshirehour #dorsethour

Dietitians in Virtual Practice: www.facebook.com/groups/ virtualpracticenetworkdietitians/ Useful to connect with others and hear what other RDs are up to

Freelance Dietitians: www.linkedin. com/groups/4123162 Good for work opportunities, webinars and CPD ideas

#RDUK is now a well-known and well-attended Twitter chat that is fabulous for meeting other likeminded people and for learning from each other. It is usually on the first Monday of the month 7.30-8.30pm

Dietitian Entrepreneurs: www.facebook.com/groups/ dietitianentrepreneurs/ Useful to ask questions and get an international flavour

Dietitian Connection Group:www. linkedin.com/groups/4471878 For webinars, blogs and business tips.

The Rooted Project Book Club #TRPBookclub is hosted at times throughout the year and is a good way of discussing a subject, as well as a nice hour of chatter

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SKILLS & LEARNING Table 2: Ideas of what to tweet/share about on social media Professional

Personal

CPD

Media quotes

Recipes you are cooking

Share events that you are going to, or that others are running

Articles you have written and your blog posts

Pictures of your meals at home

RT the science or research from others in the field

Summary of your clinic and work for the day

How you plan your own eating and nutrition

When you read an article, share the main points as tweets or a blog post

Top tips on nutrition

Personal views on foods and new products

Search for hashtags on areas you are interested in and share the content

Campaigns that are happening

Nutrition books you are reading and cookery books

Join in twitter chats and webinars

Business

Dietetic/nutrition

Speciality

Perpetual Traffic (Social Media and Web tips)

Dietitian Connection

The Guru Performance Podcast (Sports Nutrition)

Soulful PR

Food Psych Podcast

Recovery Warriors (Eating Disorders)

Being Boss

Don’t Salt my Game

The Gut loving Podcast (IBS)

Research that you are involved with Talks you are giving Table 3: Dietetic podcasts of interest

Online Marketing Made Easy

you can always catch up later on by searching for the hashtag. The huge plus of these groups is that there are so many people in them, so instead of a department of 10 people, you could have access to 700 people! Obviously, not everyone will comment and reply to you, but you will soon find people who you connect with and build relationships with. Who knows where those connections could take you. If you are like me and you like to be connected, then here are some of those social media groups to try out (see Table 1). PUT YOURSELF OUT THERE ON SOCIAL MEDIA

Social media has been a career changer for me, but it can also be an ever-changing place and very exposed. I’ve certainly been stung a few times with negativity and trolls. However, the positives outweigh the negatives and there are negatives in all areas of life. More healthcare professionals are putting themselves onto social media which is fabulous - we need to get chatting in order to get our professions and the 12

right advice trending. See Table 2 for ideas on what to post on social media. DEFINE YOUR NICHE

When I started in the freelance world, I took all the work that came along. This was good because I got a wide range of experience and I’ve been able to find out exactly the types of work I like and the bits I’m less keen on. Yes, you sometimes may have to do pieces of work that are mundane and uninspiring, but if this is all you do, then why bother? I want these pieces of work to be stepping stones to something else, or I only take on work I am passionate about. Some great advice I was once given was, “Work out what you are good at and then do just that”. If we all focus on the same area of work, then, firstly, the market could be saturated and secondly, there will be large gaps in the nutrition world of work. I specialise in eating disorders because it was my NHS role; I have lots of experience in it and I love it. However, it is also very demanding work when

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