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September 2026

Network Health Dietitians The magazine for dietitians, nutritionists and healthcare professionals

Spectrum disorders Examining dietary interventions medications Surgery vs weight-loss medications Personalising treatment for obesity

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Optimising outcomes for the critically ill

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CONTENTS SEPTEMBER 2026 08

UP FRONT 5 Highlighting COPD IN THE NEWS 6 Latest industry and product updates FOOD FOR THOUGHT 8 Should we silence all food noise? CONDITIONS & DISORDERS 11 COPD: optimising outcomes 23 Autism spectrum disorder:

CLINICAL 18 ERAS: When post-surgery nutrition fails 29 Evolving obesity treatment MYTH BUSTING 26 Collagen claims stretch the truth PAEDIATRIC 33 Infancy and nutrition risk INTERVIEW 36 Lead Adult CF dietitian David Proud on the

evidence-based approaches

DIET & LIFESTYLE 15 Plant-based milk: nutritional considerations

big pivot in cystic fibrosis support

STUDENT HUB 37 Public health placement THE LAST WORD 39 Weight-loss medications in Black and Asian populations

REFERENCES 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 Publishing Director Julieanne Murray Publishing Editor Rachel Roberts Subeditor Lisa Pritchard Copy Assistant Sue Vane Website Content Coordinator Erin Dearlove Marketing Coordinator Ava Blackwood Design Douglas Advertising Manager Richard Mair Tel 01342 824073 richard@networkhealthgroup.co.uk

@networkhealthdietitians Phone 01342 824073 Email publisher@networkhealthgroup.co.uk www.NHDmag.co.uk Address Suite 1, Forest Row Village Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES

@nhd _health_dietitians @NHDmagazine linkedin.com/company/nh-publishing ISSN 2398-8754

CONTRIBUTORS

Emma Coates RD & NHD Editor 5 Up Front

Priya Tew RD 9 Food for Thought

Aliya Porter, RNutr 15 Diet & Lifestyle

Holly Monday-Jones RD Salma Khattak ANutr 18 Clinical 23 Conditions & 11 Conditions & disorders disorders

Emma has been a Registered Dietitian for 18 years, with experience in adult and paediatric dietetics.

Priya is a Specialist Eating Disorders and IBS Dietitian. She runs Dietitian UK, works with the media and is the author of The DASH Diet and The Complete Low FODMAP Diet Plan.

Aliya is a Registered Nutritionist with 20 years’ experience. She’s worked in the voluntary sector, private practice and the NHS and runs Porter Nutrition.

Holly is an Acute, Salma is a Clinical Critical Care and Nutritionist and a Nutrition Support Team freelance writer Lead Dietitian and for nutrition and Student Lead for Betsi dietetics. Her main Cadwaladr University area of interest is Health Board Central the management of area (Glan Clwyd emotional eating and Hospital). She is the weight for women. Founder of HMJ Nutrition Services and HMJ Wellbeing Solutions.

priya_tew

porter_nutrition

priyatew

aliya.porter

priyatew

aliya-porter

HMJ Nutrition Services

coatesyRD

www.dietitianuk.co.uk

porternutrition.co.uk

HMJWellbeing

Madi Myers RNutr 26 Myth Busting

Jen Credicott, RD 29 Clinical

Hazel Duncan RD 33 Paediatric

Deeya Chodha, ANutr 37 Student Hub

Fareeha Jay RD 38 The Last Word

Madi is a Freelance Nutritionist working with individuals, hosting workshops and writing. She works across the food industry and the private sector, promoting the non-diet approach to nutrition.

Jen is a Specialist Hazel is a Paediatric Dietitian working Dietitian and has her across Gloucestershire own private practice, Hospitals NHS Kids Nutrition, which Foundation Trust, provides evidenceprivate practice and her based nutrition own freelance business. advice for infants Her interests include and children. obesity care, bariatric surgery and sustainable behaviour change.

Deeya is an MSc Dietetic student and Registered Associate Nutritionist with experience in public health placements and content creation. She’s passionate about women’s health and public health nutrition.

Fareeha is a Freelance Dietitian providing specialist advice to South Asians across the globe and has developed the South Asian Eatwell Guide.

non_diet_nutrition

jen_dietitian

nondietnutrition

jendietitian

nondietnutrition.co.uk

jendietitian.com

salma.the.nutritionist

dietitian_fareehajay kidsnutritionrd www.kids-nutrition.com

fareehaJay deeyathenutritionist

www.fareehajay.com

UP FRONT

Up front Every breath we take…

Emma Coates

Highlighting COPD

RD & NHD Editor

ello and welcome to the September issue of NHD Magazine. Breathing – it’s something many of us take for granted. We don’t really need to think about it; it just happens. There are times, of course, when we might be more mindful of the way we breathe, perhaps during a yoga class or while meditating. But in the main, it’s just going on in the background for the vast majority of us. Good respiratory health is vital for overall well-being and bodily function. Our lungs ensure the efficient exchange of oxygen and carbon dioxide and provide a defence against infection. Reduced or poor respiratory health can affect daily activities, nutritional intake and status, often leading to a significant reduction in quality of life. Respiratory disease incorporates a broad spectrum of conditions that affect the function and structure of the lungs. From asthma to cancers of the lung and surrounding tissues, pulmonary fibrosis and pneumonia to chronic obstructive pulmonary disease (COPD), common symptoms can include shortness of breath, chest pain or tightness, chronic cough, fatigue, abnormal mucus production, weight loss and loss of appetite.

A LOOK AT THE STATS Lung cancer is one of the most common types of cancer, with more than 43,000 people in the UK diagnosed each year.1 According to NICE, the UK has one of the highest prevalences of asthma in the world, with up to 5.4 million people receiving NHS treatment for the condition.2 COPD is also common, with around 1.7 million people in the UK living with a diagnosis.3 However, it is estimated that approximately 600,000 people in the UK are living with undiagnosed COPD.3

COPD is a progressive condition that may require different treatment and management approaches as symptoms emerge and change over time. As a graduate dietitian many years ago, I was introduced to the condition through my Band 5 rotation, managing inpatients with COPD and delivering patient group education sessions. I soon learned that the role of the dietitian is vital in assessing nutritional status, preventing malnutrition, improving energy levels and supporting respiratory function. Maintaining a healthy body weight is an important nutritional goal for COPD patients, but tailored advice is most certainly needed to help achieve this. Being underweight can reduce muscle strength and impair the body’s ability to fight infections. Conversely, being overweight can place additional strain on the lungs and heart, making breathing more difficult.

Therefore, achieving and maintaining an appropriate weight through a balanced diet or nutritional support is essential. IN THIS ISSUE Our cover story this issue examines a complex aspect of COPD care, with Holly Monday-Jones RD discussing the nutritional management of critically ill patients with COPD. Holly delves into current nutritional support strategies and emerging evidence for future management of this patient group. And don’t forget, we have plenty of other reading material to keep you busy, including Myth Busting with Madi. This month, Madi shakes the evidence tree to dig into the truth about collagen claims, uncovering what the science really says and separating fact from social media and marketing hype. Enjoy the read.

Emma

NEWS

Nutrition in the news NHD's digest of nutrition and industry news

Bite-sized Gym top tip Avocado can be a smart addition to a pre-workout meal.1 Thanks to its fibre content, it can help people feel fuller for longer and maintain steadier energy as part of an active routine. According to the World Avocado Organisation, it can also help in post-workout nourishment and recovery. Keto could crack depression A ketogenic diet – high fat, low carbs – might help treat bipolar depression.2 It’s already known this diet can help with drug-resistant epilepsy. But now, after a promising pilot study, the Wellcome Trust is funding a £7.9 million trial to look at whether it could also help with drug-resistant epilepsy. Weight support swap UK Weight Watchers has expanded its partnership with CheqUp, a digital weight health platform.3 Now, the Weight Watchers website will offer members a CheqUp consultation, while members of the digital platform can access the Weight Watchers app and support. Fill up with flavanols Not all five-a-days are equal, meaning fewer than one in five people get enough flavanols (500mg) into their bodies every day, researchers claim.4 Eating blueberries, plums, blackberries, broad beans and cherries, washed down with green tea, is an ideal way to top them up.

Fresh food freezes out frozen Misplaced ‘fresh-first’ shopping habits are driving higher food bills.5 Half of households throw away fresh vegetables every month, costing families up to £539 a year, according to one frozen food company.5 The manufacturer surveyed 10,750 adults across the UK, France, Germany, Italy, Sweden and Croatia, and found that household savings are being lost due to a persistent perception gap. Many consumers default to fresh over frozen under the false assumption that it’s better in quality and nutrition, only to waste it.

NEWS

Protein washing cleans up Many supermarket ‘high-protein’ snacks may not be as healthy as shoppers believe.6 ‘With protein’ is one of the biggest wellness trends in the UK, driven by millions using GLP-1 medications, which need a highprotein diet. Google searches for the term ‘protein washing’ – a marketing tactic to label products as ‘high in protein’, even when protein content is only moderately higher than standard alternatives – have risen by 488%. Oxford Online Pharmacy conducted a study on 88 high-protein snacks to

find out which products deliver the most protein for your pound and found that:6 • protein yoghurts offer the best value, costing ju st 7p per gram of protein on average; • nearly 90% of products studied contained more sugar than NHS guidelines recommend; • some protein milkshakes contained an adult’s full recommended daily sugar intake; • more than a quarter of products fail to meet the protein needs of GLP-1 medication users trying to protect muscle mass during weight loss.

Bite-sized Eggs-actly the same Supermarket Sainsbury’s is to sell only white own-brand eggs to reduce its carbon footprint.7 There’s no nutritional difference between white and brown eggs; the shell colour is dependent on the breed of the hen, with white eggs coming from white-feathered hens and brown from brown-feathered. The real determinant of an egg's nutritional profile is the hen’s environment and diet. Health inequality warning Nearly a third of adults in England are obese, with disproportionately higher rates among those from disadvantaged backgrounds.8 Rising obesity in young adults risks an intergenerational cycle of health inequality, warns a large-scale study published in The Lancet. Time-saving hack Private clinicians may be interested in a new feature of the Jane assistant app, AI Scribe, which claims to cut documentation time by up to 30%.9 Pilot data from a trial at Great Ormond Street Hospital’s GOSH DRIVE, a hub for digital innovation, found a 51.7% reduction.10

One in four would share weight-loss medication A recent survey commissioned by an online UK pharmacy raised concerns about how some people view prescription weight-management medication.* More than one in four adults (27%) said they would be willing to share oral weight-loss medication with friends or family, rising to 41% among those aged 18-34 years. One in five respondents also said they would consider sharing injectable treatments. The survey also found that 55% of people considering or using weightmanagement medication would feel comfortable using it differently from how it was prescribed. This included reducing the dose, taking breaks from treatment without medical advice, or increasing the dose before holidays or special events.

Healthcare experts warn that prescription-only weight-management medicines should only be used by the person they are prescribed for and according to clinical guidance. They stress that these treatments are most effective when used as part of a wider weight-management programme that includes dietary, lifestyle and behavioural support. *British Polling Council member 3Gem was commissioned to survey a nationally representative sample of 2000 UK adults who are taking, have previously taken, or are considering taking, weight-management treatment. Of this sample, 500 are current users and 500 have previously used such treatment. Fieldwork was carried out from 4–11 June 2026.

Widespread nutrient shortfall triggers fears Experts have described a ‘honeycomb’ of vitamin and mineral deficiencies in millions of people across the UK, with potentially severe consequences for physical and mental well-being. A new report calls out significant shortfalls across a wide range of essential nutrients, with concerning trends among younger populations and women.11 NHD has launched its redesigned website, featuring improved navigation, enhanced resources, including CPD, our dedicated Student and Paediatric Hubs, the latest nutrition news, and a refreshed user experience. Visit: nhdmagazine.co.uk.

FOOD FOR THOUGHT

Should we silence all

food noise? T

wo years ago, almost nobody used the phrase ‘food noise’. Now it is everywhere, used by patients in clinics, seen in the press, on social media, in marketing for every weight-loss jab and in tracking apps. It has become the go-to term for the constant, intrusive internal ‘chatter’ about food that so many people say they struggle with. GLP-1 medications are being highlighted as the solution to switching food noise off. As nutrition professionals, we need to pause and ask a bigger question: not just how do we quieten food noise, but why does it exist in the first place? Is it signalling something that we should help patients understand and address, rather than simply mute? WHAT IS FOOD NOISE? Until very recently, ‘food noise’ had no clinical definition. It began as a colloquial term, reported by patients rather than coined by researchers. Most of the early conversation traces back to people on GLP-1 medications describing a sudden, startling quiet when they start the medications. They describe the relief of no longer thinking about food all day and

of not being constantly preoccupied by what they ate or what they were going to eat. Only in the last year has the term been given a more formal definition. A 2025 paper defined food noise as persistent, intrusive thoughts about food that a person experiences as unwanted or distressing, and that can cause harm to the individual.1 This level of food noise is akin to rumination rather than to biological hunger. People describe this as spending all day thinking about food preparation, where to get food, what their next meal will be, the calories and the macros. Also, people describe worrying about whether they are eating the right foods, whether the balance is correct and whether they’re eating enough or not.

Priya Tew RD

This level of persistent food thought can cause social and psychological distress along with shame and stigma. It can impact working life and can be so distracting it can even cause problems when driving or using machinery.2 NOISE OR HUNGER? This is where I find myself wanting to focus my clinical time. What I see is that a great deal of what gets called food noise is not a malfunction of the brain at all. It’s the body doing exactly what it is designed to do: telling someone that their body needs more food. Picture the patient who has been dieting for months. She is cutting carbs, watching her portions, ‘being good’, eating fewer calories and constantly tracking her intake on an app. She reports that she cannot stop thinking about food – to the extent she plans her next meal while she is still eating this one; she thinks about the biscuits in the cupboard on the drive home; she feels as though her whole life has narrowed

FOOD FOR THOUGHT

to what she can and cannot have. Is that a brain that needs medicating? Or is it a hungry body trying to say that it is not getting enough? The research on restrictive eating goes back decades, and the Minnesota Starvation Experiment is a key part of the evidence base.2 When we restrict food, the body lets us know, and preoccupation with food is one of the loudest ways it does so. Higher dietary restraint is associated with more intrusive thoughts about eating. Once someone has lost weight, ghrelin stays elevated and leptin drops, keeping the brain in a food-seeking state. When we quieten food noise, we risk quietening the body’s whole communication system. For a great many people, I would suggest food noise is not something to be silenced but something to be explored, to work out why it is happening. It can be that what is needed is permission and support to eat enough so that food noise settles on its own. Saying, “It’s just hunger, eat a bit more” is not only unhelpful, but it’s also dismissive. For the patients I work with the most, this matters enormously. Preoccupation with food is a textbook feature of restriction and of eating disorders. It’s not a glitch to be pharmacologically muted; it is a signal to be understood. When the wider culture tells someone in recovery that their food thoughts are ‘noise’ to be eliminated, we are encouraging the exact opposite of what the body needs. Recovery is so often about eating enough that the noise fades and then learning to let the thoughts that remain simply exist, without panic and without reaching for a fix. SOME PEOPLE ARE MORE REACTIVE TO FOOD While it’s easy to declare that food noise is simply restriction in disguise, that’s also not the case for some people. There’s a group of people for whom food thoughts are genuinely intrusive even when they are well-fed and not restricting at all. In our Western food environment, we’re surrounded by food cues and opportunities to eat: in the media, in adverts, on streaming platforms, on social media and in shops. Food is everywhere. For some, this is not an issue; they can ignore it and only eat

when they’re hungry. For others, there’s a heightened cue reactivity that’s seen in the brain in response to food signals. This has been seen in obesity and in binge eating patients. So here, a similar level of food cues may lead to a different level of food noise, which can be dampened by GLP-1s.3 The question is how to support someone so that this level of noise doesn’t return when they come off the medication. As always, nutrition is complex, and there is no ‘one answer fits all’. As clinicians, a key part of our role and standout expertise is the ability to assess the person in front of us. To really connect with them, understand the bigger picture and incorporate not only the physical but also the social and psychosocial factors. Is this a starved mind or an over-responsive one? They can look almost identical from the outside, and they need almost opposite things. There’s another point to be made here too, about the words themselves.

‘Noise’ is often not a helpful word. It suggests that a mind full of food thoughts is broken, faulty, in need of switching off. For someone who’s trying, after years of fear, to let hunger and appetite back into their life, it can be unhelpful to hear the message that this noise shouldn’t be there. It is so negative. For someone else who is overresponsive to food cues, it can insinuate they are broken. A CALL TO OUR PROFESSION Diet culture has always been good at reinvention. It went from calorie counting to clean eating, to wellness, to longevity. And now it’s moving into neuroscience! As nutrition professionals, we are the ones who can sit with a person long enough to know whether their mind is loud because it’s starving or if it’s over-responding to food cues. Rather than simply label it as ‘food noise’, I think part of our role is to go deeper and work out what the brain is trying to say.

CONDITIONS & DISORDERS

Chronic obstructive pulmonary disease (COPD) Optimising outcomes for the critically ill

lthough nutrition is increasingly recognised as a vital component of critical care, the optimal nutritional management of critically ill patients with COPD remains challenging. Accurate nutritional assessment and calculation requirements, timing and route of nutrition, along with the potential benefits of specialised nutritional interventions, remain subjects of much debate. COPD IN THE CRITICAL CARE ENVIRONMENT COPD is a condition identified by airflow obstruction, which is typically caused by structural changes within the lungs, the breakdown of the tissue within the alveoli or chronic inflammation of the airway.¹ Reduction or limitation of airflow into the lungs often leads to reduced function and exercise tolerance. This is due to gas exchange impairments, hyperinflation of the lungs and breathing that typically requires more effort.² Advanced respiratory support through non-invasive ventilation (NIV), high-flow nasal oxygen (HFNO) or mechanical ventilation may be required for those patients who go into hypercapnic respiratory failure if there is too much carbon dioxide in the blood.

Hypercapnia can be common in the COPD patient group, particularly postrespiratory infection, post-exposure to environmental pollutants or if sudden respiratory function decline has occurred.¹ Critical illness often triggers hypermetabolism and hypercatabolism, both causing high resting energy expenditure and a high metabolic state where the body breaks down skeletal muscle proteins at an increased rate.³ These processes often contribute to lean body mass losses and significant muscle dysfunction, which can be detrimental for those with pre-existing COPD. Respiratory and peripheral muscle dysfunction affects the diaphragm. Weakness within the diaphragm can prolong mechanical ventilation and increase the chance of mechanical ventilation dependence and risk of death.⁴ It’s also worth mentioning that positive pressure mechanical ventilation typically reduces the human work needed to breathe; this increases the likelihood of muscle disuse, which affects the diaphragm further. There is also evidence to suggest that carbon dioxide production can be increased

Holly Monday-Jones RD

unintentionally through specifically carbohydrate overfeeding.⁵ This may increase ventilator dependence further. Preserving muscle mass is therefore essential, particularly within those with a pre-existing respiratory condition like COPD. Optimal nutrition assessment and support is vital to preserve muscle mass and respiratory function. MALNUTRITION IN COPD Malnutrition affects around one-third of patients with COPD who are admitted to hospital.⁶ Malnutrition typically increases with disease severity and so is more prevalent in critical care. Dyspnoea, fatigue, anxiety and depression are common in those with COPD and increase the risk of reduced nutritional intake, refeeding syndrome and malnutrition longer term. Corticosteroids, a frequent treatment option used in this patient group, contribute to muscle wastage

CONDITIONS & DISORDERS

too. In critical care, muscle mass loss is common. Muscle mass depletion often contributes to increased rehabilitation needs, longer hospital stays, hospital readmissions and healthcare costs, so is an important consideration.1 NUTRITIONAL ASSESSMENT IN CRITICAL CARE Identification of malnutrition and/or nutritional risk needs to be timely to reduce muscle wastage, minimise complications associated with mechanical ventilation and enhance recovery.⁷ However, it can be incredibly challenging to assess nutritional status in the critical care environment. Oedema, fluid shifts and inflammation can all limit traditional anthropometric and biochemical marker reliability. BMI, for example, is becoming increasingly questioned at a clinical level, as it fails to consider sarcopenia.8 Most nutritional screening tools used in the UK, such as ‘MUST’, still over-rely on BMI to identify malnutrition in those with COPD. However, not to look at lean

muscle mass loss in the critical care setting is extremely nutritionally risky, as it can delay necessary intervention. More modern evidence base supports both body composition and muscle function assessment to identify those who would benefit from additional nutritional support.⁷ The Nutrition Risk in the Critically Ill (NUTRIC) score was specifically developed for critical care, which has validated use. The evidence base, however, is conflicted on its effectiveness, with some research questioning its accuracy.⁹ This highlights that even validated critical care nutritional screening tools are not without issue and that clinical judgement is essential. More recently, the Global Leadership Initiative on Malnutrition (GLIM) has suggested using both typical nutritional risk screening and a diagnostic assessment that considers factors such as weight loss and reduced muscle mass together.⁷ Sarcopenia is common within the

COPD patient group, and so this may be more comprehensive and useful. It is important to note that in critical care units, it can sometimes be incredibly difficult to locate recorded weight history, previous dietary intake and gastrointestinal function, etc, which can make initial dietetic assessment challenging. Where information is missing, physical data, such as handgrip strength, mid upper arm circumference (MUAC) and ulna length, may be extremely useful. CURRENT NUTRITIONAL SUPPORT STRATEGIES Identifying the most effective nutritional support strategy for a patient with COPD in critical care is challenging. COPD is a highly heterogeneous condition, so it is unsurprising that the evidence base for nutritional support in critically ill patients is limited.¹⁰ An individualised approach, taking into account disease severity, current nutritional status and clinical goals, is therefore essential to minimise risk.

CONDITIONS & DISORDERS

Nutritional requirement calculation in critical care has historically always been challenging due to the fact that both underfeeding and overfeeding have direct clinical risks.¹⁰ Indirect calorimetry is considered the gold standard when it comes to calculating energy expenditure.¹¹ However, many critical care sites in the UK do not have this available to them due to cost, limited availability of the equipment required and lack of trained staff to ensure correct use of the equipment. Therefore, predictive calculations and equations are typically used in practice, despite their limited accuracy. It is very important to ensure protein provision can minimise skeletal muscle depletion so that the respiratory muscles, such as the diaphragm, can work effectively for successful ventilatory wean. The evidence base is mixed but typically supports up to 2g/kg protein per day in critically ill adults.12 There is international consensus around early nutritional support in the critical care environment, within 24–48 hours of admission.10,12 The pathway depends on the clinical state of the patient. Oral nutrition for those who can safely eat or enteral nutrition for those who are mechanically ventilated are widely recommended first-line nutrition provision approaches.12,13 In cases where

gastrointestinal intolerance or delayed gastric emptying is severe and unable to be managed with prokinetics and enteral feeding, parenteral nutrition may also be utilised. EMERGING EVIDENCE AND FUTURE DIRECTIONS Personalisation of critical care nutrition is the way forward, recognising that every patient is different. We know that predictive equations are limited and that indirect calorimetry is much more accurate. Making indirect calorimetry more accessible in the UK would be incredibly beneficial. If this can’t happen, the use of machine learning tools or artificial intelligence would perhaps improve accuracy from a nutritional requirement perspective. Otherwise, the development of COPD-specific predictive equations may be helpful. Accounting for the patient’s disease severity, inflammation and ventilatory support is sensible. More research is required to help move towards a more personalised approach. Despite evidence to support minimising muscle wastage, we still typically feed based on calorie provision rather than muscle preservation. Being able to adjust protein provision according to muscle loss is again a more personalised approach that would undoubtedly improve respiratory and COPD patient outcomes in the critical care environment. Quadriceps and diaphragm ultrasounds may help us achieve this personalisation.14 There has also been much interest in specialised nutritional strategies. Antioxidant therapy, vitamin D replacement and the addition of omega-3 fatty acids have all been recently researched to determine benefits of supplementation within this patient group.15–17 We know that many COPD patients are vitamin D deficient.16 We also know that oxidative stress is a major driver in the development of COPD.15 There is also evidence to support the statement that omega-3 fatty acids may reduce inflammation and improve respiratory function.17 Unfortunately, current research trials have been small and therefore larger, high-quality trials are required before we can change our approach.

CONCLUSION People with COPD who are admitted to critical care have an increased risk of malnutrition, ventilatory weaning delay and accelerated muscle mass loss. Early personalised and individualised nutritional assessment and intervention could improve clinical outcomes. There are many current challenges around the nutritional management of critical care patients with COPD. Further research should focus on more accurate methods of nutritional assessment, including nutritional requirement calculation and specialised nutritional strategies to improve personalisation. Nutrition should not be viewed as supportive care alone, but as a central part of respiratory recovery, rehabilitation and longterm outcome improvement.

Network Health Dietitians 14

DIET & LIFESTYLE

Plant-based milk: is the glass half full?

he consumption of milk as a standalone drink has been a part of the UK diet for centuries. Cow’s milk provides a range of nutrients, including fat, protein, calcium, riboflavin, iodine, vitamin B12 and choline.1,2 However, plant-based milk alternatives (PBMAs) have become increasingly popular in recent years, and are fast becoming an important part of the UK diet. But what are the nutritional considerations when choosing?3 The latest NDNS data (2019–2023) showed that PBMAs were consumed in smaller quantities than milk, with 14% of women and 10% of men aged 19–64 consuming plant milks, with a mean of 111g and 136g per day, respectively.4 More recent market insights show plant milks accounting for 6.7% of the total sales volume of animal and plant milks in the year to January 2025.5 Table 1 shows the total grams per day of milk consumed and identifies that girls

Mean Girls 4–10 years

Aliya Porter RNutr

generally consumed more PMBAs and 1% fat milk than boys, although there was no specific pattern in adults across the genders. Many different plant foods are used to make PBMAs, including almonds, soya, coconut, hemp, oats, rice and peas. Sales figures for plant milks show that oat-based milk and drinks have grown in market share, accounting for over half of sales volume in the year to January 2025, with soy at 23% and almond at 16%.5 There are also different versions of these milks across many different brands, for example, sweetened, unsweetened, toddler versions and organic options. Many supermarkets also have their own brands, which offer cheaper alternatives to consumers.5 Not all PBMAs are nutritionally equal. It’s therefore important for those who

Mean Boys 4–10 years

Mean Girls 11–18 years

Mean Boys 11–18 years

Mean Women 19–64 years

Whole milk (3.8% fat)

Semi-skimmed milk (1.8% fat)

109

1% fat milk

Skimmed milk (0.5% fat)

Flavoured milk drinks

Plant-based milk alternatives

Mean Men 19–64 years

Mean Women 65–74 years

Mean men 65–74 years

Mean Women 75 years and over

Mean Men 75 years and over

Whole milk (3.8% fat)

Semi-skimmed milk (1.8% fat)

111

123

107

121

1% fat milk

Skimmed milk (0.5% fat)

Flavoured milk drinks

Plant-based milk alternatives

Table 1: Total quantities of milks consumed (grams) per day: male and female (including non-consumers), by age (years 12–15 combined) 2019–20234 15

DIET & LIFESTYLE

avoid cow’s milk, whether for allergies or other reasons, to get the nutrition they need from alternative milks. Table 2 shows a range of PBMAs. Some data is unknown due to limitations in manufacturer data. Potassium values have been added based on McCance and Widdowson data for soya but are not available for other types at this time. Choline values have been included from USDA data where available, as some data are not available. NUTRITIONAL CONSIDERATIONS Macronutrients Drinks vary in energy content, with coconut milk, pea and almond drinks being significantly lower in energy than cow’s milk. Most fat content is close to cow’s milk, with Oatly’s Oat Drink being an outlier. The largest difference is in protein content, with rice and almond drinks providing just 14% of the protein provided by cow’s milk.

Free sugars Free sugars have been calculated using the Department of Health and Social Care definition of free sugars, which states that ‘all sugars in drinks except for lactose naturally present in cows’ milk and other dairy products – this includes the sugars naturally present in fruit and vegetable juices, concentrates, smoothies and dairyalternatives’.18 With the recommended daily intake of free sugars limited to 30g per day, three 200ml servings of oat and rice drinks consumed to help meet calcium requirements could contribute a significant amount of free sugar, providing 20.4g and 30g, respectively.

children. Comparisons in Table 2 show that these products are often similar to semi-skimmed cow’s milk. Calcium There is limited evidence that the bioavailability of calcium in plant milks is different from cow’s milk; however, the evidence is growing.19 These products are almost all fortified to the same level as cow’s milk, except for the organic ones, which cannot be fortified. Consumers need to be made aware of this difference, as organic is often perceived to be healthier. This is also true of homemade plant-based milks. Iodine Had this article been written more than five years ago, the fortification picture would have been very different. In 2021, the BDA, The Vegan Society

Salt There have been concerns shared on social media about the added salt in PBMAs, particularly around young

Table 2: Nutritional value of some milks per 100mL available in the UK6–16 Energy (kcal)

Fat (g)

Protein (g)

Free sugars

Salt (g)

Calcium (mg)

Semi-skimmed cow’s milk

1.7

3.5

0.11

120

Aldi Acti Leaf Soya No Sugars

1.9

3.4

0.08

120

Alpro Soya No Sugars

1.9

3.3

0.9

120

Mighty Pea M.lk

0.9

2.0

0.13

180

Oatly Oat Drink No Sugars

2.7

1.0

3.4

0.1

120

Koko Unsweetened Coconut

1.4

1.2

<0.5

120

Rude Health Brown Rice Drink Organic* unsweetened

1.0

<0.5

5.0

0.08

Not fortified

Almond Breeze Unsweetened 26

1.1

<0.5

0.15

120

Recommended intakes for women 19-64**

2175

Max 84.6

45g (for 60kg woman)

Max 30g

Max 6g

700

Potassium (mg)

Riboflavin (mg) Vitamin B12 (µg) Vitamin D (µg) Iodine (µg)

Choline (mg)

Semi-skimmed cow’s milk

156

0.24

0.9

Trace

18.2

Aldi Acti Leaf Soya No Sugars

0.21

0.38

0.75

22.4

23.6

Alpro Soya No Sugars

0.21

0.38

0.75

22.5

23.6

Mighty Pea M.lk

Unknown

Not fortified

0.9

0.75

Unknown

Oatly Oat Drink No Sugars

Unknown

Not fortified

0.38

1.1

22.5

Unknown

Koko Unsweetened Coconut

Unknown

Not fortified

<0.5

0.8

Not fortified

Unknown

Rude Health Brown Rice Drink Organic* unsweetened

Unknown

Not fortified

Unknown

Almond Breeze Unsweetened Unknown

Not fortified

0.38

Not fortified

Unknown

Recommended intakes for women 19-64**

1.1

1.5

140

425

3500

*Rice milk should not be given to under-5s as a drink due to the levels of arsenic in these drinks17 **Energy (EAR); fat based on percentage energy; protein based on a 60kg person; RNI for micronutrients; choline: US recommendation 16

DIET & LIFESTYLE

and the Food and Drink Federation worked together to raise the profile of iodine fortification.20 In 2025, a SACN review recommended that government: establish ‘minimum requirements for the vitamin A, riboflavin, vitamin B12, calcium and iodine content of plant-based drinks at a comparable level to (and assuming equivalent bioavailability from) semi-skimmed cows’ milk’, (and) encourage ‘industry to continue to fortify plant-based drinks with vitamin D’ and that industry ‘aims for plant-based drinks to be nutritionally equivalent to semiskimmed cows’ milk for levels of vitamin A, riboflavin, vitamin B12, calcium and iodine (and) fortifies plant-based drinks with vitamin D’.19 There is some way to go for all products to be fortified. With awareness about this nutrient and the NDNS data showing low levels in the population, particularly among women of childbearing age, there is a need for industry to act faster.

Choline Soya and peas naturally contain choline, so drinks made with these ingredients are likely to be higher in choline than some other drinks. There is no UK recommendation for choline; however, EFSA21 and USDA (USA)22 both have recommendations. Although the amount of choline in milk is much lower than in eggs and beef, the quantity of milk consumed in the UK means that it is a useful contributor to intakes. More work is needed to examine the role of fortification and to establish a recommended intake in the UK to determine required fortification levels. OTHER CONSIDERATIONS In addition to nutritional value, consumers need to consider cost, availability, taste, allergies, processing and the environment. The age and health of the consumer also need to be considered; for example, avoiding rice milk as a drink for the

under-fives, or prioritising protein and micronutrient content for someone recovering from a fracture. There is no scope in this article to discuss these factors, but as recommendations are made, all should be considered. CONCLUSION Plant milks have gained in popularity in recent decades, with an increase in the number of types and brands on the market. Progress has been made to fortify these products, although significant variation in nutritional value remains. There is scope for further professional campaigning in this area. Care should be taken when choosing a PBMA to ensure nutritional adequacy for the individual, as well as the preferences and barriers to access. There is work to be done to educate consumers about the differences between cow’s milk and plant-based alternatives so they can make informed choices.

CLINICAL

ER AS:

When post-surgery nutrition fails

nhanced Recovery After Surgery (ERAS) is a coordinated and multidisciplinary approach designed to reduce the physiological stress of surgery. Nutrition is paramount to this process. The evidence emphasises preoperative carbohydrate loading, minimised fasting periods, early postoperative feeding and adequate protein provision to essentially reduce catabolism, preserve muscle mass and support recovery.1,2 Evidence specifically demonstrates that implementing ERAS protocols can reduce postoperative complications, shorten hospital stays, improve functional recovery and enhance patient experience and satisfaction.1–3 However, there remains much inconsistency in practice, leading to significant consequences, particularly for older adults and those already vulnerable to malnutrition and/or sarcopenia. The challenge is no longer whether the evidence exists, but why consistent implementation continues to fail. Understanding these barriers and the nutritional implications that follow is essential if ERAS pathways are to deliver their intended benefits at a patient level. WHAT DOES ERAS NON-COMPLIANCE LOOK LIKE? While some surgical settings have embedded ERAS pathways successfully into routine care, others continue to apply only selected elements of ERAS or omit ERAS pathways entirely. There seems to be significant variation between surgical specialities, surgeons and even individual wards and healthcare organisations. Nutritional components of ERAS are often overlooked and are typically applied inconsistently. Prolonged fasting, delayed oral intake, unnecessary use of drains or nasogastric tubes and delayed mobilisation remain common despite evidence suggesting these practices

Holly Monday-Jones RD

may impair or delay recovery rather than support it.1 Outdated indicators, such as bowel sounds or passing flatus before feeding is commenced, also remain common in practice. Nutritional screening is also often overlooked in many settings, and surgery is no exception, with many surgical patients being screened incorrectly.4 Nutritional inefficiencies can result in reduced or delayed functional ability, including mobility, wound healing recovery and prolonged pain.4 The same can be said for other inefficiencies in surgical care, which typically affect nutritional status and care. For example, poor pain management can reduce mobilisation, increase the risk of ileus, reduce appetite and affect nutritional status. Enhanced recovery pathways, therefore, should always involve a coordinated MDT approach to enhance their effectiveness. WHY IS ERAS NOT BEING FOLLOWED? The reasons for nutritional inefficiencies within ERAS are complex and variable. Firstly, surgical culture and training are likely to play a significant role. Surgeons are trained to avoid disaster, so avoiding risk is often easier than pushing interventions postsurgery. Fear of surgical complications such as anastomotic leaks and/or ileus may play a part. Some surgeons may also feel that nutritional interventions are less urgent than surgery itself – a view that may stem from more traditional training approaches. ERAS typically succeeds when collaboration occurs, for example, when surgeons, anaesthetists, dietitians, nurses and physiotherapists all work together consistently. In practice, fragmentation can occur. Responsibilities within the MDT may be unclear; ERAS protocols

may not be strongly promoted by healthcare organisations, and the thought process for postoperative feeding progression is often led by fear of surgical complications.5 Time and operational pressures are often a reality in the NHS. Staffing may be lacking, particularly at weekends, which can delay nutritional support and/ or implementation of ERAS processes. Staffing issues may also lead to theatre delays, compromising support for nutrition-led pathways and, in particular, prolonging fasting preoperatively, which is not optimal. Lack of understanding of the ERAS evidence base often leads to poor delivery and implementation of the correct protocols. The importance of nutrition is often overlooked, with the technical success of surgery often considered more important than the potential after-effects.6,7 The relevance of carbohydrate loading, adequate protein provision and early feeding post-surgery may be an afterthought. THE NUTRITIONAL CONSEQUENCES Surgery increases catabolism and muscle mass loss by initiating an inflammatory stress response and increasing insulin resistance.1,2 Without early nutrition, rapid muscle wasting occurs and mobilisation and the ability to recover become harder. Even short periods of inadequate nutritional intake or poor nutritional status matter, particularly in older adult and oncology cohorts, where vulnerability is high. Poor nutritional status, even without surgical considerations, can increase infection risk and delay wound healing. It also risks longer hospital stays and more readmissions.7 Malnutrition can be both pre-existing before the need for surgery and hospital-acquired due to surgery. Poor ERAS implementation contributes to worse outcomes in both but is more

CLINICAL

evident in the hospital-acquired group.1–3 One of the norms in surgical practice is prolonged pre- and postoperative fasting. It’s commonplace for people to fast all day awaiting surgery, miss multiple meals postoperatively and receive inadequate nutritional intake for several days. Prolonged fasting increases insulin resistance, delays gut transit and exacerbates malnutrition, impacting recovery time.1,2 ERAS recommends the opposite of this: short periods of fasting, early gut-involved nutritional intake postoperatively and recovery focused on adequate, and in many cases, highprotein provision.1,2 The psychological effect on patients also needs to be highlighted. Mixed messages from staff can increase anxiety and reduce patient confidence, which in turn can reduce appetite and intake further. People want to eat and expect to do so as soon as possible – that is physiologically normal. Not allowing this may reduce overall patient satisfaction, not just with the surgery performed but with staffing and the healthcare organisation itself. Poor satisfaction can reduce patient adherence to following advice, which worsens health outcomes in the longer term.8 WHAT NEEDS TO CHANGE? To optimise surgical recovery and

patient satisfaction, nutrition needs to be treated as a core intervention. Ignoring analgesia or antibiotics would be considered harmful, but inadequate nutrition is routinely tolerated postoperatively. Medicalising starvation while also expecting optimal wound healing, patient mobilisation and rehabilitation seems illogical. Prolonged fasting should essentially be viewed as avoidable clinical harm, as it is considered one of the most accepted forms of induced undernutrition. However, many patients fast far beyond recommended guidelines and the evidence base is clear in this contributing to hospital-acquired malnutrition and worsening malnutrition in already malnourished or vulnerable patient groups.1,2 This should not continue. Surgical pathways have historically prioritised procedural success over broader metabolic and functional recovery. Strength, independence, fatigue, the ability to eat and muscle preservation all play a significant role in surgical recovery.7 Elective surgery still focuses on BMI, despite its flaws. Sarcopenia and frailty, for example, are still treated as geriatric issues rather than surgical risks. They can affect patients of all body sizes, so enhanced recovery should focus on nutritional and functional risks and not on procedure type.

The importance of protein provision following surgery is insufficiently prioritised. Surgery is fundamentally a protein catabolic event, yet focus on calorie provision overlooks this. Standard hospital menus are not designed for surgical recovery, which means that most surgical patients cannot physically meet their protein needs without intervention. CONCLUSION ERAS is evidence-based, yet its implementation remains inconsistent. Nutritional ERAS pathways are easily undermined by poor adherence. This has direct consequences for patients from a metabolic and functional perspective. If nutrition continues to be treated as supportive care rather than core and essential treatment, enhanced recovery can’t succeed. Improving surgeon education on metabolic recovery, specifically sarcopenia, protein preservation, frailty and the risks of prolonged fasting, is essential in ensuring ERAS adherence. Dietitians also need to be fully embedded in ERAS pathway development to ensure stronger MDT focus, shared accountability and engagement with the evidence base.

ADVERTORIAL INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

SHAPING THE GUT MICROBIOME IN COW’S MILK PROTEIN ALLERGY: THE PIVOTAL ROLE OF

HMO play a pivotal role in delivering immune support.12

Human milk oligosaccharides

The role of HMO in breast milk A significant component of breast milk is human milk oligosaccharides (HMO) which play a key role in immune support 12 and facilitating microbiome progression in early life. HMO act as substrates for Bifidobacterium, driving up levels of short chain fatty acids (SCFA),3 which are by-products of microbiome fermentation that regulate immune responses.2 In the absence of breast feeding, exclusive and partial formula-feeding have been shown to shift the gut microbiome toward adult patterns (higher diversity), increase proinflammatory bacteria, increase gut permeability, and result in lower concentrations of fecal SCFA.6 In addition, infants who are breastfed for shorter periods (or not breastfed) suffer more infectious diseases, such as gastroenteritis, acute otitis media, and more immune-mediated diseases.13

Importance of early-life microbiome in driving immune maturation and determining allergy outcomes The gut microbiome, defined as all of the microbial inhabitants (microbial community) and their collective genomes, plays a key role in immune system maturation and immunoregulation and therefore has significance in prevention or development and manifestations of allergic disease. 1-3 The developing gut microbiome undergoes three distinct phases of microbiome progression in the first 1000 days of life: • • •

a developmental phase (months 3-14) a transitional phase (months 15-30) a stable phase (months 31-46) 4

THE BENEFITS OF HMO IN PRIMING

® ALTHERA® HMO is the ®FIRST EXTENSIVELY HYDROLYSED ALTHERA HMO is the FIRST EXTENSIVELY HYDROLYSED THE IMMUNE SYSTEM AND PROMOTING ALTHERA HM ALTH thatOF is CMPA that is FORM ULA FOR THE MANAGEME OF CMPANT FORM ULA FOR THE NT MANAGEME Contains HMO*beneﬁcial and Contains HMO* and in the gut are During infancy, the predominant bacteria INFANT HEALTH: THE RATIONALE FOR IN INFANTS IN INWI PROVEN HYPOALLERGENIC and contains aand BLEND OF a BLEND OF PROVEN HYPOALLERGENIC contains lactose to SUPPOR T to SUPPOR lactose Biﬁdobacterium and Lactobacillus which supportTdevelopment HMO* SUPPLEMENTATION A HEALTHY A HEALTHY GUT LNnT to support growth, IMMUNE LNnT to support growth, IMMUNE 5 GUT of the infant immune system. The gut microbial community the OTA and the MICROBIOTA and MICROBI and a HEALTHY MICROBIOTA IN INFANTS IN INFANTS DEVELOPMENT andGUT a HEALTHY GUT MICROBIOTA acquired in early infancy has been proven to be critical in the DEVELOPMENT development of development an in fant’s of an in fant’s

2,12-15 2,12-15tolerance, determination of mucosal response immune immune sy stemimmune sy stemand More than prebiotics linked to microbial structure and function. 6 In infants with a higher HMO are non-digestible carbohydrates, identified 23% overall bacterial diversity, the infant microbiome is shifted towards ONLY EHFbifidogenic WITH REDU CTION ONLY EHFfactor WITH in human as the most important 7 that of an adult at a faster rate which suggests that maintaining PROVEN, EFFICAC Y PROVEN, EFFICACY milk 14,15 their role as prebiotics, HMO have MICRONUTRIENT S S Beyond AND SAFETY SIMILAR AND SAFETY SIMILAR the infant microbiota community (i.e. lower diversity)THE for as long THE MICRONUTRIENT ARE ALSO OPTIMISE D OPTIMISE significant impact on AMINO the microbiota. HMO provide ARE ALSO D TO AN TO AN AMINO as possible could present an opportunity for the prevention of to meet theLNUTRITIONAL to meet the NUTRITIONA protection against harmful pathogens due to ACIDcertain FORMULA ACID FORMULA allergic manifestations. 8 For example, where allergic sensitisation, CLINICALLY CLINICALLY NEEDS OF INFANTS NEEDS OF INFANTS Frequency of lower Freque their antimicrobial properties and adhesive properties HYPOALLERGENI C, C, eczema, wheezing or asthma exist inHYPOALLERGENI infants, lower abundance respiratory tract respi WITH of CMPA WITH CMPA that prevent growth and proliferation of harmful HELPING TO REDUC E TO HELPING REDUC E infections* Lactobacillaceae and Bifidobacteriaceae and higher abundance i 16,17 bacteria by modifying the host-microbe interaction. THE SYMPTOMS AND THE SYMPTOMS AND of Bacteroidaceae, Clostridiaceae, Enterobacteriaceae in their POTENTIAL COST S9 POTENTIAL COSTS microbial community has beenAobserved. HMO serve as both a food source for beneficial ASSOCI TED WITH ASSOCIATED WITH ADDITION OF HMO ADDITION OF HMO CMPA16,17 CMPA16,17 INFANT FORM ULA • INFAN bacteria butLTY also stop growth and proliferation• of TO SPECIA INFANT TO SPECIA LTY INFANT SUPPLEMENTED SUPPwit FORMULbacteria A REDUCE S THE FORMUL A REDUCES THE harmful by preventing bacterial adhesion to Increasing evidence suggests that blend of 2’FL ablend nd LNof 2 RISK OF INFECTIONS RISK OFAND INFECTIONS AND 16 the intestinal epithelium.

USE OF ANTIBIOTICS USE OF AND ANTIBIOTICS AND dysbiosis, could inﬂuence the • RATE OF INFECTI • RAT ANTIPYRETICS ANTIPYRETICS • • occurrence of food allergy and HMO AREHMO NATURALLY OCCURRIN G ARE NATURALLY OCCURRIN G INFECTIVESINF in heal food allergy-related conditions HMO selectively serve as food for infants duringinfant the fi IN BREAST MIL K AND CONFER MAN Y IN BREAST MIL K AND CONFER MAN Y year of li fe year of later in life. 10,11 beneﬁcial bacteria and suppress 1,2 1,2 BENE FITS TO INFANTS BENE FITS TO INFANTS SAME TREND i • The SAM the growth and proliferation •ofThe respiratory tract inf respir HMO ARE THEHMO THIRD LARGES T COMPONE NT IN BREAST MILK ARE THE THIRD LARGES T COMPONE NT IN BREAST MILK Microbiome alterations (dysbiosis) have a pivotal role in the IS SEE healthy i nfants healthy i pathogenic bacteria. 10 3,20

Increasing evidence suggests that development of•food allergy. Unique structures • Unique structures HMO different from prebioticsfromofprebiotics different dysbiosis, could inﬂuence the occurrence food allergy and food Found in breast milk Found in breast milk 18,19 18,19 FOS and GO S FOS and10,11 GOSSome of the risk factors allergy-related conditions later in life. Structure Structure 2’FL LNnT2’FL • 2’FL LNnT ma ke up LNnT for dysbiosis and foodaand allergy include • development 2’FL aand ma ke upgenetics, >30% of HMO* in reastmilk b >30% of HMO* in reastmilk b cesarian delivery, feeding and medication (including antibiotics), 2 2 of the total HMO* content of the HMO* content 3 all of which are intrinsically linked tototal the gut microbiome. 1 1 19,20

HMO

19,20

in breast milk in breast milk

Galactose

Glucose Galactose FucoseGlucose

Fructose Fucose

GOS

FOS GOS

FOS

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(

)

n=2-6

( )

n=2-10 n=2-6

(

)

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4 WAYS HMO SUPPORT THE INFANTS MICROBIOTA AND IMMUNE SYSTEM

2 HMO SUPPORT DEVE LOPMEN T OFLOPMEN THE INFANT’S IMMUNE SYSTEM: HMO SUPPORT DEVE T OF THE INFANT’S IMMUNE SYSTEM: 2

Promoting beneﬁcial Promoting a more balanced the a more l g Eliminating Eliminating pathogens StrengtheningStrengthening the Promoting balanced Promotin g l pathogens Eliminating pathogens Strengthening the Promoting a more balanced Promotin 21 through aa decoy decoy effect gut barrier gut barrier response through barrierTh1/Th2 Th1/Th2response gut bacteria21gut bacteria gut bacteria through eﬀecta21 decoy20effect Th1/Th2 response21 Breastfeeding Breastfeeding is thegold standard nutrition, including those with CMPA. Forwith the CMPA. majority is thefor goldinfant standard for infant nutrition, including those Forofthe majority of

ADVERTORIAL INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

HMO* SUPPORT THE IMMUNE SYSTEM AND PROMOTE THE DEVELOPMENT OF MICROBIOTA

High levels of HMO* 2'-FL and LNnT in breast milk may promote an early high biﬁdobacteria-dominated gut microbiota in infants 13

HMO influence the development of the gut microbiome in early childhood

Infants with CMPA fed HMO* supplemented formula have significantly fewer upper respiratory tract infections

HMO in breast milk have been identified as having the greatest influence on shaping the gut microbiome, and in particular, 2’fucosyl-lactose (2'-FL) and lacto-N-neotetraose (LNnT) have been shown to be important modifiers of bacterial composition in early infancy. 13

' Infants with CMPA fed whey based eHF with 2 -FL and LNnT in the CINNAMON study showed a statistically signiﬁcant reduction in the frequency of upper respiratory tract infections each month and a promising trend towards a reduction in the frequency of lower respiratory tract infection. Additionally, in the per protocol group, there was a signiﬁcant reduction in the risk of ear infections. 20

Clinical evidence demonstrates that the addition of 2’-FL and LNnT to a standard infant formula fed to healthy infants leads to a significantly different faecal microbial composition at 3 months of age, compared to those who received formula without HMO supplementation i.e. the microbiota represented that of breastfed infants with a higher abundance of Bifidobacteriaceae.18 Clinical significance was also demonstrated by the fact that less antibiotics were required in the healthy infant group supplemented with HMO.18

Nestlé Health Science have developed a blend of two of the most significant HMO* found in breast milk

HMO* supplemented formula positively shapes the gut microbiome in infants with CMPA

Nestlé Health Science is committed to HMO* research in infants with CMPA. Our allergy management portfolio includes extensively hydrolysed (Althéra® Advance) and amino acid-based (Alfamino® Advance) formulas supplemented with 2'-FL and LNnT for the management of infants with CMPA. Our range of hypoallergenic specialist formulas is supported by clinical evidence that conﬁrms the tolerance, safety, and growth eﬃcacy of Althéra® Advance and Alfamino® Advance for infants with CMPA.19-21

In the CINNAMON study, whey based extensively hydrolysed formula (w-eHF) supplemented with 2’-FL and LNnT further demonstrated the microbiome-modulating beneﬁts of HMO* in observed inOF healthy infants. 19 REDUCE Sinfants THEwith FREQUENCY OF IN FECTIONS A® HMO REDUCE SCMPA, THEpreviously FREQUENCY IN FECTIONS

3 The w-eHF with LNnT, inOF comparison withHMO a w-eHF IH CMPA DUE TO THE ADDITION HMO3OF NTS WITH CMPA DUE2’-FL TOand THE ADDITION

TION

without HMO*, was associated with lower microbial diversity in infants at 12 months of age. 19 HMO* supplementation appears to slow the premature shift towards an adult-type gut microbiome in contrast to infants receiving no or only some 19 70 70 42%breast milk. 41% 42% 41%

REDU CTION

100%

REDU CTION

100%

REDU CTION

The addition of the HMO* 2'-FL and LNnT to hypoallergenic extensively hydrolysed formula, positively shapes the gut microbiome of infants with CMPA12

Further sub-analysis of the CINNAMON microbiome data was conducted in infants aged less than 3 months to assess whether the change in Bifidobacterium abundance between 90 and 120 of the study was by mode of delivery. Bifidobacterium ofdays upper Otitisaffected media Otitis Gastroenteritis or of Frequency lower Frequency of upper media Gastroenteritis or abundance in those infants receiving w-eHF with 2’-FLacute and LNnT espiratory infectionstract infections (p=<0.05) diarrhoea* ry tract tract respiratory (p=<0.05)acute diarrhoea* was more Caesarean *Not reported or no effect. *Not reported or no effect. ) much ons* (p=0.003 (p=0.003 ) prominent in those born through section compared to vaginal delivery. Thus, highlighting that the beneficial effect of supplemental HMO* on Bifidobacterium was greatest in infants born via Caesarean section. 3 ORMULA Percentage of infants with >1of episode lower atory tract respir infections Percentage infantsofwith >1 respir episode of lower atory tract infections

th aENTED with a educe: L2’FL a nda LN40% nT reduce: Healthy 40% infants Healthy infants

SINFECTIONS

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20%

34.5% RR-55% p=0.027

Conclusion

Infants with CMP AInfants with CMP A

HMO oﬀer an array of functions and targeted eﬀects, including priming the infants immune system, supporting age adequate development of the infants microbiome, and correcting dysbiosis. HMO* which is structurally identical to breast milk could contribute to the critical window for healthy infants and infants with CMPA to shape the microbiome and drive immune maturation.18-21

RR-55% p=0.027

25%

ns in infections in tract 15% E IN IS SEEN IN ants

WITH CMPA 10%

19.3%

15%

19.3%

20.8%

20.8% RR-34% p=NS 13.8%

RR-34% p=NS 13.8%

10%

tggests sfi rstthat fi rst5% M HM O ofOAlthé ra ®5% ec po ease (Adapted from Pedersen et al. 2020 19 Chart not drawn to scale.) ential to dec rease 0% 0% by of CM PA by Control Test +Control rden HMO HMO* Althera® HMO* Test + HMOControl Althera®Control At 12 months, who received w-eHF with 2'-FL had a (n=87) (n=96) (n=94) (n=87) supplemented (n=87) (n=96)and LNnT (n=94) eibing over-p rescribing (n=87) infants lower diversity, measured by Richness and Shannon Index. 19 Shorter time frame of datatime collection dia gnosis mean 3.2 months versus Shorter frame (at of data collection (atage dia of gnosis mean age of 3.2 months versus ated t is well tolerated 1 week 2017) a nd sample size limitatio n didsize not limitatio allow firm 5 in st udy by1Puccio week inetstal, udy by Puccio et al, 2017) a nd sample n did not allow firm es outcomes

*HMO: structurally identical Human Milk Oligosaccharides, not sourced from breast milk.

statistical co nclusions statistical co nclusions

IMPORTANT NOTICE: We believe that breastfeeding is the ideal nutritional start for babies as breast milk provides a balanced diet and protection against illness for a baby. We fully support the World Health Organisation’s recommendation of exclusive breastfeeding for the ﬁrst six months of life followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to two years of age. We also recognise that breastfeeding may not be an option due to certain medical conditions. Parents should only feed Infant formula for special medical purposes under supervision of a healthcare professional after full consideration of all feeding options, including breastfeeding. Continued use has to be assessed by the healthcare professional in relation to the baby's progress bearing in mind any social and ﬁnancial implications for the family. Infant formula should always be prepared, used and stored as instructed on the label in order to avoid risks to a baby’s health.

® ® ALTHERA HMO CAN HAVE ALTHERA HMO CAN HAVE ECONOMI C2014;142: BENE FITS ECONOMI C2. Nance BENE FITS REFERENCES: 1. McDermott A, Huﬀnagle G. Immunology 24–31. CL et al. Children. 2020;7:50. 3. Vandenplas Y et al. EMJ Allergy Immunol. 2021;6[1]:25-32. 4. Stewart CJ et al. Nature.

The following products must be used under medical supervision. SMA® Althéra® Advance is a food for special medical purposes intended for the dietary management of infants with cows’ milk allergy. SMA® Alfamino® Advance is a food for special medical purposes, for the dietary management of infants with severe cows’ milk allergy, multiple food allergies and other conditions where an amino acid formula is recommended. 2018;562:583-8. 5. Wall R et al. Clin Med Pediatr. 2009;3:45–54. 6. O’Sullivan A et al. Nutrition and Metabolic Insights. 2015:8(S1) 1–9. 7. Moore RE, Townsend SD. Open Biol. 2019;9: 190128. 8. van den Reducing fections infants canet ha savings in Reducing infections inve fants canImmunol. have savings in Elsen LWJ et al. Front. Pediatr. in 2019;7:47. 9.in Zimmermann al. J in Allergy Clin 2019;143(2):467-485. 10. Canani R et al. Front Immunol 2019; 10: 191. 11. Tanaka and Nakayama J. Allergology International. 2017;66:4:515-522. 12. Gregory KE. Curr Pediatr Rep. 2013;1:(4). 13. Vandenplas Y, theMuse of medi cations, visits, hospi talisations the use ofGP medi cations, GP visits, hospi talisations et al. Nutrients. 2018;10:1161. 14. Lewis, Z.T et al. Microbiome. 2015;3:13. 15. Sprenger, N. et al. PLoS ONE 2017;12:e0171814. 16. Santos A et al. EMJ and associatedand healthcare resources. associated healthcare resources. Allergy Immunol.2020;5[Suppl 2]:2-10. 17. Moossavi S et al. Front. Pediatr. 2018;6:197. 18. Berger B et al. mBio 2020 ;11:e03196-19. 19. Vandenplas Y, et al. Nutrients. 2022;14:530. 20. Gold MS, et al. Nutrients. 2022;14(11):2297. 21. Hegar B et al. Pediatr Gastroenterol Hepatol Nutr 2019;22(4):330-340.

Althéra ®

rst-line® can provide savings for rst-line can provide savingsfor Althéra

cacious healthcare syProduits stems compared withHealth les Science cacious healthcare systems compared with les House Reg. Trademark of Société des Nestlé S.A. Nestlé UK, Park South, Crawley Business Quarter, Manor Royal, Crawley, RH10 9AD. NHSc 267c, Mar 2026

(or less hydrolysed) eHF ’s or more costly (or less hydrolysed) eHF ’s amino or more costly amino

M AT E R N A L H E A LT H

INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

Introducing our next generation of hypoallergenic formulas... e Pr am ic

Upgraded formulation, at no extra cost.

ze •

• Sam

e P ck a

PIP Code: 4386454

PIP Code: 4386462

Designed for the dietary management of Cow’s Milk Protein Allergy (CMPA), with a clinically proven blend of two Human Milk Oligosaccharides (HMOs*): 2’FL and LNnT*1-5

Our HMO blend is proven to support: Fast and effective symptom management1-3,6,7

Healthy growth and development1-3,6,7

Reductions in infection rates and medication use1 as well as promoting a positive gut microbiota3

Scan the QR code to order FREE samples for your patients REFERENCES 1. Vandenplas Y, et al. Nutrients. 2022;14(3):530. 2. Gold MS, et al. Nutrients. 2022;14(11):2297. 3. Boulangé CL, et al. Int J Mol Sci. 2023;24(14):11422. 4. Puccio G, et al. J Pediatr Gastroenterol Nutr. 2017;64(4):624–631. 5. Berger B, et al. mBio. 2020;11(2):e0319619. 6. Nowak-Węgrzyn A, et al. Clin Pediatr (Phila). 2015;54(3):264–272. 7. Niggemann B, et al. Pediatr Allergy Immunol. 2008;19(4):348–354. IMPORTANT NOTICE: We believe that breastfeeding is the ideal nutritional start for babies as breast milk provides a balanced diet and protection against illness for a baby. We fully support the World Health Organisation’s recommendation of exclusive breastfeeding for the first six months of life followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to two years of age. We also recognise that breastfeeding may not be an option due to certain medical conditions. Parents should only feed Infant formula for special medical purposes under supervision of a healthcare professional after full consideration of all feeding options, including breastfeeding. Continued use has to be assessed by the healthcare professional in relation to the baby’s progress bearing in mind any social and financial implications for the family. Infant formula should always be prepared, used and stored as instructed on the label in order to avoid risks to a baby’s health. The following products must be used under medical supervision. SMA® Althéra® Advance is a food for special medical purposes intended for the dietary management of infants with cows’ milk allergy. Suitable as a sole source of nutrition from birth or supplementary feeding from 6 months and up to 3 years of age. SMA® Alfamino® Advance is a food for special medical purposes, for the dietary management of infants with severe cows’ milk allergy, multiple food allergies and other conditions where an amino acid formula is recommended. Suitable as a sole source of nutrition from birth up to 12 months or supplementary feeding from 6 months onwards. *Not sourced from breast milk ®Reg. Trademark of Société des Produits Nestlé S.A. Nestlé Health Science UK. NHSc 195a August 2026

CONDITIONS & DISORDERS

Evidence-based approaches to autism nutrition

Salma Khattak RD

utism spectrum disorder (ASD) is a lifelong neurodevelopmental condition that affects how an individual communicates, processes information, experiences the world and interacts socially.1 It is characterised by restricted or repetitive patterns of behaviour, interests and activities. Due to the considerable variation in the characteristics and severity of symptoms experienced, autism is described as a ‘spectrum’. Consequently, support needs vary widely, with some individuals requiring substantial daily assistance, while others can live independently with minimal support. In addition to the core characteristics of autism, many individuals experience sensory sensitivities, gastrointestinal problems and feeding difficulties. These challenges can influence food intake and diet, potentially increasing the risk of nutrient deficiencies. As a result, researchers, healthcare professionals and families have increasingly explored the role of diet and nutrition as complementary approaches to managing autismrelated symptoms. There is growing interest in nutrition as a novel approach to the management of ASD. When considering the implementation of a dietary intervention, it is essential to evaluate the available scientific evidence regarding its potential benefits, limitations and effectiveness. It is equally important to recognise the individual's unique preferences, sensory sensitivities, feeding behaviours and nutritional requirements to ensure that any dietary approach is appropriate and sustainable.

Many NHS services now prefer the term ‘autism’ or ‘autism spectrum condition’ rather than focusing on the word ‘disorder’, but the formal diagnostic term autism spectrum disorder (ASD) is still widely used

CONDITIONS & DISORDERS

GLUTEN-FREE/CASEIN-FREE (GF/CF) DIET The GF/CF diet is one of the most widely recognised dietary interventions explored in relation to ASD. Gluten is a protein found in wheat, barley and rye, while casein is the primary protein found in milk and dairy products. The GF/CF diet involves the complete elimination of foods containing these proteins. The rationale for this dietary approach is based on the hypothesis that some autistic individuals do not completely digest these proteins, producing peptide fragments that may pass through an abnormally permeable intestinal lining (known as a ‘leaky gut’) into the bloodstream. These peptide fragments are then proposed to cross the blood-brain barrier and influence neurological function, potentially contributing to behavioural, cognitive and communication difficulties.2 Although this theory has attracted considerable interest, there is limited scientific evidence to support its validity. Several small-scale studies have reported modest improvements in behaviours, such as attention, communication, social interaction and gastrointestinal symptoms, following

implementation of the GF/CF diet. However, many of these studies have been limited by small sample sizes, short intervention periods, lack of blinding or inconsistent outcome measures. In contrast, larger, betterdesigned randomised controlled trials have generally failed to demonstrate consistent or clinically significant improvements in the core symptoms of ASD.3 While some individuals may experience improvements, such as those with diagnosed coeliac disease, casein allergy or other coexisting gastrointestinal symptoms, these findings cannot be generalised to the wider autistic population. Furthermore, eliminating gluten and dairy-containing foods without appropriate dietary planning may reduce the intake of important nutrients, such as calcium, vitamin D, fibre and certain B vitamins. Restrictive diets may also increase mealtime stress and further limit food variety in autistic individuals who already experience selective eating behaviours. For these reasons, any decision to implement a GF/CF diet should be based on individual clinical need and undertaken with guidance

from a registered dietitian or healthcare professional to ensure nutritional adequacy and appropriate monitoring. THE KETOGENIC DIET (KD) The KD is a high-fat, very lowcarbohydrate dietary intervention that alters the body's primary energy source from glucose to ketone bodies through a metabolic process known as ketosis. Originally developed as a treatment for drug-resistant epilepsy, the KD has gained interest in relation to ASD due to the higher prevalence of epilepsy and seizure disorders among autistic individuals compared with the general population.4 The potential application of the KD in ASD is based on the hypothesis that metabolic changes associated with ketosis may influence neurological function. However, research investigating the effects of KDs on ASD-related symptoms remains limited, with current evidence primarily consisting of small-scale studies, case reports and preliminary trials. Although some studies have reported improvements in areas such as social behaviour, communication and repetitive behaviours, the limited sample

CONDITIONS & DISORDERS

sizes and lack of long-term controlled studies make it difficult to draw reliable conclusions about its effectiveness.5 In addition to limited evidence of benefit, several practical and nutritional challenges are associated with implementing a KD. The highly restrictive nature of the diet can make adherence difficult, particularly over extended periods, and may result in nutritional inadequacies if not carefully planned. Common adverse effects include constipation, gastrointestinal discomfort and deficiencies in essential vitamins and minerals. These concerns are particularly relevant for autistic individuals, as sensory sensitivities, food selectivity, food refusal and atypical eating behaviours are relatively common and may make acceptance of a restrictive dietary pattern challenging. The limited research investigating KDs in autistic populations may partly reflect concerns regarding feasibility and tolerability. Implementing a dietary intervention that requires strict carbohydrate restriction may be especially challenging for individuals who already experience feeding difficulties or have a narrow range of tolerated foods. As a result, maintaining the diet may place additional demands on families and caregivers. Overall, while the KD represents an emerging area of interest in ASD management, current evidence is insufficient to support its routine use for improving symptoms. Further research is required to determine which individuals, if any, may benefit from this approach, and how potential benefits can be balanced against nutritional risks and practical challenges. ULTRA-PROCESSED FOODS (UPFS) UPFs are food products that have undergone extensive industrial processing and typically contain ingredients that are not commonly used in home cooking, such as preservatives, flavour enhancers, artificial colours, sweeteners and other additives.6 The consumption of UPFs has increased substantially in many populations, and high intakes have been associated with poorer health outcomes in the general population, including an increased risk of obesity and cardiovascular disease. Within autism communities, there is growing interest in whether

reducing UPF consumption may influence ASD-related symptoms, including behaviour, attention and gastrointestinal difficulties. However, current research provides limited evidence to support the idea that UPF intake directly contributes to core autism characteristics, or that reducing UPF consumption improves these symptoms. Existing evidence primarily relates to broader nutritional outcomes rather than autism-specific characteristics. Despite the lack of evidence for direct improvements in ASD symptoms, reducing excessive consumption of UPFs may still provide general health benefits. Diets that prioritise minimally processed foods, including fruits, vegetables, wholegrains and sources of protein, may support overall nutritional adequacy and long-term health. However, implementing a low-UPF diet may present practical challenges for autistic individuals who experience sensory sensitivities, food selectivity or restricted eating patterns. Many autistic individuals may prefer UPFs due to their predictable taste, texture, appearance and consistency, which can provide a sense of familiarity and security during mealtimes.7 Consequently, abrupt removal of preferred foods may increase anxiety, contribute to distress and potentially reduce overall food intake. Therefore, rather than complete elimination, a gradual and individualised approach that considers sensory preferences, nutritional needs and existing eating behaviours may be more appropriate. Overall, while reducing excessive UPF consumption may support general health, there is currently insufficient evidence to suggest that a low-UPF diet is an effective intervention for managing core ASD symptoms. Dietary changes should therefore focus on improving nutritional quality while maintaining an individual's food acceptance, well-being and relationship with eating. PERSONALISED NUTRITION Due to the considerable variability in the characteristics, challenges and nutritional needs experienced by autistic individuals, a one-size-fits-all dietary approach is unlikely to be appropriate. Personalised nutrition involves using individual-specific information, including age, medical history, nutritional status, dietary patterns, sensory preferences and lifestyle

factors, to develop dietary strategies that are tailored to an individual's unique needs and circumstances.8 Within the context of autism, personalised nutrition shifts the focus away from attempting to ‘treat’ autism to promoting overall health, nutritional adequacy, comfort and quality of life. This approach may be particularly valuable given the range of feeding challenges commonly experienced by autistic individuals. By accounting for these, personalised dietary strategies can support dietary variety and help address nutritional deficiencies. Emerging research is investigating how factors such as gut microbiota, genetics, metabolism and lifestyle may influence nutritional requirements and responses to dietary interventions in autism.9 As understanding of these factors develops, personalised nutrition approaches may become increasingly refined, allowing dietary recommendations to be more targeted, effective and responsive to individual needs. Rather than relying on universal dietary rules or restrictive approaches, personalised nutrition recognises the diversity of autistic experiences and emphasises the importance of respecting individual preferences and supporting well-being and long-term health outcomes.

CONCLUSION Current evidence does not support a single dietary intervention as effective for all autistic individuals.10 Due to the wide variation of characteristics and symptoms, an individualised dietary approach to ASD is considered the most appropriate and safest strategy. Personalised nutrition allows dietary support to address specific nutritional needs while respecting individual preferences and promoting overall health and quality of life, rather than attempting to treat the core characteristics of autism. Further research is needed to better understand how individual factors influence responses to dietary interventions and to establish more targeted, evidencebased approaches.

MYTH BUSTING

Myth busting with Madi Madi Myers

Collagen claims stretch the truth

ollagen supplements – in powders, pills, drinks and gummies – have become one of the most aggressively marketed nutraceuticals of the past decade. Promoted for everything from wrinkle reduction and joint health to gut repair and even brain function, collagen is now firmly embedded in wellness culture. Yet despite its popularity, no authorised health claims currently exist for collagen in the UK or EU. This hasn’t stopped social media platforms such as TikTok and Instagram from being saturated with paid adverts suggesting that collagen supplementation can reverse ageing, strengthen hair and nails, or ‘replace’ lost collagen as we age. For nutrition professionals, this raises important questions: what does the evidence actually support and where does marketing run ahead of science? WHAT IS COLLAGEN? Collagen is a structural protein produced endogenously in the human body, contributing approximately 25–30% of total protein content in mammals. It is a key component of connective tissues, including skin, tendons, ligaments, cartilage, bone and blood vessels. Structurally, collagen is rich in glycine, proline and hydroxyproline amino acids, which form its characteristic triple helix configuration. Collagen synthesis is most efficient during childhood and early adulthood, with peak levels generally reached by the mid-20s. Thereafter, production gradually declines – a process influenced not only by ageing but also by UV exposure, smoking, alcohol intake, sleep deprivation and chronic inflammation. In skin, this decline contributes to reduced elasticity and the formation of wrinkles.

There are at least 28 distinct types of collagen, although types I, II, III, V and X are the most discussed in relation to human health. Commercial supplements typically do not specify collagen type in a meaningful or standardised way, making it difficult to match products to physiological targets. Collagen occurs naturally in animal foods containing connective tissue – for example, tougher cuts of meat, skin-on poultry, gelatine and bone broth. Bone broth in particular has gained popularity due to its perceived collagen content, and it is worth noting that gelatine is simply a mixture of polypeptides formed when collagen is partially hydrolysed, often through heating. HOW ARE COLLAGEN SUPPLEMENTS MADE? Most collagen supplements are derived from animal by-products, including the bones, skin, scales and connective tissues of cows, pigs, chickens or fish. These materials undergo a multi-step industrial process involving heat, enzymes and acids to extract collagen, which is then hydrolysed into smaller peptides and dried into powders or incorporated into capsules, drinks or gummies. So-called ‘vegan collagen’ products do not contain collagen. Instead, they typically provide amino acids or micronutrients thought to support endogenous collagen synthesis. While future production may involve genetically modified yeast or bacteria, this is not yet mainstream. DOES EATING COLLAGEN INCREASE COLLAGEN IN THE BODY? This is the central claim underlying most collagen marketing and also where the evidence becomes murky.

RNutr

The idea that ingested collagen travels intact through digestion and is deposited directly into skin or joints is biologically implausible Studies show that collagen peptides can be detected in the bloodstream following ingestion, suggesting they are absorbed to some degree. However, whether these peptides reach target tissues (such as skin or joints) in sufficient concentrations to stimulate collagen synthesis remains unclear. It is also uncertain whether any observed benefits exceed those of simply consuming adequate total dietary protein. There is also little evidence that consuming collagen-rich foods meaningfully increases collagen levels in the body. As with any dietary protein, collagen is broken down during digestion into amino acids and small peptides, losing its original structure. The idea that ingested collagen travels intact through digestion and is deposited directly into skin or joints is biologically implausible. A more realistic hypothesis is that collagenderived peptides act as signalling molecules, stimulating endogenous collagen production. Even then, responses appear to vary widely between individuals, likely influenced by genetics, baseline protein intake, age and lifestyle factors.

MYTH BUSTING

CAN COLLAGEN SUPPLEMENTS SUPPORT BRAIN HEALTH? Claims that collagen improves memory, fatigue or cognitive performance are currently poorly supported. Most evidence in this area comes from in vitro or animal studies. One small pilot study in 2019 reported improvements in measures of brain structure and memory following four weeks of 5g/day collagen peptides in healthy middleaged adults.1 While interesting, the study was limited by its small sample size, short duration and exploratory nature. At present, there is insufficient evidence to recommend collagen for cognitive or neurological health. IS COLLAGEN AN EFFECTIVE ANTI-AGEING SUPPLEMENT? Meta-analyses suggest small but statistically significant improvements in skin elasticity, hydration and fine wrinkles with collagen supplementation.2 However, many of these studies are industry-funded, and there is ongoing debate as to whether independent trials show the same magnitude of effect. Importantly, a recent umbrella review of meta-analyses concluded that collagen supplements are unlikely to function as a quick fix for ageing skin.3 Any potential benefit appears modest and gradual and should be considered within the broader context of skin health, including sun protection, smoking cessation, sleep and overall nutrition. In addition, despite frequent marketing claims, there is little convincing evidence that collagen supplementation meaningfully improves hair or nail health. CAN COLLAGEN BENEFIT JOINT HEALTH? The evidence base is somewhat stronger for joint and bone health, particularly osteoarthritis, although still inconsistent. Some studies suggest small-to-moderate improvements in pain and stiffness in older adults with osteoarthritis, especially with longerterm supplementation.3 In healthy adults, randomised trials have shown modest reductions in postexercise joint or muscle discomfort.3 However, conclusions are limited by significant heterogeneity across studies,

including differences in collagen type, dose, formulation, duration and whether supplementation was combined with exercise, making it difficult to isolate collagen’s independent effects. CONCLUSION Collagen is a biologically important protein, but that doesn’t automatically make collagen supplements effective. While emerging evidence suggests potential small benefits for skin and joint health in certain populations, the current data do not support many of the expansive claims made in marketing. Much of the collagen hype reflects a broader trend in nutrition: the belief that targeted nutraceuticals can override the fundamentals of health. At present, collagen supplements are unlikely to provide benefits that meaningfully exceed those gained from adequate protein intake, a varied diet, good sleep, sun protection and avoidance of smoking and excess alcohol. For most individuals, collagen supplements are not harmful – but neither are they essential. As nutrition professionals, our role is to communicate where evidence ends and marketing begins, helping clients make informed decisions grounded in science rather than promise.

New explore10 unflavoured now available 6 mths - 10 yrs

Only spoonable Ready to Feed (RTF) in resealable pouch

6 mths - 5 yrs

6 mths* - 5 yrs

Flexible spoonable semi-solid consistency or low volume drink

Feeding infants is a journey filled with discovery and growth. We’re here to make it joyful and stress-free by providing nutrition, tastes and textures at the right time. Building strong foundations to support a childs development and pave the way for a future of healthy habits for the dietary management of PKU.

Vitaflo Paediatrics

Reassurance From The Start Expertise | Reliability | Trust

*PKU explore10 Unflavoured suitable from 6 months. PKU explore10 Raspberry and Orange suitable from 1 years. PKU squeezie and PKU explore are Foods for Special Medical Purposes, to be used under medical supervision. This information is for Healthcare Professional use only. 28

CLINICAL

Evolving obesity treatment Is there still a role for metabolic surgery?

ver the last five years, the landscape of weight management has shifted dramatically. It’s not as simple as medications versus surgery; the choices for obesity treatment are becoming more tailored. Development of highly effective incretin therapies has transformed obesity treatment, delivering weight loss outcomes previously associated almost exclusively with metabolic and bariatric surgery (MBS).1–3 Importantly, the benefits extend beyond weight loss, with improvements seen in a range of obesity-related comorbidities.3,4 Recent US data suggest that incretin therapy use increased by 140.4% between 2022 and 2024, while metabolic surgery declined by 34.1%.5 Equivalent UK data is currently limited, but as access to incretin therapies continues to increase, a natural question arises: is there still a role for metabolic surgery?

INCRETIN THERAPIES IN OBESITY TREATMENT Incretin therapies are medications that mimic or enhance the effects of naturally occurring gut hormones; specifically, glucagon-like peptide-1 (GLP-1) and, in the case of dual incretin agonists such as tirzepatide (Mounjaro), glucosedependent insulinotropic peptide (GIP). These hormones are usually released from the intestine after eating and help regulate appetite, insulin secretion and blood glucose levels. The medications work by delaying gastric emptying and binding to receptors in the brain, aiding satiety while reducing hunger and food cravings. Incretin therapies that are currently approved for use in the UK are: semaglutide (Wegovy), tirzepatide (Mounjaro) and liraglutide (Saxenda) NICE recommendations differ between agents, but in general, incretin therapies are considered for adults

Jen Credicott RD

with a BMI of ≥35kg/m2 and at least one obesity-related comorbidity, with lower BMI thresholds for some ethnic groups. However, the MHRA-approved licence is for people with a BMI of ≥30kg/m2 or a BMI of ≥27kg/m2 with one obesity-related comorbidity.6,7 Accessibility to medications can vary nationally, with some Trusts requiring referral to a specialist overweight and obesity management service and others providing treatment in primary care.6,8 THE ROLE OF SURGERY Metabolic surgery includes procedures such as sleeve gastrectomy and Roux-en-Y gastric bypass, which alter gastrointestinal anatomy and gut hormone signalling to support sustained weight loss and metabolic outcomes.9,10 The criteria for referral for metabolic surgery is a BMI of ≥40kg/m2 or a BMI of 35-39.9kg/m2 with a significant

CLINICAL

While incretin therapies are highly effective, metabolic surgery remains associated with the greatest and most sustained weight loss... obesity-related comorbidity, with lower BMI thresholds applying for some ethnic groups. Since July 2023, NICE guidelines have removed the requirement that people who meet these criteria must have tried all nonsurgical interventions first or be under the care of a tier 3 service. In short, people who meet the BMI criteria can be referred directly for multidisciplinary assessment for surgery, and so it should not be considered a last resort.6 This is particularly relevant for people with severe obesity. Delaying referral for surgery while repeatedly trialling

medication may not always be in the patients’ best long-term interests. Despite this, metabolic surgery for many patients can seem an extreme option, so incretin therapies provide a non-surgical, first-line option capable of significant weight loss and associated metabolic improvements. Medications are noninvasive, reversible and easier to scale. However, not all individuals respond adequately to incretin therapy, and some are unable to tolerate treatment due to significant gastrointestinal side effects. In addition, weight regain is common following treatment discontinuation, and the long-term cost and accessibility of these medications remain important considerations.1,2,8 While incretin therapies are highly effective, metabolic surgery remains associated with the greatest and most sustained weight loss, alongside wellevidenced improvements in metabolic health. Through permanent anatomical, hormonal and metabolic changes, surgery delivers durable benefits for a range of obesity-related comorbidities, including T2DM, hypertension, dyslipidaemia, cardiovascular disease,

metabolic dysfunction-associated steatotic liver disease (MASLD), certain cancers and obstructive sleep apnoea.10,11 Surgical outcomes are supported by extensive long-term evidence and remain an important treatment option for obesity. However, surgery is not without challenges. Patients require lifelong nutritional monitoring and supplementation, and access may vary according to local referral pathways and service provision.6,9 SHIFTING THE OBESITY TREATMENT NARRATIVE In any obesity treatment, dietary support and effective behaviour change remain integral to achieving positive health outcomes.6,9 Incretin therapies should therefore be viewed as metabolic treatments for a chronic disease, delivered alongside behavioural and nutritional support and, where appropriate, integrated within a surgical pathway. Many patients describe the reduction in appetite and ‘food noise’ experienced with incretin therapy as liberating, providing

CLINICAL

THE FUTURE OF OBESITY TREATMENT The pace of change shows no sign of slowing. Newer agents, including triple agonists that target multiple gut hormones simultaneously, are demonstrating weight loss outcomes approaching those achieved with metabolic surgery.14 An important shift is that obesity treatment is becoming increasingly individualised. The future is unlikely to involve choosing between medication or surgery in isolation. Instead, we are moving towards integrated obesity care models where pharmacotherapy may be used before surgery to reduce operative risk and/or after surgery to help treat weight regain.15,16

relief from the relentless hunger and preoccupation with food driven by the biological effects of obesity.1,2,12 (Read more on food noise in Priya Tew's Food for Thought this issue.) These experiences reinforce the understanding of obesity as a chronic, relapsing disease with complex physiological drivers, rather than a consequence of personal choices. This can help challenge the repeated failure narrative that often accompanies years of dieting, moving conversations away from simplistic notions of willpower and personal responsibility. There is still much work to be done to reduce the shame and stigma associated with overweight and obesity.13 As dietitians, we have an important role in helping patients move away from self-blame and towards a more compassionate approach to long-term health and behaviour change. As obesity treatment becomes more medicalised and increasingly commercialised, there’s a risk that conversations around weight loss become overly focused on aesthetics rather than health. Healthcare professionals have an important responsibility to challenge this

narrative, guide appropriate use and escalation of treatment and ensure that patients understand the health implications of overweight and obesity. Equally important is helping patients understand the potential health benefits associated with both incretin therapies and metabolic surgery. The goal of obesity treatment should not only be achieving a socially idealised body size. It is also about improving health, function, quality of life and access to healthcare. Treatment can lead to meaningful improvements in glycaemic control, cardiovascular risk factors, mobility, fertility, pain, sleep apnoea and MASLD, as well as increased energy and daily function and an improved relationship with food.3,4,10 Ultimately, effective obesity treatment will reduce disease burden and improve quality of life. Importantly, some cardiometabolic benefits may occur before, or even partly independently of, significant weight loss and regardless of whether an individual reaches a BMI within the traditionally defined healthy range.3,4 Framing treatment of obesity in terms of health gains rather than aesthetic outcomes is essential to supporting person-centred, evidence-based care.

CONCLUSION Incretin therapies have undoubtedly shifted the treatment of obesity, but rather than eliminating the need for metabolic surgery, they have broadened choices available for both patients and clinicians. Obesity management is quickly shifting to a more sophisticated chronic disease model incorporating pharmacotherapy, surgery, behavioural interventions and multidisciplinary care.6,13 All treatment options should aim to improve metabolic health and reduce the risks and burden associated with excess adiposity. As obesity care evolves, treatment decisions should be guided by individual preferences, comorbidities and long-term health goals. Treatment options will continue to expand, and dietitians will play an increasingly important role in helping patients navigate a complex and rapidly evolving treatment landscape while continuing to advocate for compassionate, health-centred, person-focused care. Medications and surgery are not competing interventions but part of a continuum of metabolic disease management.16,17 The question is not whether one is superior, but which approach best supports an individual’s health, circumstances and longterm outcomes.

INFORMATION FOR HEALTHCARE PROFESSIONALS USE ONLY

A 1.2 kcal/ml nutritionally complete paediatric enteral feed with 12g/L of PHGG* fibre and 100% whey peptide.

Nutritional Profile

Scan to read study:

A unique paediatric formula containing 12 g/L of PHGG fibre formulated for children with compromised/impaired GI function**

54% of the fat as MCTs

3.6g protein (12%kcal) per 100mL

5.6g PUFA (DHA and EPA) per 500mL

Tolerability and Safety of a Semi-elemental Enteral Formula with Partially Hydrolysed Guar Gum (PHGG) in Tube-fed Children Aged 1-4 Years Gerard Minor, Timothy Sentongo, Ralf G. Heine, Boutaina Zemrani

Osmolarity: 383 mOsm/l

Osmolality: 473 mOsm/Kg

*PHGG : Partially hydrolysed Guar Gum **Information is correct at the time of publication. MIMS June 2026

®Reg. Trademark of Société des Produits Nestlé S.A. Nestlé Health Science UK. NHSc 137 Aug 2026

PA E D I AT R I C

Infancy nutrition risk and

Hazel Duncan RD

The vital 1000 days that influence life – and society

nfancy is the most rapid period of growth and development in human life. During the first 1000 days, from conception to a child’s second birthday, adequate nutrition shapes brain development, immune function, physical growth and long-term health outcomes.1 While advances in healthcare have reduced infant mortality worldwide, nutritional risk remains a significant public health challenge across both low- and highincome countries. Malnutrition in infancy encompasses both undernutrition and overnutrition, each carrying immediate and lifelong consequences. Early recognition of nutritional risk factors and timely intervention are essential components of paediatric healthcare.1,2

THE VITAL TIME This initial period is a critical window for growth, development and long-term health. During this time, adequate nutrition supports rapid brain development, organ maturation, immune function and healthy physical growth. The brain develops at an extraordinary pace, forming millions of neural connections each second, making a consistent supply of essential nutrients such as protein, iron, iodine, zinc, folate and essential fatty acids vital for optimal cognitive and neurological development.1 Good nutrition also reduces the risk of stunting, wasting, micronutrient deficiencies and infectious diseases, while improving survival and developmental outcomes. Breastfeeding, appropriate complementary feeding from around six months of age and timely provision of nutrient-rich foods are crucial. Conversely, inadequate nutrition can have irreversible consequences, including impaired cognitive function, weakened immunity, poor educational achievement and an increased risk of chronic diseases, such as obesity, diabetes and cardiovascular disease, later in life.1 33

PA E D I AT R I C

Investment in maternal nutrition during pregnancy and in optimal infant feeding practices not only benefits individual children but also contributes to healthier families. Ensuring good nutrition during this critical period is one of the most effective strategies for promoting lifelong health and breaking the intergenerational cycle of malnutrition. NUTRITIONAL RISK IN INFANCY Nutritional risk refers to the likelihood that an infant will develop inadequate or excessive nutritional status due to biological, environmental, socioeconomic or medical factors. Infants are particularly vulnerable because of their rapid metabolic demands, immature physiological systems and complete dependence on caregivers for nourishment.1-3 Healthcare professionals must evaluate nutritional risk not only by measuring growth but also by considering feeding practices, medical conditions, family circumstances and developmental milestones. PREMATURITY AND LOW BIRTH WEIGHT INFANTS Numerous factors contribute to nutritional risk during infancy. Premature or low birth weight infants should have increased energy, protein, calcium, phosphorus and micronutrient intake to ensure growth is matched to that expected in utero. Many premature infants will have prolonged hospital stays and may need multidisciplinary team support due to poor feed tolerance, increased reflux/immature gastrointestinal tract and multiple infections.1 Low birth weight infants will often require patient-centred care plans to make sure their growth is optimised, which will have a positive impact on neurodevelopmental progress. It’s important to avoid excessive weight gain with these babies. FEEDING DIFFICULTIES Issues with feeding can be multifactorial and may include structural issues such as: • Cleft lip and palate • Neurological conditions, which may make infants unable to feed effectively orally • Congenital heart disease • Respiratory disorders, which

increase nutritional requirements and can result in increased energy expenditure Infants with gastro-oesophageal reflux may then develop feeding aversion, which can affect intake and increase nutritional risk.1 Persistent feeding difficulties over time will result in inadequate calorie intake, poor weight gain, concerns around hydration, and it can impact neurodevelopmental progress if sustained over a long period. INADEQUATE BREASTFEEDING Exclusive breastfeeding is recommended during the first six months of life because human milk provides optimal nutrition, immune protection and bioactive compounds that support healthy development. It is important to make sure there is adequate support for breastfeeding mums and issues such as tonguetie, poor latch and concerns around supply are supported by an adequately trained healthcare professional.3,4 FORMULA FEEDING Infant formula is a safe alternative when breastfeeding is not possible, or there is poor growth with breastfeeding alone and support strategies have been tried. It is key that parents are aware of correct instructions when preparing feeds to ensure feeding practices are safe and the infant’s growth is optimised. Issues such as overdilution, overfeeding and use of unsuitable milk products before 12 months of age will all have a detrimental impact on an infant’s growth and development, as well as cause potential electrolyte imbalances and nutritional deficiencies.3,4 MICRONUTRIENT DEFICIENCIES Although energy intake is important, micronutrient deficiencies often have profound developmental consequences. Iron deficiency This is the most common nutritional deficiency during infancy. Risk factors include prematurity, low birth weight, delayed introduction of iron-rich complementary foods and excessive cow’s milk consumption after infancy. It can be associated with impaired cognitive performance, behavioural issues and reduced learning capacity.5 We should make sure parents are aware of high iron foods to be included in

Ensuring good nutrition during this critical period is one of the most effective strategies for promoting lifelong health... the diet, given alongside high vitamin C-containing food as a strategy to optimise absorption, and avoid tannins which inhibit absorption. Advice should be given around appropriate supplementation if parents are unable to source adequate iron from the diet. Vitamin D deficiency Infants at risk include those who are exclusively breastfed without supplementation, have limited sunlight exposure (long-term hospital admissions), have darker skin pigmentation and live in regions with reduced sunlight. Local policies should be followed regarding vitamin D supplementation to minimise the risk of deficiency, which can lead to rickets, delayed motor development and poor bone health. Zinc deficiency This may cause issues around poor growth, reduced appetite, increased risk of infections and poor wound healing. Supplementation may be required to correct deficiencies. GROWTH MONITORING Monitoring growth is the cornerstone of nutritional assessment. Growth includes the monitoring of weight, length and occipitofrontal circumference, also known as head circumference – an important element to measure routinely, as this helps assess brain growth and development, as well as early detection of disorders such as microcephaly, macrocephaly and other disorders that impact brain development.1 Looking at the trend of an infant’s growth allows you to assess whether you are concerned about the growth and associated nutritional risks. Warning

PA E D I AT R I C

signs include an intake crossing two major centile lines, failure to regain birth weight appropriately, poor weight gain, growth faltering (but within two major centile lines) and disproportionate head growth. Early detection allows timely nutritional intervention, which in turn reduces long-term risk. EMERGING CHALLENGES Social deprivation is increasing as more families are living in poverty. Social deprivation is a major determinant of nutritional risk during infancy. Families living in poverty may experience food insecurity, limited financial resources, inadequate housing and reduced access to health education, all of which can compromise infant feeding practices. Caregivers facing economic hardship may struggle to afford infant formula, nutrientrich complementary foods, or to get to healthcare appointments. Maternal factors associated with social deprivation, such as poor nutrition during pregnancy, lower educational

attainment, mental health challenges and limited breastfeeding support, can further increase the risk.4,5 Infants from socially disadvantaged households are at greater risk of growth faltering, iron deficiency, vitamin deficiencies, recurrent infection, and developmental delays. Conversely, some deprived populations are also at increased risk of childhood overweight and obesity due to reliance on inexpensive, energy-dense, nutrient-poor foods. Addressing nutritional risk requires more than dietary advice; it demands policies and interventions that tackle the wider social determinants of health, including poverty reduction, food security, access to healthcare, parental education and community support services.4,5 Climate change and food insecurity further threaten nutritional health by disrupting food systems and increasing the cost of nutrient-rich foods. Healthcare professionals must combine evidence-based guidance with culturally sensitive communication to help families navigate increasingly complex nutritional information.

CONCLUSION Nutritional risk during infancy represents one of the most important determinants of lifelong health. The rapid pace of infant growth creates both remarkable opportunities and significant vulnerabilities. Biological conditions, such as prematurity, feeding disorders and chronic illness, interact with socioeconomic factors, caregiver knowledge and healthcare access to influence nutritional outcomes. Early recognition through regular growth monitoring, comprehensive nutritional assessment and timely intervention can prevent many adverse consequences. Ensuring optimal infant nutrition requires a collaborative effort involving families, healthcare professionals, communities and policymakers. By promoting breastfeeding, supporting appropriate complementary feeding, preventing micronutrient deficiencies and addressing the broader social determinants of health, healthcare systems can help every infant achieve their full growth and developmental potential. Investment in infant nutrition is not only an investment in child health but also in the future health, productivity and well-being of society as a whole.

INTERVIEW

David Proud, Lead Adult Dietitian on the big pivot in cystic fibrosis support David Proud has worked exclusively in adult cystic fibrosis (CF) care since 2011. He explains to NHD Magazine how dietitians – a key part of the MDT – have made a ‘dramatic pivot’ due to an increase in obesity in the CF population.

he UK Cystic Fibrosis Standards of Care emphasises the importance of a comprehensive MDT, with dietitians playing a central part. David explains: “There’s a direct link between nutritional status – including weight and body composition markers such as lean tissue and fat mass – and respiratory function, as well as reduced morbidity. The dietitian is therefore a key member of the MDT, contributing to all aspects of patient care, from routine monitoring through to complex nutritional management. “The exact number of dietitians specialising in CF is unknown. However, CF specialist dietitians are required to join the BDA CF Specialist Dietitians Group, which currently has 203 registered members.” CHALLENGING Historically, and for people who don’t qualify for highly effective CF transmembrane conductance regulator (CFTR) modulators, a qualification dependent on their gene mutation, a unique challenge for the

We see our patients' journeys through all chapters and events in life, good and bad, supporting them throughout

dietitian has been to help patients meet their high nutritional needs. “While currently being updated, the UK guidelines state that the energy requirements of people with CF could be as much as 200% more than their non-CF peers,” David advises.1 “The introduction of the highly effective CFTR modulator elexacaftor/tezacaftor/ ivacaftor (ETI) in 2020 significantly reduced hospital admissions, while improving nutritional status, lung function and life expectancy. “However, an upward trend of people becoming overweight and obese has also been observed. As a result, dietitians have had to make a dramatic pivot in a brief period, moving from nutritional support that minimises the risk of low-weight malnutrition to nutritional messaging and education around the theme of healthy eating and lifestyle. It’s difficult for many patients too, as they have to adjust lifetime habits.” DIVERSE The role of a dietitian working in CF is both rich and complex. David explains: “In a single clinic, I may be supporting a recently transitioned young adult who’s still trying to get to grips with managing pancreatic enzyme replacement therapy (PERT) to minimise gastrointestinal symptoms. Then I move to an older adult who needs heart health education due to an elevated lipid profile. A third patient may request sports nutrition advice and a body composition assessment as they plan to run their first marathon. A mum-to-be is seeking nutrition advice during pregnancy, a life stage made more possible due to ETI. Another patient diagnosed with CF diabetes reviews carbohydrate

counting education. My final patient of the clinic has been diagnosed with CF-related low bone mineral density and requires nutritional advice.” REWARDING The nature of David’s specialist work means he has the opportunity to develop rapport not just across appointments but across years and even decades. “I meet young adults as they transition from paediatric to adult care; an important part of my role is to settle their worries and those of their parents about the move,” he says. “We see our patients' journeys through all chapters and events in life, good and bad, supporting them throughout. I feel privileged to share in some of their most important milestones.” David Proud is a Lead Adult CF dietitian for the All Wales Adult CF Centre, University Hospital Llandough, Co-Chair of the BDA Specialist CF Dietitian Group and is a member of the CF Trust Clinical Advisory Group.

STUDENT HUB

Out of my comfort zone in a public health placement Deeya Chodha is studying an MSc in Dietetics and Nutrition at London Metropolitan University. She tells us why her public health placement in charitable organisations such as FEAST With Us and Bags of Taste opened her eyes to barriers in healthy eating.

Deeya Chodha ANutr

social isolation. This highlighted for me that social connection holds an important role in improving mental and physical outcomes.4

aining experience in charities was a great opportunity to get insight into public health, expand my knowledge, develop my skill set and make a positive impact.1 It also revealed to me the many challenges and barriers faced by people and families when it comes to nutrition. I’d say, for students and future healthcare professionals, it’s crucial to be aware of them.2

WHY I VOLUNTEERED During my undergraduate degree in nutrition, I had the opportunity to work in two community-focused organisations tackling real-life challenges: FEAST With Us and Bags of Taste. Working in this environment aligned with my personal and professional values of compassion and empathy. Little did I know that this experience would greatly influence how I view nutrition.3 ACCESS TO HEALTHY FOOD IS A PRIVILEGE During my placement, I collaborated with chefs and fellow volunteers to develop nutritious meals from surplus ingredients. I’d speak to members of the community following the meal and would

hear frequently that this could be their only hot meal of the day. It opened my eyes to the growing prevalence of food insecurity, resulting in increasing dietary health inequalities. In both organisations, I witnessed many factors that affect dietary choices, such as time, transport, poverty and the rising cost of living.4 I also learnt about the barriers to food people face, such as access to a kitchen and basic cooking equipment. While it’s easy to assume that a lack of knowledge drives poor dietary choices, this experience highlighted access to food as a key factor. THE IMPORTANCE OF COMMUNITY A community meal isn’t just a plate of food; it’s a moment of nourishment, care and dignity.5 At FEAST With Us, I saw the importance of community – for those facing food insecurity, this is crucial. After making the meals with the chefs and service users, people would sit together around a table, eating, talking, laughing and sharing their experiences. This provided an opportunity for those facing tough times to connect. When I spoke to service users, they’d tell me how important this is for them in reducing

CONFIDENCE CAN BE GAME-CHANGING Helping build confidence and providing encouragement is vital in initiating positive behaviour change – as my experience at Bags of Taste confirmed.6 I mentored a small group, providing support, encouragement and inspiration to cook healthy food, as well as equipping the group with knowledge and skills to start a long-term habit. The impact that encouragement and confidence can have is well known. But witnessing this was an incredibly rewarding experience and highlighted to me its importance. WHY I RECOMMEND VOLUNTEERING IN PUBLIC HEALTH Through my experience with Bags of Taste and FEAST With Us, I’ve developed more empathy and compassion. I’ve gained an insight into barriers people face in achieving good nutrition and learnt about the importance of being realistic and considering the social, environmental and economic factors. This experience pushed me out of my comfort zone by exercising my ability to translate scientific information into plain English for service users and adapting my approach for people from a range of cultures and religions. I'm taking into my future studies and professional life an improved ability to speak more confidently with people. I’d highly encourage students to gain experience in public health and take opportunities to push themselves out of their comfort zone – it’s so valuable.

Students, your career starts before graduation The new and improved NHD Student Hub is designed to help you get career-ready. Discover career-focused blogs, studentwritten articles, spotlighted peer research and writing opportunities to build your byline before you’ve even qualified.

Visit the new Student Hub at nhdmagazine.com/student-hub - it’s just one click away.

THE LAST WORD

The last word Weight-loss medications A different response in Black and Asian populations

emaglutide and tirzepatide are two of the most effective newer pharmacological treatments for T2D and obesity. Semaglutide is a GLP-1 receptor agonist, while tirzepatide has a dual mechanism, acting on both GLP-1 and GIP receptors, enhancing its effects on glycaemic control and weight loss. Both medications improve blood glucose by stimulating insulin secretion, suppressing glucagon release, slowing gastric emptying and increasing satiety, thereby reducing overall calorie intake. Clinical trials have demonstrated significant reductions in HbA1c and body weight, along with cardiovascular benefits. However, adverse effects have been reported, with the most common being gastrointestinal, such as nausea, vomiting, diarrhoea and constipation.

VARYING RESPONSE Emerging evidence suggests that treatment response and tolerability may vary across ethnic groups due to both biological differences and disparities in healthcare access.1 Evidence from clinical trials and meta-analyses indicates that both semaglutide and tirzepatide are effective and generally well tolerated in Asian populations. The STEP 6 trial showed that once-weekly semaglutide produced significant weight loss and improvements in glycaemic control and cardiometabolic risk factors in East Asian adults with overweight or obesity, with or without T2D.2 Similarly, a systematic review and meta-analysis found that tirzepatide significantly reduced HbA1c and body weight in both Asian and non-Asian populations, with Asian participants demonstrating slightly greater reductions at certain doses.3 In terms of safety, both medications show broadly similar profiles across populations, with gastrointestinal side effects being the most common. However, differences in treatment response have been observed.

Asian populations tend to have higher body fat percentages and greater visceral adiposity at lower BMI levels, which may contribute to greater weight loss responses but also a higher likelihood of gastrointestinal intolerance. In contrast, non-Asian populations have shown slightly greater improvements in glycaemic control in some analyses, along with a different pattern of metabolic and nutritional adverse events. These findings suggest that ethnicity may play a role in both efficacy and tolerability, although further research is needed to clarify these differences and guide potential dose optimisation strategies.4 CONTRASTING OUTCOMES Comparative evidence also supports the superiority of tirzepatide over insulin in diverse Asian populations, including participants from China, Japan, South Korea, India and Taiwan.5 In adults with T2D inadequately controlled on oral therapies, tirzepatide produced greater reductions in HbA1c, more substantial weight loss and a higher proportion of patients achieving glycaemic targets compared with insulin. While insulin remained effective for lowering blood glucose, it was associated with weight gain and a higher risk of hypoglycaemia. In contrast, tirzepatide was associated with weight reduction but a higher incidence of mild-to-moderate gastrointestinal side effects.6 Overall, tirzepatide demonstrated superior metabolic outcomes in this population. Beyond glycaemic control and weight loss, cardiovascular outcomes and broader treatment disparities have also been explored. In a review of more than 4000 participants examining the influence of race and ethnicity on cardiovascular outcomes in individuals with diabetes and obesity, findings suggested that GLP-1 receptor agonists such as semaglutide may provide cardiovascular benefits

Fareeha Jay RD

across ethnic groups, including Asian, Hispanic and Black populations, although the magnitude of benefit may vary. Some evidence suggests stronger cardiovascular effects in Asian populations, while Black populations also benefit, but to a slightly lesser and more variable extent. The review also highlighted disparities in access and uptake of newer diabetes therapies, with lower use rates observed in some ethnic minority groups across healthcare systems.7 These findings highlight that outcomes with GLP-1 receptor agonists are influenced not only by biological variation but also by socioeconomic and healthcare access factors. Black and South Asian populations may experience differences in treatment response and adherence, which are further shaped by income, education, cost barriers and access to care.8 Such factors can delay treatment initiation or reduce long-term effectiveness, even when pharmacological efficacy is high.

CONCLUSION Overall, the evidence suggests that semaglutide and tirzepatide are highly effective treatments for T2D and obesity across populations, but both biological and social determinants of health influence outcomes. This underscores the importance of equitable access to care, patient education and support strategies to improve adherence. However, current clinical trial data remain limited for specific ethnic subgroups, highlighting the need for more inclusive research to better understand variations in efficacy, safety and cardiovascular outcomes, and to support more personalised, evidence-based treatment approaches.

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