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FOR GASTROENTEROLOGY

ISSUE 13. 2021 - NO 1

VO I C E O F PRI M ARY C ARE GASTR OENTER OLOGY

THE PRIMARY CARE SOCIETY

THE DIGEST Vol 8. Issue 13 2021 - No 1

MAKING A DIFFERENCE IS WHAT WE DO BEST

The Digest is the scientific journal of The Primary Care Society for Gastroenterology. We welcome comments on the content as well as ideas for contributions to future issues. Managing Editor (for Satellite PR) Pauline Kent Guest Editor Dr Sophie Nelson Sub Editor Steve McCubbin Assistant Editor (for Satellite PR) Vicky Proctor Designer (for Satellite PR) Leah Whiffin Publisher The Primary Care Society for Gastroenterology PCSG Secretariat, c/o Satellite PR 154-158 Shoreditch High Street London E1 6HU Tel: +44 (0) 20 3872 4901 Printer Hollinger Print 12 Burnet Road Norwich NR3 2BS Commercial For sponsorship or advertising opportunities please contact Pauline Kent, Director at Satellite PR, a multi-award-winning healthcare agency with over 30 years’ pan-European experience. Email: pauline@satellitepr.com Contributor guidelines Guidelines for writers are available on request. Follow us Facebook.com/PCSGastro/ Twitter @PSCGastro

www.satellitepr.com info@satellitepr.com

A NOTE FROM THE EDITOR

Welcome to The Digest The Women’s Edition DR SOPHIE NELSON Guest Editor of The Digest

’m very proud to introduce the first ever Women’s Edition of The Digest, featuring an exclusively female cast of contributors and with a particular focus on women’s health complaints. Within the following pages you will read articles discussing the menopause and how it can affect GI health, the inspiring work of the London-based Milk Bank project and fascinating research into gut-dwelling parasites and how they might help us to better understand health issues endemic to the West. We’ve known for a while that women are more likely to suffer from complaints such as IBS. Indeed, more research is required in the field of female gut health into understanding why this might be the case. In Dr Deirdre O’Donovan’s article, IBS and gender (p12), we read that “gender-related differences are most likely related to changes in the menstrual cycle and hormonal levels as the symptoms of IBS become worse and more severe during menstruation. Females complaining of dysmenorrhea experienced IBS symptoms more frequently than those without dysmenorrhea, for example. In addition, menopause seems to be associated with the exacerbation of IBS symptoms.” Gastroenterologist and Chair of Supporting Women in Gastroenterology (SWiG), Dr Helen Fidler (p16) also discusses the paucity of women working in the field. “As far as specialist areas are concerned, GI is woefully behind when it comes to gender balance and SWiG wanted to not only ask why, but also find out how to provide support.” She describes her experience of working in a largely male-dominated sphere and how we can begin to redress the balance through conversation, mentoring female practitioners and more female role models in senior positions. This Women’s Edition of The Digest honours the contribution made by many excellent women in the field of gut health. At a time when the world looks to redress pervasive issues of inequality, including the gender pay gap and #MeToo, the PCSG keeps pace.

We want to hear from you!

Letters for publication and suggestions for editorial contributions should be emailed to editor@pcsg.org.uk

Cover illustration The cover is inspired by Andy Warhol’s screenprint adaptation of The Birth of Venus designed by Will Pirkle (for Satellite PR)

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IN THE ISSUE

06 Contributors 10 News

Human milk banking: an unexpected opportunity to improve public health

IBS and gender – have females drawn the short straw?

The NHS and female GPs – is there an issue we need to address?

16 Supporting women in Gastroenterology 4

24 The triad relationship between the host, gut bacteria and intestinal parasites

33 Living with an enteric stoma 36 A day in the life of Dr Jelena Rakić Matić

THE DIGEST ISSUE THIRTEEN

In my shopping trolley with The Gut Stuff

Life as a GPwER: Building bridges between primary and secondary care 44 Recipe: Roast Cod and Mediterranean Vegetable Tray Bake 47 Menopause and the gut

"Babies keep being born..." 60 The changing face of medicine – a new era for women 54 Tea and toast Monotonous diets increase the risk of poor nutrition status, and then, poor health

63 How eating disorders hide in plain sight

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CONTRIBUTORS

EDITOR DR SOPHIE NELSON Sophie Nelson is a salaried GP in Wilmslow, Cheshire. She also works as a GPwSI at Manchester Royal Infirmary, both in outpatients clinics and the endoscopy suite. She graduated from the University of Manchester in 2006 and is a member of The Royal College of General Practitioners and The Royal College of Surgeons of Edinburgh, and has a Master's degree in Surgical Sciences from Edinburgh University. She is an active member of the PCSG Committee, having recently returned to work after maternity leave.

DR HELEN FIDLER Helen Fidler is Chair of the Supporting Women in Gastroenterology (SWiG) section of the BSG and Deputy Chair of the UK BMA Consultants Committee. Helen qualified in 1987 and was appointed to her current position as a consultant gastroenterologist in the Gastroenterology Department at Lewisham and Greenwich Trust in 1998.

DR JELENA RAKIĆ MATIĆ Jelena Rakić Matić is from Zadar, on the Adriatic Coast of Croatia, and practises family medicine at the Health Care Centre Zagreb West. She has worked as a GP for 11 years. She is also a member of the executive board of KoHOM (Coordination of Croatian Family Medicine) and president of the Organizing Committee of KoHOMs Congress and represents KoHOMs in EQUIP and in ESPCG.

DR KATHERINE PARKIN Katherine Parkin is a foundation doctor, working at St Thomas’ Hospital. She graduated in April from King’s College London and has voluntarily started work early to help out with the Covid-19 pandemic. She also has a BSc in Human Nutrition and Metabolism. She is particularly interested in Obstetrics and Gynaecology, having been President of her university’s O&G Society. In her spare time she enjoys art and netball.

DR NATALIE SHENKER Dr Natalie Shenker trained in medicine at Oxford University and initially worked in paediatric surgery before embarking on a research career. Having collaborated with a hospital milk bank during her PhD in epigenetic risk factors for breast cancer at Imperial College London, she co-founded the Human Milk Foundation (HMF), a charity that aims to ensure equity of access to screened donor milk when breastfeeding is impossible or taking time to establish. The HMF is establishing a network of human milk banks based on the innovative model of the Hearts Milk Bank (HMB), established in 2017. Natalie is currently a UKRI Future Leaders Fellow at Imperial College London, focusing on human milk science and the role of breastfeeding in maternal and planetary health.

DR MELISSA LAWSON Melissa Lawson is a Research Associate at the University of Manchester in the Faculty of Biology, Medicine and Health. She graduated with a Microbiology Honours BSc and an MSc in Pathobiology from the University of Guelph, Canada. She then pursued a PhD in Immunology awarded from the University of Bern, Switzerland. After this she relocated to the Quadram Institute of Bioscience as a Marie Skłodowska-Curie Individual Fellow, investigating the importance of diet on gut bacteria community dynamics in early life. Currently in Manchester, Melissa has expanded her research depth to examine the symbiotic relationship between the host, gut bacteria and intestinal parasites. In addition, Melissa is actively involved in engaging the wider community regarding the importance of the microbiota and health, through her interactions as a STEM ambassador and at public engagement seminars.

THE GUT STUFF Inspired by the research work they did with Prof Tim Spector, today twins Alana and Lisa Macfarlane run The Gut Stuff, a company dedicated to informing the public about gut health in a way that’s accessible, affordable and easily digestible to everyone. The twins and their team attend conferences and run events on gut health, their gut blog contains recipes and support for people who might be suffering from a GI-related health problem, and their website and social media is packed full of educational resources on a range of GI topics. Most importantly, though, they have done wonders for bringing gut health, a difficult, sometimes embarrassing topic, further into the public eye.

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CONTRIBUTORS SOPHIE MEDLIN

DR LILY LAMB Lily Lamb is a GP in Northumberland, an NIHR In Practice Fellow and medical student educator based in the School of Medical Education at Newcastle University. She is Chair of the North East England Faculty of the Royal College of GPs, and co-convenor of the Leadership strand of the Changing Face of Medicine project. She is passionate about educating our future doctors, supporting our existing GPs, raising the profile of general practice, and improving the future of our profession. She has three children and is married to a gastroenterologist. She loves running, kayaking and exploring the beautiful Northumberland countryside and coastline in her spare time.

Sophie Medlin (@sophiedietitian) is a consultant Colorectal Dietitian and co-founder of CityDietitians (citydeititians. co.uk). Sophie worked in the NHS for many years. specialising in the nutritional management of patients before and after colorectal surgery. She began working with stoma charities and stoma supply companies over 10 years ago and moved to work as a lecturer in Nutrition and Dietetics at King’s College London, where she undertook a research project to understand more about the nutritional implications of stoma surgery. Sophie now runs her business offering evidencebased nutrition to individuals, companies and the media, and she continues to work actively with the stoma community.

URSULA ARENS

DR DEIRDRE O’DONOVAN Deirdre O’Donovan graduated from the Royal College of Surgeons in 1996 and subsequently obtained her MRCP (UK). She completed a research fellowship in the Royal Adelaide Hospital in South Australia and was conferred with a PhD in Medicine in 2005 from University College Cork. She was awarded an MA in Healthcare Management in 2006. She obtained her certificate of completion of Specialist training in Gastroenterology and Internal Medicine in 2007. She is a member of the Irish Society of Gastroenterology and American Gastroenterological Association. She is co-author of 27 peer reviewed papers and four book chapters. Her clinical interests are gastrointestinal functional disorders, inflammatory bowel disease and colorectal cancer screening, and her research interests include gastrointestinal motility and biomechanics, appetite regulation, and colorectal cancer.

Ursula Arens has a degree in dietetics, and she has a monthly column for dietitian readers in Network Health Digest magazine. Her career has been with food and pharmaceutical companies, and she was senior scientist at the British Nutrition Foundation for many years.

JESS GRIFFITHS Jess Griffiths is an Eating Disorders Practitioner and Beat’s Clinical Training Lead, working with Beat to develop and deliver training courses. She uses both professional and personal experience to help health professionals understand what someone with an eating disorder is going through.

OLIVIA SHELTON Olivia Shelton is a Caseloading Midwife at St Thomas’ Hospital in London, specialising in caring for vulnerable women with both medical and social complexities. She worked at University College of London Hospital before that, completing her preceptorship programme, after graduating from the University of Huddersfield. More recently, Olivia has obtained a Master’s Degree in Perinatal Mental Health at London South Bank University, where she centred her research on the effectiveness of mental health Mother and Baby Units (MBUs) and mental health support for pregnant women in prison. Since the start of Covid-19, Olivia has focused her efforts on ensuring women with complex mental health needs have a clear understanding of the issues they could face and support available to them throughout the crisis.

Beat is the UK’s eating disorder charity. They exist to end the pain and suffering of eating disorders. Beat is there for anyone affected by these illnesses, including people with eating disorders, their loved ones, and professionals who work directly with them, or who otherwise may come into contact with them.

VICKY PROCTOR Vicky Proctor is the in-house copywriter for Satellite PR. She has a Master's degree in Creative Writing from the UEA and an undergraduate degree in History of Art and Chinese Studies from Edinburgh University. She is also the founder and editor of Leslie Magazine, an arts and literary magazine dedicated to play and humour. She has been published by The Guardian and has written a satirical novel (as yet unpublished!).

The Primary Care Society (PCSG) makes no representation, nor gives any warranty, about the accuracy or effectiveness of any research finding or surgical or medical procedure or facts contained in any research paper or otherwise in The Digest. Readers must make their own assessment of the potential effectiveness of any such information. The PCSG, to the maximum extent permitted by law, disclaims all liability for any injury to any person incurred as a consequence of any information in The Digest. The PCSG shall not therefore be liable for any direct, indirect, special, consequential or economic damage, whether in contract, in tort, or otherwise, arising out of the use of The Digest or the reliance on any of the information in it. The views expressed in The Digest are not necessarily those of the PCSG.

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NEWS BY VICKY PROCTOR

VOL 8. ISSUE 13

2021 - NO 1

A Challenging Year for the Society 2020 has been a challenging year, not least for the PCSG and its members. Due to Covid-19 restrictions, the committee has been forced to cancel both the Summer Meeting in Manchester and the Annual Scientific Meeting in November. The Digest Women’s Edition has also been delayed until now. Despite all this, there is much to celebrate about 2020 as well as look forward to in 2021, including the announcement of a new Guts and Glory Award winner, plus the Liver Edition of The Digest...

Why are patients avoiding their GP?

Going digital with online Gut Talks

Over half of the UK say that Covid-19 has made them more likely to try and diagnose their own symptoms before consulting a healthcare professional, YouGov research conducted over the summer on behalf of Thermo Fisher Scientific has found. The survey of more that 2,000 UK adults aged 18+ showed that many are still reluctant to go straight to their GP when symptoms of an illness or health condition appear and will instead try to manage their condition alone first.

2020 has forced the world to reconsider how it approaches so much that we previously took for granted. As far as healthcare is concerned, we’ve seen monumental shifts take place that would normally have required generations of planning. Whereas previously we might have interacted face to face, today most of our daily communication occurs online or over the phone. This includes GP appointments, business meetings and education.

Fifty-two per cent say the pandemic has made them more likely to try and diagnose their own symptoms if feeling unwell, before consulting a GP. The survey also found that since the beginning of the lockdown 39% are reluctant to visit their GP because they didn’t want to waste their doctor's time. A quarter of respondents (25%) said they didn’t want to visit their GP because they were worried about catching Covid-19. As we go forward into 2021, one of the challenges faced by primary care is rebuilding relationships with patients and supporting them as we move into a new era of healthcare, one much changed by the pandemic.

That's why the PCSG is taking a practical approach and giving 2021 an online focus with quarterly webinars focusing on key areas of interest and the hottest, most current topics, such as liver disease, IBD, the microbiome and earlier detection of GI cancer. Our educational talks will focus on the needs of GPs in delivering better gut health outcomes for their patients in Covid and post-Covid times.

An OBE for Roger Jones PCSG founding president Dr Roger Jones has been appointed Officer of the Order of the British Empire (OBE) in the 2021 New Year’s Honours for services to general practice. Roger is also the Editor of the British Journal of General Practice, chair of the Royal Medical Benevolent Fund and Provost of the South London Faculty of RCGP. His continued efforts on behalf of the PCSG have been instrumental in its growth and influence. Congratulations Roger!

Furthermore, instead of our Annual Scientific Meeting at the Wellcome Collection, this year we will be creating a ‘live’ virtual meeting online, complete with opportunities for Q&As and CBD points to be earned. As it will still offer the same high-quality talks from experts all over the UK and Europe, and still provide opportunities to our sponsors for sponsored talks, we predict this ASM will be every bit as interesting, and with attendance that much easier, we could see even more healthcare professionals taking part.

WITH THANKS TO OUR PCSG CORPORATE SUPPORTERS

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Find outmore moreatat atallergyai.com thinkcoeliac.co.uk Find out Find out more thinkcoeliac.co.uk Find out more at thinkcoeliac.co.uk Go to Coeliac disease via the menu Autoimmune Disease – GI – Coeliac disease Find out more at thinkcoeliac.co.uk © 2019 Thermo Fisher Scientific Inc. All rights reserved. All trademarks are the property of

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© 2019Fisher Thermo Fisher Scientific Scientific Inc. All All rights rights reserved. All trademarks trademarks are the the property property of of Thermo Scientific and its subsidiaries unless otherwise specified. are © 2019 Thermo Fisher Inc. reserved. All Thermo Fisher Scientific and2019. its subsidiaries subsidiaries unless otherwise specified. are the property of © 2019 Thermo Fisher Scientific Inc. All rights reserved. All trademarks Date of preparation: March TFS_IDD_UK1863 Thermo Fisher Scientific and its unless otherwise specified. Date of preparation: preparation: March 2019. TFS_IDD_UK1863 Thermo Fisher Scientific and2019. its subsidiaries unless otherwise specified. Date of March TFS_IDD_UK1863 Date of preparation: MarchPediatrics 2019. TFS_IDD_UK1863 1. Cristofori F, et al. JAMA 2014:168;555-560. 2. El-Sahly M, et al. Nutr J 2015;14:92. 3. National Institute for Health and Care Excellence. 1. Cristofori F, et et–al. al.Recognition, JAMA Pediatrics Pediatrics 2014:168;555-560. 2. El-Sahly El-Sahly M, et al. al.London: Nutr JJ 2015;14:92. 2015;14:92. 3. National National Institute for Health Health and Care Care Excellence. Coeliac Disease assessment and management (NG20).M, 2015. National Institute for Health and Care Excellence. 4. Lasa JS, et al. Arq 1. Cristofori F, JAMA 2014:168;555-560. 2. et Nutr 3. Institute for and Excellence. Coeliac Disease Recognition, assessment and management (NG20).M, 2015. London: National Institute for Health and Care Care Excellence. 4. Lasa Lasa JS, et al. Arq Arq 1. Cristofori F, 2014;51:144-50. et––al.Recognition, JAMA Pediatrics 2014:168;555-560. 2. El-Sahly et al.London: Nutr J 2015;14:92. 3.G,National Institute for 2008;40(2):104-107. Health and Care Excellence. Gastroenterol 5. Karaca N,and et al. Turk J Gastroenterol 2015;26:484-6. 6. Campisi et al. Dig Liver Dis 7. et Holmes Coeliac Disease assessment management (NG20). 2015. National Institute for Health and Excellence. 4. JS, al. Gastroenterol 2014;51:144-50. 5. Karaca Karaca N, et al. al. TurkJ JJF,Gastroenterol Gastroenterol 2015;26:484-6. 6. Campisi Campisi G, for et al. al. Dig9.Liver Liver DisDisease 2008;40(2):104-107. 7. et Holmes Coeliac – Recognition, assessment and management 2015. London: National Institute Health and Care Excellence. 4. LasaCeliac JS, al. Arq GK. ArchDisease Dis Child 2002; 87: 495-499. 8. N, Ludvigsson et al.(NG20). J Am Med Inform Assoc 2013: e2; e306-e310. Celiac Foundation: Disease Gastroenterol 2014;51:144-50. 5. et Turk 2015;26:484-6. 6. G, et Dig Dis 2008;40(2):104-107. 7. Holmes GK. Arch Dis DisAvailable Child 2002; 87: 495-499. 8. N, Ludvigsson F,Gastroenterol et al. al. JJ Am Am Med Med Inform Assoc Assoc 2013: 2013: e2; e306-e310. e306-e310. 9.Liver Celiac Disease Foundation: Celiac Disease Gastroenterol 2014;51:144-50. 5. Karaca et al. TurkJJ JF, 2015;26:484-6. 6. Campisi G, et al. Dig9. DisDisease 2008;40(2):104-107. 7.2018. Holmes Symptoms. from87: https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/24477-2; LastFoundation: accessed July GK. Arch Child 2002; 495-499. 8. Ludvigsson et Inform e2; Celiac Celiac Disease Symptoms. Available from87: https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/24477-2; LastFoundation: accessed July 2018. GK. Arch DisAvailable 495-499. Ther 8. Ludvigsson J F, et al. J Am11. MedSingh Inform Assoc 2013: e2; e306-e310. 9. Celiac Disease Celiac Disease 10. Elfström P,Child et al.2002; Aliment Pharmacol 2014;40(10):1123-32. P, et al. Am J Gastroenterol 2015;110:1539-1548. 12. Grace-Farfaglia, P. Symptoms. from https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/24477-2; Last accessed July 2018. 10. Elfström P, et et al. al. Aliment Aliment Pharmacol Ther 2014;40(10):1123-32. 11. Singh Singh P, P, et et al. al. Am Gastroenterol 2015;110:1539-1548. 12. Grace-Farfaglia, P. Symptoms. Available from https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/24477-2; accessed July 2018. P. Nutrients 2015;7:3347-3369. 13. MurchTher S, et2014;40(10):1123-32. al. Arch Dis Child 2013;98:806-811. 14.Am Shar S and Leffler 2015;110:1539-1548. D. Womens HealthLast (Lond Engl) 10. Elfström P, Pharmacol 11. JJ Gastroenterol 12. Grace-Farfaglia, Nutrients 2015;7:3347-3369. 13.K,Murch Murch S, et2014;40(10):1123-32. al. Arch Arch Dis Dis Child Child16. 2013;98:806-811. 14.Am Shar and Leffler Leffler 2015;110:1539-1548. D. Womens Womens Health (Lond (Lond Engl) 10. Elfström P, et al. Aliment Pharmacol Ther 11. Singh al. J Gastroenterol 12. P. 2010;6(5):753-766. 15. Smedby et al. Gutet 2005;54:54-59. Violato M, etP,al.etPLoS One 2012;7(7):e41308. 17. Werkstetter KJ, etGrace-Farfaglia, al. Gastroenterology Nutrients 2015;7:3347-3369. 13. S, al. 2013;98:806-811. 14. Shar SS and D. Health Engl) 2010;6(5):753-766. 15. Smedby Smedby K,Murch et al. al. S, Gutet2005;54:54-59. 2005;54:54-59. 16. Violato M, M, et et al. al. PLoS PLoS One 2012;7(7):e41308. 2012;7(7):e41308. 17. Werkstetter Werkstetter KJ,Engl) et al. al. Gastroenterology Gastroenterology Nutrients 13.K, al. Arch Dis Child16. 2013;98:806-811. 14. Shar S and Leffler D. Womens Health (Lond 2017; doi:2015;7:3347-3369. 10.1053/j.gastro.2017.06.002. 2010;6(5):753-766. 15. et Gut Violato One 17. KJ, et 2017; doi: 10.1053/j.gastro.2017.06.002. 10.1053/j.gastro.2017.06.002. 2010;6(5):753-766. 15. Smedby K, et al. Gut 2005;54:54-59. 16. Violato M, et al. PLoS One 2012;7(7):e41308. 17. Werkstetter KJ, et al. Gastroenterology 2017; doi: 2017; doi: 10.1053/j.gastro.2017.06.002.

FEATURE

IBS and gender – have females drawn the short straw? Dr Deirdre O’Donovan

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders, characterised by abdominal pain and abnormal bowel habits. It can present as predominantly diarrhoea (IBS-D), constipation (IBS-C), or both (IBS-M). The Rome IV criteria is frequently used for the clinical diagnosis of IBS,1 yet there is no definitive investigation as no biomarker has been found, so IBS is a diagnosis of exclusion. Inflammation may play a pathogenic role in IBS and studies have highlighted the persistence of mucosal inflammation at the microscopic and molecular level, with increased recruitment of enteroendocrine cells. Substantial overlaps between IBS and inflammatory bowel disease have also been reported.2

self-report symptoms. These responses are then assessed by investigators according to one set of diagnostic criteria. The pathophysiology of IBS has many factors. Studies have suggested there are sex and gender-associated differences in the prevalence and subtypes of IBS, as well as the effectiveness of treatment for it. In most populations, IBS symptoms are more common in females compared to males.5 Rates in women are approximately one and a half to three times higher than those seen in men,6 yet the underlying mechanism by which women exhibit an increased vulnerability to IBS remains largely unknown.

The condition affects around 11% of the population globally, but it depends upon which diagnostic criteria are used. Only around 30% of people who experience IBS symptoms will consult physicians about them.3 IBS affects patients through reduced quality of life, more time off work and greater use of healthcare than a control group of patients without IBS, and the condition has a significant disease burden in terms of increased absenteeism from school or work and reduced health-related quality of life.4 Most studies addressing prevalence of IBS are community surveys, postal questionnaires or telephone interviews which invite individuals to

Rates in women are approximately one and a half to three times higher than those seen in men, yet the underlying mechanism by which women exhibit an increased vulnerability to IBS remains largely unknown.

Photo: Anastasiia Fedorova/Shutterstock.com

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New research coordinated by the Karolinska Institutet in Sweden links certain DNA variants to increased risk of IBS in females. The researchers used genotype data from more than 300,000 UK Biobank participants in a genome-wide association study (GWAS). They found DNA variants that associate with increased risk of a diagnosis of IBS in women but not in men, specifically from a region on chromosome 9 previously reported to also influence puberty timing in women. This observation may provide an additional rationale for investigating the role of sex hormones and autonomic dysfunction in IBS.7 By following up this result in 2,045 patients from IBS expert centres in Sweden, Belgium, the Netherlands, Italy and the US, the researchers observed further associations with constipation-predominant IBS as well as harder stools, again only in women. The gender-based difference in the prevalence of IBS appears around puberty and increases during the early adult years. In females, IBS occurs most commonly from the late teens to the mid-40s. However, as age continues to increase, the incidence in females decreases and approaches that in males aged around 70 and above.8 Although data is limited, these gender-related differences are most likely related to changes in the menstrual cycle and hormonal levels as the symptoms of IBS become worse and more severe during menstruation.8 Females complaining of dysmenorrhea experienced IBS symptoms more frequently than those without it, for example.9 In addition, menopause seems to be associated with the exacerbation of IBS symptoms.10 The prevalence of chronic pain disorders that often overlap with IBS, such as chronic fatigue syndrome, migraine, fibromyalgia etc, are higher in women with IBS, suggesting an association between symptoms and hormone status.11 Hormone replacement therapy (HRT) points further towards that association. The incidence of IBS among non-HRT users was assessed to be 1.7 per 1,000 person-years, while the rate among HRT users was 3.8 – almost a twofold increase. These results were consistently observed regardless of the specific regimen of HRT prescribed, route of administration (oral or transdermal) or duration of treatment.12 Ruigómez et al. concluded that the increased risk of developing IBS as a result

of HRT use was due to the presence of exogenous oestrogens. These acted in a similar manner to naturally-occurring endogenous sex hormones that circulate at higher concentrations before menopause. By eliciting a yet-to-be-defined physiological mechanism, these heightened levels could very well be responsible for the observed preponderance of female IBS patients over males. Therefore, in the case of women with IBS symptoms, more attention should be paid to menstrual irregularities, menopausal status, the use of contraceptives and HRT, and history of gynaecological surgery.13 Women with IBS reported lower quality of life (QoL); higher levels of fatigue, depression and anxiety; and less positive well-being and self-control than men with IBS.14 In an outpatient study on IBS, women were found to be more likely to avoid certain foods, jobs, domestic activities, sexual intercourse and socialising than men.15 The serum levels of IL-5, IL-6, IL-10 and TNF-α were significantly higher in patients with IBS compared to healthy controls.16 A meta-analysis showed that inflammatory cytokines in patients with IBS vary between men and women. Serum TNF-α levels were higher in women with IBS than in men with IBS, and interleukin (IL)-10 levels were significantly lower in men with IBS than male controls, suggesting that elevated baseline IL-10 levels in healthy men appear to serve as a protective factor against IBS.17 Women tend to report more severe, more frequent, and longer-lasting pain than men.18 Some studies comparing women with IBS with healthy women have shown that visceral perception is similar or increased in women with IBS compared to healthy women.19 However, there is no conclusive data suggesting that gender influences visceral pain perception in healthy and IBS subjects. In a study conducted to investigate food groups and food items that cause gut symptoms in patients with IBS, females tended to report more food items that cause symptoms than males. Increased fibre and fish intake, decreased fatty meal intake, reduced sweets, red meat, and reduced coffee and alcohol intake were all significantly different between the case and control groups of women. The male IBS group showed only significantly lower bread intake than the male control group. As the number of foods reported to cause GI symptoms increased, patients’ QoL was decreased. Female IBS patients were also more willing than males to change their dietary habits due to their gut symptoms.

The authors also concluded that the experience of living with IBS differs between men and women due to differing societal expectations, life situation and the everyday construction of gender identities. Gender stereotyping by healthcare professionals perpetuates, rather than alleviates, the suffering experienced by men and women with IBS. In healthcare encounters, women risk being trivialised, and men risk being overlooked due to the ‘female health concern’ label attached to IBS.20 Patients with IBS have altered intestinal microbiota compared to healthy individuals – the dysbiosis is well established in literature. Individuals presenting with low self-rated health or high BMI have lower gut microbiome richness. However, no gender distinct microbial signature was observed in IBS.21 Treatment of IBS is important because of the impact on patients’ QoL. Response to treatment varies and some patients do not respond well. Research carried out in Japan showed that lower mental component status and female sex were independent risk factors for poor therapeutic response in patients with IBS.22 Treatment approach is multimodal and requires an assessment and modification of lifestyle (diet, sleep, and exercise), gut-directed pharmacotherapy, support and reassurance, psychological therapies and alteration of the gut microbiota. IBS remains one of the most difficult GI disorders to manage regardless of its benign nature. Recommending probiotics has long been an alternative to conventional medicine for treating many diseases and is an attractive treatment modality for IBS, considering its low costs and favourable safety profiles. In the context of dysbiosis as the pathogenesis of IBS, probiotic treatment seems reasonable and possibly ideal as it restores the intestinal microbiota. Many studies have indicated that probiotics might play important roles in maintaining gut homeostasis by modulating immunity and increasing epithelial barrier function. The therapeutic effect of probiotics in IBS depends on the strains used and the different mixtures and dosages of these strains. Gender differences may also influence the response to probiotics in IBS treatment, but these differences have not yet been fully explored.23 NICE also recommends that people with IBS who choose to try probiotics should be advised to take the product for at least four weeks while monitoring the effect. They should be taken at the dose recommended by the manufacturer.24 The World Gastroenterology Organisation (WGO) guidelines, Irritable Bowel Syndrome: a Global Perspective, offer useful information on the diagnosis, evaluation and management of IBS.25 Exploring the issue of IBS in females unearths more questions than answers. Hopefully, as IBS research continues, these queries will be resolved. Until then, females will have to continue to carry the increased susceptibility to IBS among

their other burdens and the juggling acts they perform in everyday life while dealing with such conditions. It is important that, as clinicians, we try to understand these gender differences in the medical care setting and apply them to IBS sufferers as it can provide better clinical outcomes. References 1. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016;150(6):1262–1279. 2. Ng QX, Soh AYS, Loke W, Lim DY, Yeo WS. The role of inflammation in irritable bowel syndrome (IBS). J Inflamm Res. 2018;11:345–349. Published 2018 Sep 21. doi:10.2147/JIR.S174982 3. Canavan, Caroline et al. The epidemiology of irritable bowel syndrome. Clinical epidemiology vol. 6 71-80. 4 Feb. 2014, doi:10.2147/CLEP.S40245 4. Akehurst RL, Brazier JE, Mathers N, et al. Health-related quality of life and cost impact of irritable bowel syndrome in a UK primary care setting. Pharmacoeconomics. 2002;20(7):455–462 5. Quigley EM, Bytzer P, Jones R, Mearin F. Irritable bowel syndrome: the burden and unmet needs in Europe. Dig Liver Dis. 2006;38(10):717–723. 6. Kennedy TM, Jones RH, Hungin AP, O'Flanagan H, Kelly P. Irritable bowel syndrome, gastro-oesophageal reflux, and bronchial hyper-responsiveness in the general population. Gut. 1998 Dec;43(6):770-4. 7. Ferdinando Bonfiglio, et al. Female-specific Association Between Variants on Chromosome 9 and Self-reported Diagnosis of Irritable Bowel Syndrome. Gastroenterology, 2018 Vol. 155, No. 1, 07. 168-179. 8. Mulak A, Taché Y. Sex difference in irritable bowel syndrome: do gonadal hormones play a role? Gastroenterol Pol. 2010;17:89–97 9. Olafsdottir LB, Gudjonsson H, Jonsdottir HH, Björnsson E, Thjodleifsson B. Natural history of irritable bowel syndrome in women and dysmenorrhea: a 10-year follow-up study. Gastroenterol Res Pract. 2012;2012 doi: 10.1155/2012/534204. 534204 10. Georgescu D, Reisz D, Gurban CV, et al. Migraine in young females with irritable bowel syndrome: still a challenge. Neuropsychiatr Dis Treat. 2017;14:21–28. 11. Do fluctuations in ovarian hormones affect gastrointestinal symptoms in women with irritable bowel syndrome? Heitkemper MM, Chang L Gend Med. 2009; 6 Suppl 2():152-67. 12. Ruigómez A, García Rodríguez LA, Johansson S, Wallander MA. Is hormone replacement therapy associated with an increased risk of irritable bowel syndrome? Maturitas. 2003;44:133–140. doi: 10.1016/S0378-5122(02)00321-3. 13. Chandar AK. Diagnosis and treatment of irritable bowel syndrome with predominant constipation in the primary-care setting: focus on linaclotide. Int J Gen Med. 2017;10:385–393. 14. Simrén M, Abrahamsson H, Svedlund J, Björnsson ES. Quality of life in patients with irritable bowel syndrome seen in referral centers versus primary care: the impact of gender and predominant bowel pattern. Scand J Gastroenterol. 2001;36:545–552. 15. Corney RH, Stanton R. Physical symptom severity, psychological and social dysfunction in a series of outpatients with irritable bowel syndrome. J Psychosom Res. 1990;34:483–491. 16. Vara, Ellen Johanne et al. Altered levels of cytokines in patients with irritable bowel syndrome are not correlated with fatigue. International Journal of General Medicine vol. 11 285-291. 6 Jul. 2018. 17. Cremon C, Gargano L, Morselli-Labate AM, et al. Mucosal immune activation in irritable bowel syndrome: gender-dependence and association with digestive symptoms. Am J Gastroenterol. 2009;104:392–400. 18. Miller V, Whitaker K, Morris JA, Whorwell PJ. Gender and irritable bowel syndrome: the male connection. J Clin Gastroenterol. 2004;38:558–560. 19. Chang L, Mayer EA, Labus JS, et al. Effect of sex on perception of rectosigmoid stimuli in irritable bowel syndrome. Am J Physiol Regul Integr Comp Physiol. 2006;291:R277–R284. 20. Böhn L, Störsrud S, Törnblom H, Bengtsson U, Simrén M. Self-reported foodrelated gastrointestinal symptoms in IBS are common and associated with more severe symptoms and reduced quality of life. Am J Gastroenterol. 2013;108:634–641. 21. Hugerth LW, Andreasson A, Talley NJ, et al. No distinct microbiome signature of irritable bowel syndrome found in a Swedish random population Gut Published Online First: 10 October 2019. doi: 10.1136/gutjnl-2019-318717 22. Yamada E, Tsunoda S, Abe T, et al. Factors associated with poor therapeutic response in outpatients with irritable bowel syndrome: a multi-center study in Japan. J Gastroenterol. 2017;52:301–307 23. Lee BJ, Bak YT. Irritable bowel syndrome, gut microbiota and probiotics. J Neurogastroenterol Motil. 2011;17(3):252–266. 24. NICE 2017. Irritable bowel syndrome in adults: diagnosis and management. Available from: www.nice.org.uk/guidance/CG61 25. World Gastroenterology Organisation Global Guidelines. Irritable Bowel Syndrome: a Global Perspective. “Produced by the World Gastroenterology Organisation (WGO) Guidelines and Publications Committee.” www.worldgastroenterology.org

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FEATURE

Supporting women in Gastroenterology Dr Helen Fidler Interviewed by Vicky Proctor, Assistant Editor, The Digest The Digest caught up with Helen Fidler, Chair of the Supporting Women in Gastroenterology (SWiG) section of the British Society of Gastroenterology (BSG) and Deputy Chair of the UK BMA Consultants Committee. Helen qualified in 1987 and was appointed to her current position as a consultant gastroenterologist in the Gastroenterology Department at Lewisham and Greenwich Trust in 1998.

Recognising that there was an issue regarding female representation in secondary care gastroenterology, SWiG began life five years ago as an informal network aimed at supporting women within the field. As far as specialist areas are concerned, GI is woefully behind when it comes to gender balance and SWiG wanted to not only ask why, but also find out how to provide support. Particularly when statistics show that in earlier medical training the male/female split is far closer to equal, it would seem that it was possible that while more women were choosing medicine as a career than ever before, gastroenterology was not a path they felt comfortable following when it came to specialisation. Founded by ‘inspirational, dream team’, consultants Penny Neild, Jayne Eaden, Siwan Thomas Gibson and Cathryn Edwards, in its earliest iteration SWiG was an informal network. From here, a highly successful mentoring group was established that aimed to recruit a higher number of women to the field, as well as support their career progression all the way through to more senior leadership roles. According to Helen, however, “it soon became apparent that the committee was more much more than a network to provide mentoring and informal meetings – it was essential”.

From here, a highly successful mentoring group was established that aimed to both recruit a higher number of women to the field, as well as support their career progression

Helen became involved two years ago and, as a self-described ‘political animal’ plus an already active member of the BMA, she set about establishing SWiG as a BSG committee section in its own right. She believed that while it might be relatively easy to ignore or pass over a so-called ‘network’ (no matter how essential it was), an established committee could not be ignored. Not only this, but a committee would be awarded a yearly budget and a body of elected figures would take responsibility for activity and have a democratic mandate within the organisation. Taking over as Chair in the autumn of 2018, Helen began to notice other gender-equality issues within the BSG – only 1 in 10 of the BSG elected council members at the time was a woman; a drastic under-representation of female voices. In an effort to redress the imbalance, Helen decided to stand with three colleagues – Harriet Gordon, Melanie Lockett and Manmeet Matharu – at the next council election. At the time, her colleagues had been reluctant, for the usual impostersyndrome based reasons. Yet when the results came in, all four were rather amazed to find that they had been chosen to sit on the new council. “A more diverse range of voices, from both men and women, brings greater perspective and greater movement,” Helen explains. In addition, by encouraging women to take up more visibly high-level roles, Helen and her colleagues were working to fashion themselves as much-needed role models to some of the younger and newer recruits to gastro. If a woman can see other women in the field, especially in more senior positions, she is more likely to follow that career path herself.

“A MORE DIVERSE RANGE OF VOICES, FROM BOTH MEN AND WOMEN, BRINGS GREATER PERSPECTIVE AND GREATER MOVEMENT” WWW.PCSG.ORG.UK | 17

A female consultant also warned her against less than full-time work, saying ‘it will be the death of your career’

Helen describes the pressures of essentially taking up a kind of female ambassador-type position in a largely male-dominated sphere: “I was still scoping at 39 weeks pregnant for my fourth child. At the time, it felt important not to show what would be perceived as weakness to my male peers.” She believes one of the main problems in secondary care gastro is the culture that surrounds less-than-full-time work. Unfortunately, the bottom line is that if a woman gets pregnant, she risks being seen as unambitious and, in a world where 80% of childcare is carried out by women, there is still very little respect for those who have to leave on time to collect their children. The result is that women in the field feel unable, or unwilling, to go part-time at the expense of their career. It would seem that like in many high-pressure, or high-intensity, work environments, there is an unhealthy machismo in gastroenterology that needs to be addressed. Following the birth of her first child, Helen returned to work after only six weeks maternity leave. After a month back on the job, however, she realised she needed to reduce her hours to parttime. Upon hearing of her decision, one male colleague told her “We’d all like to work less than full-time.” He added that he had a wife and children to support – implying that this was a luxury for women who clearly wouldn’t need to financially support their own family. A female consultant also warned her against less than full-time work, saying 'it will be the death of your career’. Helen went on to become the second UK 'less than full-time' trainee in gastroenterology. In addition, recent data suggests that a significant proportion of trainees in difficulty are women in gastro, with one region showing that to be the case with seven out of eight trainees. Going forward, as Chair of SWiG, Helen tells me that it’s important to set an example to trainees and younger doctors, and work to unpick the toxic and blatantly outdated culture that surrounds how people, and especially women, work. SWiG still has a lot of work to do and while progress is being made to attract a greater number of women to the field, there is still the gender pay gap hurdle to overcome. Not to mention

difficulties sourcing funding for the body: “Some Pharma companies are unwilling to sponsor a female-centric committee aimed at supporting women as they don’t see the value in it. And this inequality is reflected in our patient population as well as our workforce. Consider IBS for example – 40% of diagnoses are in young women, yet the condition has been seen as a dead end when it comes to care and treatment, despite the impact it has on the sufferers’ quality of life. If the condition was more prevalent in middle aged men, do you think there’d be the same response? “Our last annual SWiG day in Liverpool was very well attended by both men and women and I was humbled to speak with 11 other SWiG section members, including five male members, at the event.” Helen tells me that SWiG values its many male members, who are essential to bringing about gender equality. She adds that she wouldn’t be upset if Supporting Women in Gastroenterology one day became Supporting Diversity in Gastroenterology, but that that’s something for further down the line.

SWiG values its many male members, who are essential to bringing about gender equality

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Phone +44 151 550 4 550 info@biohithealthcare.co.uk www.biohithealthcare.co.uk WWW.PCSG.ORG.UK | 19

Our expert panel

The NHS and female GPs – is there an issue we need to address?

Dr Lily Lamb Lily is a GP based at the School of Medical Education at Newcastle University.

Dr Marion Sloan Marion is a GP based in Sheffield with a special interest in women’s health and gastroenterology.

Dr Patricia Wilkie Patricia is a social scientist, researcher, author and lifelong patient activist.

Members of the PCSG respond to an article in The Times by Paul Morgan-Bentley and Anna Lombardi, ‘GP crisis: ‘Third world’ conditions at surgeries with no female doctor’.1

Dr Sarah Pedley Sarah trained at the University of East Anglia. She has worked at a GP practice in North Norfolk as a foundation doctor.

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Editor: Do you agree that the reported shortage of female GPs is an issue within the NHS? Lily Lamb: The shortage of all GPs is an issue in the NHS, both male and female. We know that 51% of the GP workforce is actually female, and my experience is that over 50% of teams I work with are female. As a nation, we have just under 27,000 FTE GPs, which is a 6% fall in numbers from 2015. We need more GPs of both sexes to meet the healthcare needs of our UK population. We are seeing an increasing ageing population, many of whom have comorbidities, and these patients require more input from GPs. GPs are also essential in health promotion, helping patients to reduce the risk of developing illness; without the time or capacity to do this there is a risk that important preventative work does not happen. Patricia Wilkie: Yes, it can be for many female patients. There are more women in society and more women attend GP surgeries, hence more appointments with female GPs are required. A survey of the attitude of female patients to accessing a female GP should be carried out, listened to and acted upon. Women do not form a strong united voice lobbying for more female GPs.

Sarah Pedley: It is clear from patient comments that at present the shortage of available female GPs at practices is a problem. And, it is understandable that some patients may prefer to see a female GP, especially those from older generations. However, more generally I believe we need to further explore the reasoning behind this preference. For example, it is reasonable to aim to provide a female member of staff where an intimate examination needs to be carried out on a patient who has previously been abused, or where religious beliefs require it. For most other patients, it could also be emphasised that male GPs have had the same extensive training as female GPs and have plentiful prior experience of examining female patients. They can also offer a female member of staff to act as a chaperone while they are examined.

Marion Sloan: No. I would reword that statement to say, ‘the reported shortage of GPs is an issue within the NHS’. General Practices are independent contractors working for the NHS, operating within a finite financial framework. I believe that both general practice and the general public would welcome investment to create more GP appointments overall. What has the NHS done to ensure that patients have access to a female GP should they require one? MS: The NHS needs to ask, ‘Where have all the females gone?’ Perhaps the NHS trains more female GPs than male ones. Some choose to work less than full time. Why is this? Is it a choice between money and motherhood? Is it the baby or the bank balance? Or, is the cost of daily demand too draining, despite women having mastered multi-tasking and being multi-talented? The NHS has chosen not to contribute sufficient cash to foster and retain the female GP numbers sufficient to create a positive patient choice of a female GP for personal or cultural reasons. However, it is more than money that retains female GPs – it’s being part of an effective team, and feeling supported and valued. It’s having a job where there is time to chat with colleagues over a coffee or quickly check out a question.

SP: There are now more female doctors graduating from medical school than male; this is partly due to universities encouraging more female students to pursue careers in the fields of science, technology, engineering and mathematics. Many female doctors are attracted to general practice because the working hours tend to be more regular – something which is perceived to be more compatible with family life. Although society’s view of male and female roles is changing, it is still statistically more likely that the mother will stay home to care for the children than the father, thus taking female GPs away from the front line at work. This is something which we may be able to improve, with policies such as allowing couples to split maternity leave, but ultimately it is the couple’s choice and practicalities such as breast feeding do factor.

PW: Not all practices have a female GP, plus many female GPs work part- time. This means access to a female GP and continuity of care can be difficult for patients. Some practices may offer a request from a female patient to see a female GP, or a consultation with a GP from another practice, a locum GP, a paramedic, an advanced nurse practitioner or health care assistant. These appointments may be a ’one-off’ and may solve the immediate problem, but do not provide continuity of care for the patient still faced with anxiety about the next appointment.

LL: The Government and NHS have recognised the shortage of GPs across the country and have employed strategies to increase recruitment and retention. There are now a record 16,000 GPs in training – a significant proportion of these are women. Patients are able to request to see a female or male GP when they book their appointment, and in most surgeries this is achievable. Many practices now employ nurse practitioners (NP), who are highly trained. Many have skills in women’s health and are able to make diagnoses, treat and refer if needed. If seeing a female GP or NP is not possible, for example in surgeries where all the permanent staff are male, often surgeries will work in groups to provide extended access surgeries and there are opportunities to book with a female GP or NP outside the practice.

What are some of the barriers to patients accessing female GPs? PW: Women may not know they have a choice to request to see a female GP, or whether there’s one in the practice at all as not all staff are always named and gender information’s not clear. Due to long waiting times to see a female GP, female patients have little choice about how they are treated and cared for.

MS: Simple: insufficient GP time to meet demand. However, the world now looks very different from what it looked like BC – Before Corona! The general public is showing great respect for the NHS. There WWW.PCSG.ORG.UK | 21

EXPERT PANEL INTERVIEW is gratitude. Gone is the grumbling. Footfall in surgeries has fallen off a cliff edge. Where has all the illness gone? Maybe, in a post-corona world, communities will be more resilient and able to cope with minor illness without seeing a GP at all?

if they don’t want to spend more of their career doing gynaecology, and what if they want to pursue a specialist interest in a subject area not related specifically to women at all? May using them in this way reduce job satisfaction and lead to a further loss of female doctors?

LL: The barriers in many cases are the

MS: Primary Care Networks are emerging NHS organisations. There is potential for new developments, driven by local need, funded from network monies to be delivered at scale across a patch. Maybe we could develop this at pace?

same as the barriers to accessing all GPs: lack of GPs, lack of appointments, lack of funding, and in surgeries where the majority of GPs are male, obviously the female GPs will have greater demands on their time. Many women work part-time due to caring responsibilities and this may reduce the number of appointments they offer compared with their male colleagues, though in many practices male GPs also choose to work part-time, undertaking caring responsibilities themselves or electing for a portfolio career.

SP: The fundamental issue is that there are not enough GPs (male or female) to meet the demand for appointments at present. More emphasis should be put on educating patients about which service is correct for their medical need; many issues do not require GP consultations, and this therefore limits the time GPs have to address issues that require their attention. This issue extends to female GP appointments, so the reason why a patient has requested to see a female only should be investigated and addressed. General medical consultations, including medication checks, can be dealt with by either a male or female GP.

What more could the NHS do to ensure patient access to a female GP? SP: If a female GP is absolutely necessary for specific examinations and consultations, then these should be prioritised at the expense of other consultations which could be dealt with equally as well by a male GP or other healthcare professional. Although this may free up more female GPs to deal with those appointments for which a female is necessary, I wonder how beneficial this is to our female GPs; what

PW: Publicise widely that female patients can consult a female GP and, if a female GP is not easily available, list all the alternatives. Encourage female patients to ask their practice patient participation group (PPG) to speak to the practice about access to a female GP and what they are doing about it.

LL: The NHS should help patients recognise the presentations that require input from a GP by raising awareness of important female health issues, such as cancer and sexually transmitted infections. More can be done to support female GPs to remain in practice when they have children or caring responsibilities. Retainer schemes are an example of an excellent initiative to allow GPs to reduce their clinical commitments while they have other responsibilities – awareness and availability of these schemes should be increased. During the Covid-19 pandemic we have seen innovative ways of working, including GPs undertaking telephone and video consultation from home. These new ways of working may be more accessible to female GPs with caring responsibilities and allow them to return to work or increase their number of clinical sessions, which in turn would improve access to female GPs.

How can the NHS recruit more female GPs? PW: The NHS needs to demonstrate that being a GP is an attractive career choice for women. A quality survey of female doctors to identify issues that

would encourage women to be GPs seems important and for the NHS to listen to the requirements and act upon them.

SP: If the root of the problem is not enough female GP ’hours’, then the solution in theory should be to train more female doctors and encourage them to go into general practice. This path could be achieved by ensuring pay is fair, offering scholarships to female medical students, promoting ’job-share’ opportunities between female GPs and providing improved practical and psychological support to GPs already working.

LL: The NHS is already doing well at recruiting female GPs. We know 55% of our medical students are female, and three in five GP trainees are female, and that 51% of the GP workforce is female. We need general practice to be sustainable for female GPs and to provide flexibility when required. We also need general practice to be seen as an attractive career option by our medical students and junior doctors, to be seen as the intellectually stimulating and academic career many students aspire to. We need to celebrate the positive aspects of our ability to provide continuity of care, to manage such a huge variety of problems in all ages, and to really make a difference to our patients. We also need females in leadership roles within general practice, to act as role models and provide guidance and support for women joining the specialty.

MS: By making general practice a great place to work again. By investing in the development of effective teams again. By timetabling ‘thinking time’ into everyone’s working week. By fixing flexible job packages for all. Do you think there are any reasons the NHS may struggle to recruit more female GPs? (Brexit? The nature of the job? Entrenched stereotypes?) LL: There are problems with the current job that detract from its attractiveness, including the workload and long hours.

There are entrenched stereotypes that general practice is not intellectually stimulating, and there is ongoing denigration of general practice by hospital specialists which many medical students are exposed to. If general practice can be appropriately funded, adapt to our changing society and healthcare needs, and put the health and wellbeing of staff as well as patients at the heart of changes made, a career in general practice should be an attractive option for female and male doctors. It is really positive that the Government has pledged to deliver 6,000 additional GPs. I hope that we see that plan delivered, as well as the intention to provide thousands more members of the wider practice team, as this is essential to ensure that patients can access high-quality general practice when they need to.

MS: The females are out there. I’m biased, but research confirms that female GPs listen better, communicate better and pick up cues better. They make patients feel more comfortable and that makes them feel better. They earn that introduction, ‘Hello, this is MY doctor’. So, we just need looking after better. PW: Female GPs’ way of working, where they listen more and may take longer in consultations, may not fit in well with the current GP work culture (male dominant).

For all working women, flexibility to care for dependents is essential as well as consideration of work/life balance. Hence an examination of the culture in which female GPs would like to work and in which female patients would like to be treated is needed.

What do you think? Share your thoughts with us on Twitter @PCSGastro

SP: Due to the changing nature of gender stereotypes and the provision of better maternity leave cover and childcare provision, more women may be choosing to train in hospital specialities; this takes female doctors away from general practice. There is also the rumbling threat of general practice becoming a seven days a week service. Over the past 10 years we have seen an exodus of NHS doctors to countries such as Australia and New Zealand, which at times has been attributed to the pressure of working in the NHS. Brexit may also make it more difficult to continue recruiting doctors from countries in the European Union. The NHS has tried to tackle this by increasing the number of medical school places in the UK. However these doctors will not be ready to join the workforce for at least five years and it takes a further five years after this to become a GP. Any benefit to the GP workforce from an increase in the number of medical school places will therefore not materialise for at least 10 years.

Scan me ...to view the original article in The Times – ‘GP crisis: ‘Third world’ conditions at surgeries with no female doctor’

References: 1. Morgan-Bentley, Paul and Lombardi, Anna. (2020) ‘GP crisis: ‘Third world conditions at surgeries with no female doctor’ The Times, 22 December [Online]. Available at: https://www. thetimes.co.uk/article/gp-crisis-third-worldconditions-at-surgeries-with-no-female-doctorjgkqb8wcp?ni-statuscode=acsaz-307 Photo: Monkey Business Images/Shutterstock.com

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FEATURE

The triad relationship between the host, gut bacteria and intestinal parasites Dr Melissa Lawson

Over the past few decades there has been increased interest in the importance of the complex microbial world that exists within our gastrointestinal tract. The gut microbiome consists of a variety of microorganisms including bacteria, viruses, fungi, archaea, and unicellular and multicellular organisms/parasites. Through the advancement of science, and in particular sequencing technology, we have been able to identify thousands of bacterial species within the human gastrointestinal tract. Co-evolution between humans and the gut microbiota have generated a mutualistic relationship whereby the microbes provide essential dietary and host immune education/ maturation, while in return the host provides a warm, nutrient-rich niche. This co-evolution is highly complex and relies on the host and the gut microbiome maintaining a homeostatic balance for health. However, a variety of external factors, including diet, antibiotics and intestinal infections can contribute to changes and disruptions to the gut microbiota over time. After birth, the gut microbiome is also in its infancy and developing in response to both maternal diet and environmental factors. At this time infant nutrition is paramount in structuring the neonatal microbiota, and is heavily influenced by the parent’s choice to breast feed (Derrien et al., 2019).1 Maternal breast milk contains a variety of nutrients including sugars, fats and proteins, and it also contains immunological factors (like antimicrobial peptides and maternal-specific antibodies) that aid the infant immune system in development and prevention of disease. The gut microbiota of a healthy, fullterm, breast-fed infant is simple in structure and dominated by a few key types of bacteria, including Bifidobacterium and Bacteroides (Derrien et al., 2019).1 As we age, the infant gut microbiota undergoes vast changes in both structure and composition, reaching over 1,000 different species and upwards of 100 trillion bacteria in total. Other components of the gut microbiome that are often ignored, as they are a rare occurrence in developed countries, are multicellular organisms such as intestinal helminths. According to the World Health Organization (Fact Sheet 2020), 1.5 billion people are infected with helminths worldwide, particularly in developing countries in poor communities and it frequently leads to high morbidity, notably in children. The life cycle of intestinal helminths begins by ingesting eggs from the environment and leads to the generation of large parasitic worms (centimetres in length) within the gastrointestinal tract, where these parasites can also have pervasive influence over the structure and composition of gut bacteria. These infections are often chronic, and most individuals remain infected

for their entire life. These parasites either live in the intestinal lumen or embed into the intestinal lining in direct contact with the host and the gut microbiota. The parasites have also co-evolved with bacteria, and have developed a highlydependent relationship with the gut bacteria for permissive egg hatching, moulting and infection required for parasite survival in a mammalian host. In the absence of all microorganisms (germfree mouse models) many intestinal parasites struggle to survive, including the intestinal whipworm Trichuris (White et al., 2018).2 Although data is limited (and often contradicting) in human trials, much of what we know regarding the triad relationship between the host-bacteria-parasite has been generated using animal models. In addition to Trichuris, the roundworm Heligmosomoides has also been shown to alter its surrounding gut microbiome in the host in such a manner that promotes helminth survival and limits secondary parasitic infections within the same host at the same time (Rapin et al., 2020; Houlden et al., 2015).3,4 The importance of this bacterial change in response to the parasite is currently being investigated for potential therapeutic targets. Interestingly, it was recently published that some of these intestinal helminths also carry their own gut microbiota, further adding to the complexity of the parasitic relationship between the gut microbiota, host and intestinal parasites. During helminth infection there is always a trade-off between parasitic burden in the gut and host immunity against the intruding worms; during pregnancy this imbalance becomes amplified causing a decrease in conception and full-term pregnancy rates, and furthermore enhances a woman’s risk of secondary helminth infections (Blackwell et al., 2015).5 This increased susceptibility may be due to the physiological changes a woman’s body undergoes during pregnancy such as hormone shifts, reduced microbial diversity, and enhanced mucus production and lactation (Yatich et al., 2009).6 Changes in the maternal gut microbiome induced by parasite infections either during gestation and/or postnatally influence the mother’s immune system (and breast milk composition) and ultimately has an effect on the infant’s health. Recent work in sheep models found that female ewes with high helminthspecific antibody titres were associated with offspring that have lower intestinal parasite burden (Leivesley et al., 2019).7

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As parasitic infection in early life adds additional health burdens to infants, the transfer of anti-helminth immune properties (possibly the transfer of immune specific T cells or antibodies) in utero and through lactation are likely critical for infant health (Darby et al., 2019).8 Breast milk also contains prebiotics (defined as compounds that induce either the growth or activity of beneficial organisms) that may contribute to the observed changes in both composition and diversity of the infants’ gut microbiota; and this microbial shift drives infant immune health. The increased incident of autoimmune diseases in developed countries has occurred over the past >65 years, largely due to the use of antibiotics, vaccinations and improved socioeconomic factors like increased hygiene (Bach, 2002).9 We currently do not see this upward trend of immune-related diseases in developing countries. This inverse effect of health-related illness is commonly referred to as the ‘hygiene hypothesis’ (Bach, 2002).9 What is currently being proposed is that the helminth-mediated changes in the gut microbiota may be the link that reduces the incidence of autoimmune diseases. Using mouse models, helminth-infected females prior to and during pregnancy had pups with improved protection against asthma (Zaiss et al., 2015)10 and other atopic diseases (Straubinger et al., 2014),11 such as those on the rise in developed countries. It may be possible that the presence of intestinal helminth infections in the mother and/or during early-life dramatically shape the microbial structure in the infant during this critical window of opportunity for immune development. However, the exact mechanism that drives helminth-induced enhanced infant immunity during reproduction and/or leads to the generation of a robust

Images on intestinal helminths. (A) Photo of the whipworm Trichuris (<50mm in length) and the roundworm Ascaris (<35cm in length) collected from human stool. (B) Photo of female Heligmosomoides worms (<21mm in length). (C) Electron microscopy image of a mouse caecum colonised with Trichuris. Images provided by Dr Emma Lawerance (A) and Dr Stefano Colombo (B).

What is currently being proposed is that the helminth-mediated changes in the gut microbiota may be the link that reduces the incidence of autoimmune diseases. immune response in infants remains unclear. As the incidence of autoimmune diseases is dramatically reduced in developing countries where helminth infections are prevalent; and in developed countries where we are faced with many autoimmune diseases like diabetes, and inflammatory diseases such as IBD and obesity that have been shown to be associated with the gut microbiota, it begs the question: How do intestinal parasites alter the gut microbiota, and will we be able to harness this information for new therapeutic treatments to autoimmune/ inflammatory diseases in first world countries? References: 1. Derrien M, Alvarez AS, de Vos WM. The Gut Microbiota in the First Decade of Life. Trends Microbiol. 2019;27(12):997–1010. 2. White E, et al. Manipulation of host and parasite microbiotas: Survival strategies during chronic nematode infection, Science Advances 14 Mar 2018: Vol. 4, no.3 3. Rapin A, Chuat A, Lebon L, Zaiss MM, Marsland BJ, Harris NL. Infection with a small intestinal helminth, Heligmosomoides polygyrus bakeri, consistently alters microbial communities throughout the murine small and large intestine. Int J Parasitol. 2020 Jan;50(1):35–46. 4. Houlden A, Hayes KS, Bancroft AJ, Worthington JJ, Wang P, Grencis RK, et al. Chronic Trichuris muris Infection in C57BL/6 Mice Causes Significant Changes in Host Microbiota and Metabolome: Effects Reversed by Pathogen Clearance. Kim CH, editor. PLoS One. 2015 May 4;10(5):e0125945. 5. Blackwell AD, Tamayo MA, Beheim B, Trumble BC, Stieglitz J, Hooper PL, et al. Helminth infection, fecundity, and age of first pregnancy in women. Science (80). 2015 Nov 20;350(6263):970–2. 6. Yatich, N. et al. Malaria and intestinal helminth co-infection among pregnant women in Ghana: prevalence and risk factors. The American journal of tropical medicine and hygiene 80 6 (2009): 896-901 . 7. Leivesley JA, Bussière LF, Pemberton JM, Pilkington JG, Wilson K, Hayward AD. Survival costs of reproduction are mediated by parasite infection in wild Soay sheep. Gaillard J, editor. Ecol Lett. 2019 May 20;22(8):ele.13275. 8. Darby MG, Chetty A, Mrjden D, Rolot M, Smith K, MacKowiak C, et al. Pre-conception maternal helminth infection transfers via nursing long-lasting cellular immunity against helminths to offspring. Sci Adv. 2019;5(5):1–10. 9. Bach J-F. The Effect of Infections on Susceptibility to Autoimmune and Allergic Diseases. N Engl J Med. 2002 Sep 19;347(12):911–20. 10. Zaiss MM, Rapin A, Lebon L, Dubey LK, Mosconi I, Sarter K, et al. The Intestinal Microbiota Contributes to the Ability of Helminths to Modulate Allergic Inflammation. Immunity. 2015 Nov;43(5):998–1010. 11. Straubinger K, Paul S, Prazeres da Costa O, Ritter M, Buch T, Busch DH, et al. Maternal immune response to helminth infection during pregnancy determines offspring susceptibility to allergic airway inflammation. J Allergy Clin Immunol. 2014 Dec;134(6):1271-1279.e10.

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CHARITY SPOTLIGHT

Human milk banking: an unexpected opportunity to improve public health Dr Natalie Shenker

How did the milk bank begin and how long did it take to be fully functional?

Tell us a bit about yourself and your training before the start of the milk bank. I trained at Oxford and graduated in 2003, with my heart set on becoming a paediatric surgeon. After house jobs, I did a fellowship in Australia and came back to London full of ideas for research. I completed my MRCS and a surgical rotation at Guy’s and St Thomas’ and started developing PhD applications at the Institute of Child Health while I was working at Great Ormond Street Hospital (GOSH). Then Modernising Medical Careers came along in 2007 and threw the whole plan out the window. A simple administrative error destroyed my PhD plans; I carried on with training but became really disillusioned with funding constraints and toxic working conditions. Eventually, I stepped out of training to do an MSc in developmental and reproductive biology at Imperial, and life changed forever. I developed a strong interest in epigenetics and completed a PhD at Imperial as part of a group trying to understand epigenetic risk markers for breast cancer. A serendipitous moment during maternity leave led to a novel collaboration with our local hospital milk bank, and I started to develop assays that could work with cells in mother’s milk to develop novel cancer screening tools.

A serendipitous moment during maternity leave led to a novel collaboration with our local hospital milk bank, and I started to develop assays that could work with cells in mother’s milk to develop novel cancer screening tools.

In 2015, the NHS milk bank network in London and the South East effectively collapsed. It was very difficult to witness, having worked with them for two years and learning how essential access to screened donor milk was. There have been calls to action from the WHO and The Lancet over the past three years stating donor milk should be used to feed vulnerable babies when mother’s milk is unavailable, but there was no coherent plan in the UK to meet this need. I saw a clear public health case for creating a new model of milk banking, which could provide assured and equitable access to preterm and sick babies, but also act as a centre of lactation support and training. One of my major driving motivations was also to keep the cancer research going and fill gaps in the evidence base for how milk banks operate. This led to the idea of the Hearts Milk Bank, co-founded with Gillian Weaver, who is a leading expert in human milk banking globally. If we could create a milk bank that was effectively free from funding constraints, then provision of donor milk could be assured, and research would follow. With the support of a massive team, who brought skills we didn’t even know existed, Hearts recruited its first milk donor less than a year after I had the idea, and sent out its first litre of donor milk to a hospital neo-natal intensive care unit (NICU). The next 18 months after this were really difficult – we were completely naïve about the world of non-profit funding and had a very steep learning curve with the help of the Cambridge Social Ventures team at the Judge Business School. We were really saved by our community and local MP, who stepped in when our first lab space was facing imminent closure, moving in to state-of-the-art laboratories at the Rothamsted Institute at the end of 2018. Since then, it has been an absolute joy and the entire charity has flourished – this year we will become the largest milk bank in the UK, and we are reaching globally in terms of raising awareness, research collaborations and supporting milk bank development.

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70% of donors have a healthy baby and pump extra

30% of donors have a sick baby and pump to maintain their own supply

Where/who does the milk come from? And where/who does the milk go to? We’ve recruited just under 600 milk donors over nearly three years, and each has their own story and motivation for donation. Around 70% of donors are at home. Most have healthy babies and pump an extra container of milk each day for donation. Some are dealing with hyperlactation, which can be very disabling, and our lactation consultant works with them to manage their supply down. The other 30% are facing very challenging times with a sick baby in hospital and are pumping to maintain their own supply while their baby is nil by mouth or taking very small volumes. They can build up a very large stock which makes storage in hospitals difficult. A third group of donors are very close to our hearts – they have suffered the death of a baby, through late miscarriage, stillbirth, or death shortly after birth. They then choose to donate some or all of their milk as a tribute to their baby, and we support them as best we can through the process of screening and donation. Most of the milk donated is pasteurised

A small percentage have suffered the death of a baby and pump as a tribute to their baby

in very small 50-ml volume containers for delivery to hospital neonatal units. Donor milk is needed when mothers are unable to produce any or enough milk for premature babies, which can be common when mothers face such stressful circumstances, and have received antenatal corticosteroids (which can delay lactogenesis). Multiple Cochrane reviews have shown cases of necrotising enterocolitis are reduced when babies received an exclusive human milk diet, and when used appropriately, mothers are also more likely to see donor milk as a bridge to them establishing their own supply. When doctors tell mothers that their milk is very important, but then go on to give formula if she is struggling to meet a baby’s needs, then it is a very different message being given. Given the large numbers of mothers donating, we always have a surplus of donor milk. Under the supervision of a Prioritisation Panel, our lactation support team supplies donor milk on clinical request to babies who would not qualify for donor milk under the tight rationing in the NHS. We have now supported over 100 families, half with mothers who cannot breastfeed. They might be undergoing treatment for cancer,

When doctors tell mothers that their milk is very important, but then go on to give formula if she is struggling to meet a baby’s needs, then it is a very different message being given. have had bilateral mastectomies, or need to take the rare medications that are contraindicated to breastfeeding. But excitingly, the other 50% have mothers with challenging starts to their breastfeeding journeys – a huge contributor to why the UK has some of the worst breastfeeding rates in the world. Our work with them has been very encouraging, with around 60% going on to exclusively breastfeed their babies. What's been most surprising is the psychological effect on the mothers, which is sometimes very marked. We might be the first practical help they have received since being discharged with their babies, and some of the stories are heartbreaking. The need to revolutionise the support of new mothers is so clearly there.

We aim to develop new tools for milk analysis, which will not only advance our understanding of human milk and all its complexity but aim to help milk banks start personalising donor milk batches to different clinical conditions. What kind of research is going on in the background?

What does your job entail on a daily basis?

In May 2019, I was awarded a £1.2 million UKRI Future Leaders Fellowship, ‘Maximising the Public Health Benefit of Human Milk Banking’. This will enable a vast amount of research to get up and running, and with start-up charity experience I’m very good at making money stretch. We’re about to finally launch the first phase of recruitment into the Breastmilk Epigenetic Cohort Study (BECS), so those precious milk samples can finally start being collected. The first wave of recruitment this year will include around 300 mothers, but over time this will be extended to around 20,000 women. We aim to develop new tools for milk analysis, which will not only advance our understanding of human milk and all its complexity but aim to help milk banks start personalising donor milk batches to different clinical conditions. We have started to notice already how milk from donors with older babies and toddlers can have very different effects than milk from mothers with much younger babies.

Juggling! No day is ever the same – I set a list of objectives for each week, but they can often be affected by events. This week was a classic example of that, as not only was I trying to steer some students towards submitting manuscripts and deal with a large increase in demand for donor milk, but I had to write a report on milk banking’s response to Covid-19 and squeeze in an unexpected invitation to Downing Street. Sometimes, my kids get sick and everything gets dropped again. The best thing about my work, though, is the team (both clinical and research) that has developed around our initial vision. Their commitment, passion and fun are what keeps me going when the workload seems overwhelming.

We are very open to collaboration, and have started a range of really exciting projects across a very broad set of questions: Can donor milk support maternal breastfeeding when used appropriately in the context of late preterm babies? What about babies readmitted with feeding problems? What is the psychological impact on the mother of receiving donor milk? How much milk would be needed if all NICUs in the country had equitable access? How can milk donors be better supported? What technology could make milk banking more efficient? What is the carbon footprint of milk banking?

To find out more please visit the websites below or email Natalie at natalie@humanmilkfoundation.org

heartsmilkbank.org

What does the future hold, both for you and for the milk bank? The next year is focused on consolidating the rapid growth of Hearts and getting the next Five Year plan in place for the Human Milk Foundation. There is no reason why access to donor milk cannot become much more widely available than it has been for the past four decades, but the major challenges will be changing mindsets and creating logistics solutions. For me, my major challenge is keeping focused on the end goal of creating a national framework for donor milk provision. With new scientific findings appearing, seemingly weekly, about the links between infant feeding and gut-brain-microbiome development, with implications for how we understand childhood onset diseases such as autism, type 1 diabetes, and gastrointestinal motility disorders, finding solutions to support mothers who want to breastfeed to be able to seems more important than ever.

humanmilkfoundation.org

If you would like to donate milk, please visit www.ukamb.org/milkbanks to find your closest human milk bank. If you have a patient who may benefit from donor milk, please contact the team at info@heartsmilkbank.org. Photos: wavebreakmedia/Shutterstock.com, evso/Shutterstock.com

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You’ve probably never seen an oral iron like FERACCRU® before For the treatment of adults with iron deficiency (ID)1

For more information please visit

www.feraccru.co.uk PRESCRIBING INFORMATION: Feraccru 30mg hard capsules (ferric maltol) Please refer to the full Summary of Product Characteristics (SmPC) before prescribing. Presentation: Red hard capsules. Each capsule contains 30 mg iron (as ferric maltol). Indication: Feraccru is indicated in adults for the treatment of iron deficiency. Dosage and administration: Adults: Feraccru should be taken orally. The whole capsule should be taken on an empty stomach (with half a glass of water). The recommended dose is one capsule twice daily, in the morning and evening. The absorption of iron is reduced when Feraccru is taken with food. Treatment duration will depend on the severity of iron deficiency but generally at least 12 weeks treatment is required. The treatment should be continued as long as necessary to replenish the body iron stores according to blood tests Children: The safety and efficacy of Feraccru in children (17 years and under) has not yet been established. No data are available. Elderly and patients with hepatic or renal impairment: No dose adjustment is needed in elderly patients or patients with renal impairment (eGFR ≥15 ml/ min/1.73 m2). There is no clinical data on patients with impaired hepatic function and/or renal impairment (eGFR <15 ml/min/1.73 m2). Contraindications: Hypersensitivity to the active substance or to any of the excipients; haemochromatosis and other iron overload syndromes; patients receiving repeated blood transfusions. Warnings and precautions: Not recommended for use in patients with inflammatory bowel disease (IBD) flare or in IBD patients with haemoglobin (Hb) levels <9.5 g/dl. Iron deficiency or iron deficiency anaemia (IDA) diagnosis

should be made based on blood tests; it is important to investigate the cause of the iron deficiency and to exclude underlying causes of anaemia other than iron deficiency. Feraccru contains lactose and so patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine. This product also contains Allura Red AC (E129) and Sunset Yellow FCF (E110); these may cause allergic reactions. Interactions: Food has been shown to inhibit uptake of Feraccru and so treatment should be taken on an empty stomach. Avoid concomitant administration of Feraccru and IV iron, dimercaprol, chloramphenicol and methyldopa. Feraccru should be given at least 2 to 3 hours apart from: penicillamine, bisphosphonates, ciprofloxacin, entacapone, levodopa, levofloxacin, levothyroxine (thyroxine), moxifloxacin, mycophenolate, norfloxacin, ofloxacin, tetracyclines, calcium and magnesium salts e.g. magnesium trisilicate. Fertility, pregnancy and lactation: A moderate amount of data on the oral use of ferric iron in pregnant women indicate no malformative nor feto/ neonatal toxicity. Systemic exposure to the intact ferric maltol complex is negligible. Feraccru may be considered during pregnancy if necessary. No effects of oral ferric iron have been shown in breastfed newborns/infants of treated mothers. Ferric maltol is not available systemically and is therefore unlikely to pass into the mother’s milk. Feraccru can be used during breastfeeding if clinically needed. There are no data on the effect of ferric maltol on human fertility. Effects on ability to drive and use machines: Feraccru has no or negligible influence on the ability to drive and use machines. Undesirable effects: Common side effects:

Abdominal pain, flatulence, constipation, abdominal discomfort/distension, diarrhoea, discoloured faeces and nausea. Refer to the SmPC for a full list and frequency of adverse events. Price and pack sizes: £47.60 for 56 capsules. Legal category: Prescription Only Medicine. Marketing Authorisation Number: EU/1/15/1075/001 Marketing Authorisation Holder: Norgine B.V., Antonio Vivaldistraat 150, 1083 HP Amsterdam, Netherlands. Date of preparation: December 2020 For further information contact: Norgine Pharmaceuticals Limited, Norgine House, Moorhall Road, Harefield, Middlesex, United Kingdom UB9 6NS. Telephone: +44(0)1895 826 606. E- mail: medinfo@norgine.com. Company reference: UK-HAE-FER-2000095 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Norgine Pharmaceuticals Ltd on: Tel. +44 (0)1895 826 606 E-mail medinfo@norgine.com FERACCRU is a registered trademark of the Shield group of companies, licensed to the Norgine group of companies. NORGINE and the sail logo are registered trademarks of the Norgine group of companies. Reference: 1. FERACCRU® Summary of Product Characteristics. Available from: https://www.medicines.org.uk/emc

Date of preparation: February 2021 UK-HAE-FER-2100033

FEATURE

Living with an enteric stoma Sophie Medlin

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It is anticipated that most people living with a colostomy should be able to get back to a normal diet relatively quickly after their stoma has been formed.

In the UK, approximately 1 in 500, or around 13,500 people, live with an enteric stoma either temporarily or permanently.1 This means that, on average, each GP will have four patients registered to them who have an ileostomy or colostomy.2 Despite this, people living with a stoma often report that their GP has little knowledge or understanding of their condition. This article will explore the short and long-term consequences of living with a stoma and will highlight the need for more robust support and monitoring of these patients.

As is generally well understood, a colostomy refers to an opening on the abdominal wall which allows faeces to pass from the colon into a bag as opposed to via the rectum. A colostomy will most commonly be sited on the lower left-hand side of the abdomen. Colostomies are most typically sited due to rectal cancer. The motions that are passed from a colostomy will usually be fairly similar to what would typically be passed via the rectum. For example, they will function periodically, once or twice per day, and the stool should be reasonably well formed. It is anticipated that most people living with a colostomy should be able to get back to a normal diet relatively quickly after their stoma has been formed. An ileostomy is a stoma which is formed from the ileum, meaning that the colon is defunctioned or has been excised and small bowel content will pass through the stoma into a stoma bag which is typically sited on the right-hand side of the abdomen. Ileostomies are often used temporarily to allow the colon or rectum to heal following colorectal surgery, or to defunction part of the gut due to Crohn’s disease. Permanent ileostomies are commonly used following a total colectomy for ulcerative colitis, among other reasons. Due to fact that people with an ileostomy do not have a colon, the stool that they pass into their bag is usually the consistency of toothpaste or porridge. It can be harder for people with an ileostomy to manage their hydration as their colon would normally absorb water and electrolytes. The small bowel will adapt over time, but the early stages can be particularly problematic. As with people living with a colostomy, many people with an ileostomy can tolerate their normal diet but, particularly in the early phases, they can experience unpredictable output, with high volumes of undigested food in their bag which can deter them from branching out and achieving nutritional adequacy. A jejunostomy is a stoma from the jejunum. These patients have short bowel syndrome and would typically be under close supervision from a Nutrition Support Team in Secondary Care.

Patients can easily become disheartened when their barriers to weight loss are not acknowledged by healthcare professionals.

The most important thing to remember about patients with an ileostomy is that they are at risk of nutritional deficiencies. In a 2017 study of 783 patients with end ileostomies, 17% had iron deficiency anaemia, 31% had B12 deficiency, 13% were deficient in vitamin D and 8% had zinc deficiency.3 Due to resection of the terminal ileum in many ileostomy patients, B12 deficiency is unsurprising, but to date there isn’t a routine safety net in place to alert GPs of the need to screen for B12 or iron deficiency in these high-risk patients. Due to effective mechanisms of B12 storage in the liver, patients may not present with B12 deficiency for many months after surgery and many can be symptomatic of deficiency without being outside the normal range. Unsurprisingly, vitamin deficiencies in these patients are associated with much worse quality of life.3

It is suggested that GPs utilise patient management software to flag these patients for routine screening where this is not in place already. As with the general population, the diet of patients with a stoma will have a significant impact on their bowel function, with certain foods causing wind, which can be noisy and cause embarrassment. Other impacts include looser output, which can lead to leaks, odour and even constipation in colostomy patients. Many people living with a stoma gain weight. While there is little published data on this, it is likely to be due to the combined effect of relying on low-fibre, high-carbohydrate foods to limit challenges with their stoma output and emotional eating, associated with changes in self-image. Many patients with a stoma also reduce their physical activity due to the perception that their condition limits their capability. Unfortunately, weight gain with a stoma can lead to complications, with a BMI over 30kg/m2 being considered to be high risk for a parastomal hernia.4 Typical approaches to weight management are less likely to be effective for these patients as increasing fruit, vegetables and wholegrain foods, reducing carbohydrates or other standard methods are likely to cause problems with stoma output. Due to the emotional eating aspect and the additional burden of the likelihood of ‘failure’ on standard weight loss regimens, these patients can easily become disheartened when their barriers to weight loss are not acknowledged by healthcare professionals. Patients with a stoma will need support from a specialist dietitian. However, resources are limited across the UK. Charities such as Colostomy UK and stoma bag manufacturers, such as Coloplast, have excellent resources for stoma patients, including information on managing weight with a stoma, which would be a preferable place to direct patients to compared with standard weight management tools and resources. Patients with stomas generally have dietary patterns associated with higher risk of lifestylerelated diseases such as diabetes and cardiovascular disease. Often the dietary requirements for managing stoma output conflict with the dietary requirement needed to manage blood glucose or lipids. Without appropriate support for both aspects of their diet, patients can become despondent about their ability to manage their conditions. Managing two dietrelated conditions at once will be outside the remit of practice nurses and these patients should be referred to dietitians for specialist support. Due to societal pressures on what is considered to be ‘feminine’, many women find the adjustment to life with an ostomy traumatic. Wind, potential leaks, perceived smells and the need to make changes to clothing and underwear can mean that women feel they have more of a sense of loss of identity after stoma formation, and many report they feel less attractive.5 Women who are struggling with this would benefit from support from a stoma nurse or from a health psychologist as poor understanding of stomas among counsellors may damage to the therapeutic relationship. While many people struggle with life with a stoma, there is a growing number of patient advocates and support groups on social media who are destigmatising stomas and demonstrating that it is more than possible to live a positive and healthy life with a stoma. People like Mesha Moinirad (@mrcolitiscrohns), Kimberly Holiday-Coleman (@cancerwarriorcolostomyqueen) and Omma Ahmed (@ostomateforlife) use social media as a tool to share their stories and empower others to live more freely.

Key messages 1. Screening for nutritional deficiencies is important for ileostomy patients – a reminder system for this is helpful.

2. The management of lifestyle-related diseases, including obesity, is complex in stoma patients and specialist resources and referrals are needed.

3. Women may suffer with adjusting to life with a stoma and referral to a health psychologist can be helpful.

4. Encourage patients to find an online community or support group to destigmatise their condition and enable acceptance.

References 1. http://www.colostomyuk.org/ information/what-is-a-stoma/ 2. http://www.pulsetoday.co.uk/ news/all-news/number-ofregistered-patients-per-gp-risesto-almost-2100/20039037.article 3. Schiergens, T. S. et al, (2017). Long-term quality of life of patients with permanent end ileostomy. Diseases of the Colon & Rectum, 60(1), 51–60. 4. Osbourne W, North J, and Williams, J; Using a risk assessment tool for parastomal hernia prevention, British Journal of Nursing 2018 27:5, 15-19 5. Tripaldi, C. (2019). Sexual function after stoma formation in women with colorectal cancer. British Journal of Nursing, 28(16), S4–S15. doi:10.12968/ bjon.2019.28.16.s4

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FEATURE

A day in the life of Dr Jelena Rakić Matić Interviewed by Vicky Proctor, Assistant Editor, The Digest

We caught up with Jelena in mid-lockdown. Thank you, Jelena, for setting aside some time to fill us in on your work as a family doctor in Croatia and your views on primary care gastroenterology.

Dr Jelena Rakić Matić, 38 I am a family medicine specialist and I have been working as a GP for 11 years. Before that I did my internship at the Andrija Stampar Teaching Institute of Public Health in Zagreb.

TELL US A BIT ABOUT YOU

I was born in Zadar, on the Adriatic coast – my parents still live there. I finished high school in my home town and then moved to Zagreb to study medicine. I remained in the city after I met my husband and now we have a daughter who’s six. I am a member of the executive board of KoHOM (Coordination of Croatian Family Medicine) and, for the past two years, I’ve also been president of the Organizing Committee of KoHOM’s Congress. (We had planned a conference this May, but sadly it had to be cancelled due to the Covid-19 pandemic.) I am also KoHOM’s delegate in EQUiP and in ESPCG. In my (rare) spare time, I like to get lost in a good book!

WHERE DO YOU WORK? WHAT DOES A TYPICAL DAY LOOK LIKE? AND WHAT SORT OF PATIENTS DO YOU LOOK AFTER?

There are three big health centres in Zagreb and I work in one of them: Health care centre Zagreb West. I have around 1,900 patients in my care, with around 350-400 of them aged over 65. The main body of patients I treat are between 30-65 and I also see some children, but only those over seven, as in Croatia children under seven are seen by a primary care paediatrician. (I do really enjoy working with children, though – it brings me a lot of joy!) It’s worth mentioning that there are a lot of social problems in Croatia, including unemployment and PTSD following the war. A number of my consultations include helping older patients to manage these conditions. Of course, like every other GP I deal with chronic illnesses (Diabetes mellitus, hypertension, COPD etc.), I take care of my palliative patients and I deal with acute conditions. We work according to a schedule of even and odd days and I have between 80 and 120 consultations per day (examinations, telephone consultations, prescriptions). After that I do house visits. We are also expected to take up shifts during weekends and holidays to address the needs of patients outside normal surgery hours.

WHY DID YOU WANT TO WORK IN PRIMARY CARE?

WHERE DID YOUR INTEREST IN GASTROENTEROLOGY COME FROM?

This is down to my first ever mentor and employer, Ruzica Ivanovic. She not only gave me my first position as a family GP but was also an inspiration to me. All I can say was that she was a real doctor – in the traditional sense – and I wanted to be like her! As she worked in a little, what you might call ‘rural’ surgery, her role in the community was very important and she took on a lot of social and emotional care roles as well – she did a lot for her patients. After working with her I knew I wanted to work in family medicine. My interest in GI began during my time at college. We had to work rotating shifts in different specialist areas, and I chose gastro. My curiosity grew from there really. It’s hard to explain, I just enjoyed learning about it and gravitated towards it, and over the years my interest has remained. I do think that if I hadn’t been a GP, I would have been a gastroenterologist. I gained a lot through qualifying as a specialist gastroenterologist as well and although I continue to practise family medicine, I appreciate the insight I have into gastro. Especially as I have met the patients in secondary care, I can better understand what they are going through and what my colleagues are up against. I guess you could say that specialisation gave me a greater understanding of the patient journey.

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Photo: 1147227107/Shutterstock.com

WHICH ASPECT OF YOUR WORK MAKES YOU PROUDEST? I am extremely proud of the deep knowledge I have of my patients. Working as a family GP, I have insight into their lives that no one else does and I am able to help them with issues because of this intimacy. This kind of bond doesn’t grow overnight, it takes years of working in a place, with a group of people, taking an interest in their lives. I believe that it’s through this connection that a GP can directly impact upon a patient’s life for the better. This epidemic particularly shows the importance of family medicine, our knowledge of the patient, the ability to triage, treat, comfort and counsel over the phone, e-mail or do a Skype consultation. This is the greatness of family medicine, and today I am very happy and proud that this is my specialty.

WHAT ARE THE BIGGEST CHALLENGES FOR PRIMARY CARE GASTROENTEROLOGY IN YOUR COUNTRY? The greatest problem facing doctors in Croatia is administration. It’s possible to spend a whole day with paper instead of patients and that can be incredibly frustrating. As a result, sometimes we have long waiting lists to see specialists, we have discrepancies between guidelines and discrepancies between guidelines between locations. Every clinic has its own set of rules and there is no standardisation – this impacts continuity of care. Then there’s the fact that public health insurance, for example, has a different set of prescription guidelines to professional guidelines, which means we see a lot of time-wasting and a lot of unnecessary delay and paperwork.

WHAT COULD GPS IN OTHER COUNTIES LEARN FROM THE WAY YOU DO THINGS? For one, our E-Health system is very developed. This has been such a great help during the pandemic, with patients unable to get face-to-face consultations, particularly for prescriptions. The E-Health system means that a lot of that kind of work can be carried out online. We’re also extremely close to our patients. I can recognise many of my patients’ voices over the phone, I know their history and I know what’s going on in their lives. I think this is something quite rare in modern healthcare – this level of knowledge and intimacy. It also means that doctors are better equipped to provide an all-round, holistic standard of care, meaning they can help their patients better socially, as well as simply treating their health complaint. Finally, we have an open-door policy regarding doctor’s appointments on the primary health care level in Croatia, which means that patients don’t usually suffer long delays in treatment. This is a bit of a double-edged sword, though. On the one hand, if a patient has a problem, they can receive treatment for it on the day. On the other, we do see abuse of that system and on occasions I have seen patients three, four or five times in one week.

IF YOU HAD THE CHANCE TO RUN YOUR COUNTRY’S HEALTH SERVICE FOR ONE DAY, WHAT WOULD YOU CHANGE IN THE WAY GASTRO PATIENTS ARE CARED FOR? I would create a standardised and complete set of guidelines that could be used nationwide, and that would empower doctors to make confident decisions about their patients’ healthcare journey. Plus, ensuring that National Health Insurance guidelines matched professional guidelines. At the moment, we see so much time-wasting as patients skip from department to department, from primary to secondary care. For example, even if I know that a patient needs a colonoscopy, that patient must still go to see a gastroenterologist, who will then refer them for a colonoscopy. With a concise set of guidelines, doctors would feel confident and empowered to make decisions like these. The same goes for practising what I call ‘defensive medicine’; many doctors are making decisions based on satisfying the patients‘ demands rather than their own professional knowledge, which can also be damaging to the patients’ journey and to the healthcare system at large.

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OUR MISSION

IMPROVING GUT HEALTH FOR EVERYONE

THE PCSG FREE TO JOIN FOR HEALTHCARE PROFESSIONALS

PCSG MEMBER BENEFITS: Automatic subscription to The PCSG Digest eMagazine Access to PCSG Guidelines developed by primary care for primary care GutTalks - influential videos from expert speakers on gastroenterology Invitations and free entry to PCSG events

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FEATURE

Life as a GPwER: Building bridges between primary and secondary care Dr Sophie Nelson Interviewed by Vicky Proctor, Assistant Editor, The Digest

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Note: GPs with Extended Roles (GPwERs) undertake roles that are beyond the scope of GP training and the MRCGP and require additional training. The term GPwER includes those previously referred to as GPs with Special Interests (GPwSIs). Information on training to become a GPwER in gastroenterology can be found on the PCSG website here: http://www.pcsg.org.uk/become-an-endoscopist/

There is no set pathway or framework for becoming a GPwER in Gastroenterology. Each of my colleagues came at it from a different angle. Some of us dipped our toes in the endoscopy waters during previous careers and came back to it during GP training. Some others pursued it after qualifying as a GP via specific postgraduate courses, like my fellow PCSG board member, Charlie Andrews, did at The University of South Wales. Unlike our colleagues in Dermatology, who can now follow specific training to achieve certification via the British Association of Dermatologists, theoretically anyone can call themselves a GPwER in Gastro – the title means something different to everyone. Why become a GPwER, you might ask? Firstly, on a personal level, working some of the week in a different place, with a different team and with a different focus – be it in hospital Outpatients, Endoscopy, or any other area not usually inhabited by GPs – is a valuable way to add variety to our working week and thus combat burnout among primary care physicians. Our diverse experience and range of skills is what enables us to move quite easily into other areas outside of our usual surgeries, helping us to be aware of what is happening in the other areas of the NHS and avoid any potential antipathy from spending too much time in the same place with the same routine.

I have been genuinely heartened by the enthusiasm of the hospital consultants to hear the GP perspective.

But more broadly, GPwERs play an invaluable role in creating links between primary and secondary care.

In Manchester Foundation Trust, where I spend a day a week, there are many GPwERs across the hospitals in specialities including Dermatology, Oncology, Frailty and Palliative Care. I’m one of two GPwERs in Gastroenterology, although our jobs are really quite different. I spend time in general Outpatient clinics and Endoscopy whereas she has developed an interest in Hepatology and is clinical lead for Gastroenterology at the CCG. We work closely with our consultant colleagues each week and then meet as a group of primary and secondary care doctors, along with other relevant managers and CCG colleagues, every six weeks to plan the future of the Gastro services in the region as a team. This communication has been more important than ever since the Covid-19 pandemic hit in order to mount a collaborative response to the pressures on the Gastroenterology services in the region, in particular the sudden lack of access to endoscopy, even for those patients with suspected cancer who normally have been seen within two weeks.

Photo: Roman Zaiets/Shutterstock.com

I have been genuinely heartened by the enthusiasm of the hospital consultants to hear the GP perspective. It has added relevance to education events, which are now often planned together to make sure everyone gets the most out of them. We have opened an advice and guidance service in the past year which has allowed GPs fast access to advice about specific scenarios, and we have put together diagnostic pathways to map out the investigation and management of some of the more common Gastro conditions in primary care. In previous years, it was thought that GPwER might occupy a middle ground between the surgeries and the hospitals, a sort of tier 2 service to investigate and manage patients independently without secondary care input. A few of these separate community centres do still exist, but not many are functioning entirely independently of the hospital now, and I wonder if this is because GPwERs actually don’t want to work completely alone any more. Community endoscopy is fairly common nationally, but these are often run by private companies, and tend to simply scope and report back to the referrer rather than actively managing the patient’s complaints. To anyone interested in becoming a GPwER in Gastro, I would say be sure to approach the PCSG and ask to be put in touch with a member in your CCG who might be able to help. Other PCSG members can play an important role in informally mentoring GPs interested in specialising. As mentioned before, there is a lack of a formal training scheme, and one of the goals for the PCSG in the future is to work on a standardised programme like that of our GPwER Dermatology colleagues.

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Recipe and photo by Dr Joan Ransley for Love Your Gut. For more recipes visit: www.loveyourgut.com/love-your-gut-week/new-recipes/

RECIPE

Roast Cod and Mediterranean Vegetable Tray Bake This colourful dish epitomises all that is healthy about the Mediterranean diet. Colourful vegetables, fish, olive oil and pulses. It is important to include a diverse range of colourful vegetables in the diet, not only because they contain vitamins and minerals but also phytonutrients. Phytonutrients are compounds that give plants their rich colours as well as their distinctive tastes and aromas and many of them can increase the diversity of the microbes in our gut and benefit many aspects of our health. Chickpeas are a type of pulse. They are an important source of fibre and a group of carbohydrates called galacto-oligosaccharides (GOS). These carbohydrates promote the growth of a range of beneficial bacteria in the gastrointestinal tract. A healthy population of gut bacteria helps to reduce the risk of colorectal disease.

INGREDIENTS

METHOD

2 red onions, peeled

Preheat the oven to 220°C/Gas mark 7

800g mixed peppers (yellow, red, orange), cut in half and deseeded 16 (200g) cherry tomatoes 4 cloves garlic, finely chopped 2 tbsp olive oil 400g tinned chickpeas 4 cod fillets, skinless, around 125g each For the basil oil 1 25g pack of fresh basil 1 clove garlic, finely chopped 1 tbsp pine nuts 1 tbsp fresh lemon juice 3 tbsp olive oil

COOK TIPS 1. Cut the vegetables up into small, even pieces so they cook quickly. 2. If you are short of time use readymade fresh pesto to finish the dish. 3. Get ahead and cook the vegetables up to 4 hours before cooking the fish. Then just warm through the vegetables in the oven, top with the fish and cook for 10-15 minutes.

Cut each red onion into eight wedges. Slice the peppers into 10cm strips approximately 1cm wide, and place in a roasting tray. Add the cherry tomatoes and garlic. Drizzle with olive oil and, with your hands, mix together so the vegetables are coated with a thin film of oil. Place the vegetables in the oven to roast for 20 minutes. They should be soft and just beginning to caramelise. Remove from the oven and stir through the chickpeas. Place the four pieces of cod onto of the vegetables and return to the oven. Cook for a further 10–15 minutes. Meanwhile prepare the basil oil. Place all the ingredients for the basil oil in a food processor and process for approx. 20 seconds, until smooth. Season to taste. Remove the baking tray from the oven and drizzle with the basil oil before serving. Serve with chunks of crusty bread. Per Serving (g)

Per 100g

Calories (Kcal/KJ)

452 / 1893

82 / 342

Protein (g)

6.1

Fat (g)

3.3

Saturated fat (g)

2.3

0.4

Carbohydrate (g)

5.8

Sugar (g)

2.6

Fibre (g)

9.6

1.7

Sodium (g)

128.5

23.2

Salt equivalent (g)

0.32

0.06

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Together we know more. Together we do more.

Optimising maintenance therapy for ulcerative colitis:

Real choices

When mesalazine doesn’t seem to be working, stepping up to immunosuppressants isn’t the only option

Real solution

Salofalk Granules are easy to take, they have a pleasant vanilla flavour, and they’re a proven way to help patients get the most from their mesalazine1-3

Optimising therapy with once-daily Salofalk Granules in patients who were inadequately maintained on previous mesalazine resulted in:2

69%

fewer days off work

45%

fewer GP visits due to UC

Prescribing Information (refer to full SPC before prescribing): Salofalk gastro-resistant prolonged-release granules Presentation: Stick-formed or round, greyish white gastro-resistant prolonged-release granules in sachets containing 500mg, 1000mg, 1.5g or 3g mesalazine per sachet. Indications: Treatment of acute episodes and the maintenance of remission of ulcerative colitis. Dosage: Adults: Once daily 1 sachet of 3g granules, 1 or 2 sachets of 1.5g granules or 3 sachets of 1000mg or 500mg granules (equivalent to 1.5 – 3.0g mesalazine daily) preferably taken in the morning, according to individual clinical requirement. May be taken in three divided doses (1 sachet of 500mg granules three times daily or 1 sachet of 1000mg granules three times daily) if more convenient. Maintenance: 0.5g mesalazine three times daily (morning, midday and evening) corresponding to a total dose of 1.5g mesalazine per day. For patients known to be at increased risk for relapse for medical reasons or due to difficulties to adhere to three daily doses, give 3.0g mesalazine as a single daily dose, preferably in the morning. Children: There is only limited documentation for an effect in children (age 6-18 years). Children 6 years of age and older: Active disease: To be determined individually, starting with 30-50mg/kg/day once daily preferably in the morning or in divided doses. Maximum dose: 75mg/kg/day. The total dose should not exceed the maximum adult dose. Maintenance treatment: To be determined individually, starting with 15-30mg/kg/day in divided doses. The total dose should not exceed the recommended adult dose. It is generally recommended that half the adult dose may be given to children up to a body weight of 40kg; and the normal adult dose to those above 40kg. Method of administration: Taken on the tongue and swallowed, without chewing, with plenty of liquid. Contra-indications: Hypersensitivity to salicylates or any of the excipients. Severe impairment of renal or hepatic function. Warnings/Precautions: Blood tests and urinary status (dip sticks) should be determined prior to and during treatment. Caution is recommended in patients with impaired hepatic function. Should not be used in patients with impaired renal function. Mesalazine-induced renal toxicity should be considered if renal function deteriorates during treatment.

50%

fewer steroid courses used

Mesalazine, the Dr Falk way

Cases of nephrolithiasis reported; ensure good hydration. Patients with pulmonary disease, in particular asthma, should be carefully monitored. Patients with a history of adverse drug reactions to preparations containing sulphasalazine should be kept under close medical surveillance. If acute intolerance reactions e.g., abdominal cramps, acute abdominal pain, fever, severe headache and rash, occur, stop treatment immediately. Severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), have been reported. Discontinue treatment at the first appearance of signs and symptoms of severe skin reactions, such as skin rash, mucosal lesions, or any other sign of hypersensitivity. Salofalk granules contain aspartame, a source of phenylalanine that may be harmful for patients with phenylketonuria. Salofalk granules contain sucrose: 0.02mg, 0.04mg, 0.06mg and 0.12mg (500mg/1g/1.5g and 3g granules respectively). Interactions: Specific interaction studies have not been performed. Lactulose or similar preparations that lower stool pH: possible reduction of mesalazine release from granules due to decreased pH caused by bacterial metabolism of lactulose. With concomitant treatment with azathioprine, 6-mercaptopurine or thioguanine consider a possible increase in their myelosuppressive effects. There is weak evidence that mesalazine might decrease the anticoagulant effect of warfarin. Use in pregnancy and lactation: There are no adequate data. Do not use during pregnancy unless the potential benefit outweighs the possible risks. Limited experience in the lactation period. Use during breastfeeding only if the potential benefit outweighs the possible risks; if the infant develops diarrhoea, breast-feeding should be discontinued. Undesirable effects: Headache, dizziness, peri- and myocarditis, abdominal pain, diarrhoea, dyspepsia, flatulence, nausea, vomiting, aplastic anaemia, agranulocytosis, pancytopenia, neutropenia, leukopenia, thrombocytopenia, peripheral neuropathy, allergic and fibrotic lung reactions (including dyspnoea, cough, bronchospasm, alveolitis, pulmonary eosinophilia, lung infiltration, pneumonitis), acute pancreatitis, impairment of renal function including acute and chronic interstitial nephritis and renal insufficiency, nephrolithiasis, photosensitivity especially with pre-existing skin conditions, alopecia,

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), myalgia, arthralgia, hypersensitivity reactions such as allergic exanthema, drug fever, lupus erythematosus syndrome, pancolitis, changes in hepatic function parameters, hepatitis, cholestatic hepatitis and oligospermia (reversible), asthenia, fatigue, changes in pancreatic enzymes, eosinophil count increased. Legal category: POM. Basic cost: Salofalk 500mg granules, pack size 100 sachets - £28.74; 31.47€. Salofalk 1000mg granules, pack size 50 sachets – £28.74; 32.87€. Salofalk 1.5g Granules, pack size 60 sachets - £48.85; 51.29€. Salofalk 3g Granules pack size 60 sachets - £97.70; 104.06€ (UK- NHS price; IE - PtW). Product licence number: Salofalk 500mg granules – PL08637/0007; PA573/3/1. Salofalk 1000mg granules – PL08637/0008; PA573/3/2. Salofalk 1.5g granules PL08637/0016; PA573/3/7. Salofalk 3g granules PL08637/0025; PA573/3/6. Product licence holder: Dr Falk Pharma GmbH, Leinenweberstr.5, D-79108 Freiburg, Germany. Date of preparation: November 2020 Further information is available on request. Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/ (UK residents) or in Ireland at https://www.hpra.ie/homepage/ about-us/report-an-issue/human-adverse-reaction-form. Adverse events should also be reported to Dr Falk Pharma UK Ltd at PV@drfalkpharma.co.uk. References: 1. Salofalk Granules. Summary of Product Characteristics. 2. Aldulaimi D et al. Poster DRF16/057 presented at the BSG Annual Meeting, June 2016, Liverpool UK. 3. Keil R et al. Scand J Gastroenterol 2018; 21: 1-7. UC: ulcerative colitis Date of preparation: January 2021

DrF 20/226

FEATURE

Menopause and the gut Dr Katherine Parkin

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The problem

The female reproductive hormones include oestrogen and progesterone. There are three naturally occurring oestrogens: estrone, estradiol and estriol, which act on oestrogen receptors (ER): ERα and ERβ. Estradiol and progesterone, primarily released from the ovaries, are known for their role in reproductive regulation. However, estrone, in smaller amounts, is released from non-reproductive tissues, including adipose tissues and the GI tract. Receptors for both oestrogens and progesterone are found all over the body, allowing them to regulate other body functions. The functions of the GI tract are numerous; maintaining fluid balance, absorption of nutrients and excretion of waste products, to name a few. Both oestrogen and progesterone have been shown to play a role in the regulation of GI tract function throughout life. Oestrogen and progesterone regulate gastric motility, through controlling smooth muscle contractility.1 Oestrogen also regulates the permeability of the GI tract, having a role in electrolyte and fluid balance.2 Oestrogens also play a role in glucose and lipid metabolism, with low levels predisposing to metabolic disturbances and insulin resistance.3 As such, it would seem logical that alterations in these hormones associated with the menopause would cause GI disturbances.

Photo: fizkes/Shutterstock.com

Reproductive hormones and their role in GI function

Every woman will experience menopause at some point in their life. For some women, this transition is without complication, but for the majority, this period is associated with a host of uncomfortable symptoms. Vasomotor, mood and urogenital problems are well-known ones. However, gastrointestinal (GI) changes can also occur in the perimenopausal period and continue into post-menopause. The GI system is influenced by a large number of regulatory pathways. Among these are reproductive hormones (oestrogen and progesterone). While it is known that these hormones impact on GI function, their role in the menopause and GI disturbances is not well documented. This lack of evidence may be in part due to the difficulty in attributing the symptoms to the menopause alone, as well as the huge variation in presentation of menopause in women.

Common GI issues during Menopause

Hormone Replacement Therapy

Conclusions

The GI disturbances seen in post-menopausal women are varied, and due to the complex nature of GI regulation, it is difficult to determine whether these symptoms are due to the menopause alone, or other factors such as age and weight. There is an increase in obesity seen in postmenopausal women.4 Sex hormones, along with other appetite-regulating hormones, such as leptin, are released in decreasing amounts. Leptin is responsible for satiety, and low levels are associated with obesity.3 Particularly, menopause is associated with an increase in abdominal adiposity, which as we know, predisposes to a host of diseases including cardiovascular and metabolic problems. This increase in abdominal adiposity also, in part, may result in the increase in dyspepsia seen in post-menopausal women.3 The increase in pressure, along with the hormonal changes resulting in increased gastric acid secretion and reduced gastric expansion, causes the classical restrosternal discomfort experienced with dyspepsia and GORD.3 Thirty eight per cent of postmenopausal women reported altered bowel habits compared to 14% of premenopausal women,5 and in women with IBS, it has been shown that pain-related symptoms get worse after menopause.6 However, when adjusted for age, it was found that the differences in reporting between pre- and postmenopausal women was not significant. This difference in evidence with regards to GI symptoms reflects the complex nature of GI regulation.

Hormone Replacement Therapy (HRT) is the provision of exogenous oestrogen with/without progesterone. Therefore, if the decrease in production of endogenous hormones may result in this increase in GI problems, it would infer that replacing these hormones could treat these issues. However, the BNF states that one of the common side-effects of HRT is GI disturbances. Oestrogens in HRT have been shown to relax the oesophageal sphincter, resulting in acid reflux. Its use for treatment of symptoms associated with Irritable Bowel Syndrome (IBS) was associated with an increase in symptoms compared to those not using HRT .7 It’s hypothesised it may be due to women with more severe IBS symptoms also having more severe menopausal symptoms, therefore being more likely to be prescribed HRT, or a difference in the metabolism of endogenous and exogenous hormones.6 However, one well-known effect of continuous HRT treatment is a reduction in incidence of colorectal cancer. ERβ receptors are found in reduced amounts in colorectal cancerous tissue compared to healthy tissue, supporting the belief that oestrogens are protective against it.

With menopause causing symptoms in the vast majority of women, it is important for GPs to consider if GI symptoms in peri- and post-menopausal women may be due to this hormonal change. The current evidence leaves us in a slight conundrum when it comes to GI symptoms in these women. Menopause brings an increase in GI disturbances. However, so does HRT. It is very likely that due to the multifactorial nature of GI regulation, these issues are not due to menopause alone. It is important to remember that HRT’s benefits may outweigh its risks in some women and can be beneficial for other symptoms of the menopause. Further research is still needed into how to prevent these common GI symptoms and establish the extent that these hormonal imbalances are responsible. References 1. Nordenstedt H, Zheng Z, Cameron AJ, Ye W, Pedersen NL, Lagergren J. Postmenopausal hormone therapy as a risk factor for gastroesophageal reflux symptoms among female twins. Gastroenterology. 2008 Apr 1;134(4):921–8. 2. Chen C, Gong X, Yang X, Shang X, Du Q, Liao Q, et al. The roles of estrogen and estrogen receptors in gastrointestinal disease. Oncol Lett. 2019/10/11. 2019 Dec;18(6):5673–80. 3. Lurati AR. Effects of menopause on appetite and the gastrointestinal system. Nurs Womens Health. 2018 Dec 1;22(6):499–505. 4. Davis SR, Castelo-Branco C, Chedraui P, Lumsden MA, Nappi RE, Shah D, et al. Understanding weight gain at menopause. Climacteric. 2012 Oct 1;15(5):419–29. 5. Triadafilopoulos G, Finlayson M, Grellet C. Bowel dysfunction in postmenopausal women. Women Health. 1998;27(4):55–66. 6. Heitkemper MM, Chang L. Do fluctuations in ovarian hormones affect gastrointestinal symptoms in women with irritable bowel syndrome? Gend Med. 2009;6 Suppl 2(Suppl 2):152–67. 7. Ruigómez A, García Rodríguez LA, Johansson S, Wallander M-A. Is hormone replacement therapy associated with an increased risk of irritable bowel syndrome? Maturitas. 2003 Feb 25;44(2):133–40.

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Yakult Educational Grant

N : te Da ng 1 si 02 lo /2 t C 09 ex 30/

Is there a conference or training course that you are keen to attend? Yakult are offering grants of up to £1,000 to support healthcare professionals, researchers and students in their participation in a virtual, national or international conference or training course. VISIT YAKULT.CO.UK/HCP

Yakult is a science-based company, dedicated to scientific research and education. Contact us at science@yakult.co.uk or on 020 8842 7600 for more information. 50

IN MY SHOPPING TROLLEY

In my shopping trolley

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Now, we ain’t all got the time to set up a full fermenting station in our kitchens, but there are some easy, affordable and accessible ’gut friendly’ items we always slip into our shopping trolley…

Chicory When you’re reaching for the lettuce, grab some chicory instead. It’s a bit ‘left field‘, but chicory is like the Queen of prebiotic foods. It contains prebiotic inulin that feeds all the good bacteria living in our guts. It also has a slightly more unusual crunchy, bitter taste – we love it with Roquefort and walnuts.

Olive Oil Gallons of the stuff! Olive oil is very rich in polyphenols which are great for your gut and help to reduce cholesterol and protect against heart disease. A polyphenol is a natural chemical found in some plantbased foods with antioxidant properties. And yes, we get a little confused with this word too, but if something has antioxidant properties, it means it has the power to combat the negative effects of ‘free radicals’, which can cause stress-related cell damage to the body, including ageing. Think of antioxidants as the little superheroes in your body, fighting/sweeping up the ‘free radicals’ that a person naturally produces and that you are exposed to as part of day-to-day life.

Sourdough More and more evidence is coming out to suggest slow, fermented bread is easier to digest. It’s made with a lactic acid starter, something which contains strains of bacteria called lactobacillus that add friendly microbes to your gut – bring on the warm bread, we say!

Dark chocolate As you know, cocoa is the ingredient in chocolate and it also contains polyphenols (hurrah!). There are many categories of polyphenols, but those found in cocoa are known as flavanols. This basically means the more cocoa content (over 75% is what you should be aiming for) in the chocolate, the more flavanols and so the more health benefits. This explains why dark chocolate has just over seven times the number of polyphenols than milk chocolate (!!).

IN MY SHOPPING TROLLEY r and have lots of “picky” In the office, we try to all eat togethe loads of different types bits for variety in our diets. Plus, team even put sauerkraut of sauerkraut and ferments... the y this year - talk about in their pancakes for Shrove Tuesda living the brand!

Live yoghurt

Photo credit: Jones Knowles Ritche

Live yoghurt still contains lots of the beneficial ‘good‘ bacteria for your gut and if you want to upgrade further, swap this for Kefir (fermented milk) which is now becoming more readily available in supermarkets.

Nuts and seeds mix Firstly, nuts and seeds are great for fibre. Secondly, until we know which role each bacteria plays in our gut, there is considerable science pointing to the fact that a ‘diverse‘ microbiome is what we should be aiming for. The best way to achieve this is by eating 30 different plant-based foods per week (including nuts and seeds) – so, multi-seed packs containing lots of different types of nuts and seeds can absolutely help you on your way.

Green under-ripe bananas Pears

Dig for the ones at the back that no one else wants – they contain resistant starch that can make the long journey through the stomach and small intestine undigested, meaning they make it all the way to the gut to feed the friendly bacteria. Whatta journey! Photos: Bozena Fulawka/ Shutterstock.com (chicory), Angel Simon/Shutterstock.com (olive oil), anmbph/ Shutterstock.com (sourdough), freepik/Freepik.com (chocolate), Kaiskynet Studio/Shutterstock.com (banana), Maks Narodenko/Shutterstock.com (pear), Pixel-Shot/Shutterstock.com (nuts), Nina Firsova/ Shutterstock.com (live yoghurt)

Pears contain a whopping 6.2g of fibre (skin on, mind). As a nation, only 9 out of 10 of us are getting our recommended daily intake of 30g of fibre a day – so we all need to find ways to up our intake considerably!

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FEATURE

Tea and Toast

Monotonous diets increase the risk of poor nutrition status, and then, poor health

Photo: Julia Metkalova/Shutterstock.com

Ursula Arens

There are many reasons to eat well. Good health. The enjoyment of a variety of delicious foods. The pleasure of sharing tasty treats with family and friends. And there are many reasons not to eat well. The practical difficulties of shopping and storage of perishable items. The high cost of fresh, attractive foods. The time it takes to prepare meals, and then the annoyance of washing up: who ever loved a greasy frying pan? The waste of leftovers or out-of-date items. And then the boredom of same-old choices that may be quick and easy, but spark no joy. The challenge for doctors and health professionals is the observation of the latter. Tea and Toast diets are observed in many older patients or those living alone. What are the best ways to improve diets and nutrient intakes in those who are not inspired by capers in the kitchen (or capers in meals?) So let’s start with tea and toast. Tea is a wonderful drink supporting hydration, and for many, the only way to also consume some milk. Toast is fine, but best as wholemeal, and so providing some fibre and B vitamins. Toast plus protein is even better: peanut butter, scrambled eggs, baked beans or cheese and tomato all offer additional nutrients. Toast plus jam or honey may be the breakfast default, but these choices score few nutri-points. And so to protein. Most adults in the UK consume more than adequate intakes, which are defined as 0.8g protein per kg body weight. Someone weighing 9 stone (57kg), should have a protein intake of at least 46g; for someone weighing 12 stone (76kg) protein intakes should be at least 61g. There is a reduction in muscle mass with age, and to reduce the risk of sarcopenia (more extreme loss of muscle size and strength, linked with weakness and frailty), greater intakes of protein are helpful. Intakes of at least 1g protein per kg body weight are recommended, so about 60g for smaller adults, and about 80g for larger adults. Some protein food with every meal is a good rule, either animal-sourced (dairy, meat, fish, poultry, egg) or plant-sourced (beans, lentils, nuts or meatstyle products such as Quorn™). For people with poor appetites, milk or soya drinks help boost protein intakes. And so to all other nutrients except fibre. Energy intakes should be enough to cover requirements without excess: obviously body weight is the long-term measure of this. Both eating more and eating less is a challenge, and needs support and longer-term goals. Sugary and sweet snacks are a risk to dental health, and linked with foods low in nutrients (cakes, biscuits,

sweets). Rather, snacks should be nutritious: Banana plus peanut butter, oat cakes plus cheese, yogurts plus fruit. Fortified breakfast cereals are a useful source of many vitamins, and there is a wide variety to match budgets and tastes. Fats add flavour and essential fatty acids to diets, and the health hierarchy is topped by fatty fish containing omega 3, such as mackerel, salmon and sardines. Liquid vegetable oils, such as olive or rapeseed oil, are a good way to add flavours to salads and vegetables, and enhance the absorption of vitamins. The animal-source fats from dairy and meat contain the most saturates, which should be limited. Everyone in the UK is advised to take vitamin D supplements in winter and spring months, and this is especially true for older people, or those with only occasional exposure to sunshine. In fact, cheap multi-vitamin supplements are a good general recommendation. And so to fibre. Most people recognise this food component as an ‘eat more’ nutrient. The undigestible components found in fruits and vegetables, in wholegrain breads and cereals, in beans and lentils, and in nuts and seeds, provide many health benefits. Fibre supports fullness and weight control, reduces the risk of constipation, and promotes many aspects of bowel health including maintaining the much discussed ‘good bacteria’ community resident in the colon. Fibre is the common theme of many foods described as healthy, but while most UK diets contain less than 20g, dietary guidelines advise daily intakes of 30g. More fibre choices means wholegrain choices more often, and finding ways to add fruits and salads and vegetables to meals. Munching on dry lettuce is not the way: there are thousands of tasty formats to enjoy plant foods: frozen or canned, in soups or sauces, fried or oven roasted, or flavoured with dressings. Traffic light choices such as tomato (red), carrot (amber) and spinach (green) guarantee the most vitamins and antioxidant benefits.

Dietary benefits to those you identify as tea and toasters involve the letters A, B, C & D. Include:

A protein food with every meal, Brown (wholemeal) foods, Coloured fruits & vegetables, and vitamin D supplements. Keep the message simple and engaging. Eating should be a pleasure, not a chore.

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MAKING AN IMPACT FOR PATIENTS WITH COELIAC DISEASE

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Supporting the gluten free community and improving their safety

Finding the 1 in 100 with coeliac disease

Is it coeliac disease? online assessment as part of a multichannel campaign reached 150,000 people checking their symptoms since 2015

Pharmacy pilot scheme to identify patients with IBS symptoms and anaemia, not already on a GFD to offer screening – 10% of those screened had positive antibody tests

A valued Food and Drink Guide Providing the suitability of over 150,000 products for a gluten free diet, available on and in hard copy.

2 acclaimed apps Award winning Gluten Free Food Checker helping over 37,000 users scan foods for their gluten free diet.

Gluten Free on the Move helping nearly 10,000 people find over 7,000 places to eat out confidently.

Engaging young people through our Moving On and Young Champions packs

Ensuring the external landscape provides better care and service to those with coeliac disease

to manage their coeliac disease and educate others about the condition

A new website - www.coeliac.org.uk Working with the public bodies such as NICE to support and develop guidelines on the diagnosis and management of coeliac disease and a NICE Quality Standard in coeliac disease Working with the Food Standards Agency on a revised standard for gluten free legislation Improving safety in eating out with our widely used GF Accreditation scheme – over 3,300 venues have been approved

Improving safety in products with Europe’s leading gluten free product certification mark the Crossed Grain Trademark – now on over 19,000 individual products across the globe Annual coeliac disease conference for healthcare professionals and researchers supporting their CPD with the latest updates in research

Until one day we can ﬁnd the answers to our

research priorities to ensure no one’s life is limited by gluten

Ensuring we have the right governance structures Research Strategy Board and engaging our in place to award research projects that will community with our Member Review Panel. achieve real world improvements through our These are their research priorities:

Finding the triggers for coeliac disease

Better support for healthcare professionals

Understanding neurological forms of coeliac disease

Finding less invasive tests to recognise coeliac disease

Improving safety for people eating outside the home

Finding a cure for coeliac disease

Preventing the onset of coeliac disease

Understanding the causes of refractory coeliac disease

Understanding the link between coeliac disease and other conditions

Finding the best post diagnosis support

Download our Research Priorities brochure here

www.coeliac.org.uk

rewritten and optimised for a better user experience with over 1,000 GF recipes

Lola used her Young Champions pack to hold a cake sale at her school.

“When I got the pack I asked if I could do a cake sale because usually when there is one at school there are no cakes that I can have. So we sold only gluten free things as well as lactose and nut free cakes. For the first time EVERYONE could have something — it was a big success and I was happy that we raised a lot of money for Coeliac UK.”

Achievements so far

Identifying the toxic fragments of gluten – work that has underpinned the development of a vaccine

Exploring biomarkers for identifying gluten related neurological conditions

Identified new genetic variants in coeliac disease, also involved in Type 1 diabetes – research towards a better understanding and maybe one day preventing CD

Evaluation of risks and necessary controls for gluten free production in a commercial kitchen environment that uses wheat flour

FEATURE

“Babies keep being born…” Olivia Shelton Interviewed by Vicky Proctor, Assistant Editor, The Digest

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Photo: kovop58/Shutterstock.com

The Digest caught up with Olivia Shelton, a caseloading midwife at the busy Guy’s and St Thomas’ Trust (GSTT), to find out how the pandemic had affected her and her colleagues’ experiences in the maternity units and further afield. Having worked at GSTT for the past three years (following her midwifery training at the University of Huddersfield and starting her career at University College London Hospital), Olivia is well-placed to describe the upheaval and, with a particular interest in Perinatal Mental Health, she can provide insight into how the situation has affected the nation’s new mums. As part of a team of five, Olivia cares for vulnerable women in the community before and after the birth of their baby. Her day-to-day duties have typically included visiting and supporting women in their homes, hosting classes and caring for women in labour. The role is varied and, before the pandemic hit, she ran her own antenatal clinic. It helped to educate expectant mothers on subjects like what to expect during birth, signs of labour, what pain medication is available to them, caring for a newborn baby and breastfeeding. Then, postnatally, the clinic supported them as they transitioned into parents with their baby. Since the pandemic struck last March, however, Olivia’s role has adapted to minimise contact with vulnerable pregnant mothers, new mothers and their newborn babies. This meant home visits were put on indefinite hold. (Interestingly, and perhaps unsurprisingly, enquiries regarding home births massively increased during lockdown. However, many maternity wards around the UK were advised to suspend home births in order to concentrate staff in hospitals where women could be attended to safely, adhering to safety measures.) Olivia and her four colleagues were disbanded and reassigned to different areas of maternity and she found herself on the labour ward all the way through the lockdown. More recently though, Olivia and her team have been allowed to re-enter the community and take up their former duties. Olivia explains that many of her normal appointments have gone online, as with so much of NHS routine care in recent times. Her antenatal classes have also moved online, or more recently, to community ‘hubs’ that have been repurposed from services that are just not possible under current social distancing rules – podiatry, for example. She tells The Digest that it’s a relief to be able to get back out into the community caring for women and their families.

When lockdown was introduced, she explains, the Royal College of Obstetricians and Gynaecologists (RCOG) couldn’t offer much guidance, particularly when it came to home visits and how and when pregnant women should self-isolate. Now, we know there’s no evidence that pregnant women are more likely to get seriously ill from the coronavirus, although they have been placed on the list of those at ‘moderate risk’ of the virus as a precaution. Olivia says her job was made particularly difficult by the uncertainty about Covid – how long it would last, how it would affect babies, and who was at risk and to what extent. In her line of work, being able to reassure mothers is paramount and yet, with no concrete information, this becomes difficult and women’s mental health has suffered. The role she was redeployed to saw her caring for women during labour. So how had this been impacted by the pandemic? Olivia explained that having to wear full PPE means that providing that invaluable facial encouragement is hampered massively. Distressed mothers cannot recognise a smile behind a mask, which means reassurance has to be more consciously verbalised by the midwife. Olivia believes that new mothers’ mental health will have been significantly impacted by giving birth during the pandemic. The women she has spoken with have struggled with not being allowed to have their birth partner present during ultrasound scans and induction of labour. Although this is changing now, Olivia says, there was a period when a person could meet five friends at the pub, but women in labour couldn’t have their birth partner comfort them during labour or attend the ultrasound. It wasn’t easy for women to reconcile themselves to this. Most women have a vision of how they want their birth and maternity leave to be, and the weeks and months that follow, Olivia explains, but this was all thrown into disarray by Covid precaution measures. “It’s not how I imagined it would be,” was a phrase she hears often.

The Covid-19 pandemic has created a challenging climate for pregnant and postpartum women. The unknown of pregnancy and motherhood is a psychological trigger for many, and the lack of certainty surrounding the Covid-19 situation is likely to cause considerable anxiety. As a result, all women, and particularly vulnerable women (for example, those with underlying health conditions), are likely to be more susceptible to perinatal mental health conditions. For many women with existing perinatal mental health conditions, establishing a routine is stabilising. However, as a result of Covid-19, many women would have been required to change their routine. Women may have children who aren’t at school, they can’t go to cafés or see friends to socialise and seek peer support. – The Royal College of Midwifes

Olivia says that her job was made particularly difficult by the uncertainty about Covid – how long it would last, how it would affect babies, and who was at risk and to what extent. In her line of work, being able to reassure mothers is paramount and yet, with no concrete information, this becomes difficult and women’s mental health has suffered. Olivia underscores how much she loves being a midwife and how rewarding the role can be, yet, as in all lines of work, the pandemic has created new stresses and difficulties. Her original team of caseloading midwives kept in touch while working on different wards and were incredibly supportive of one another. Olivia explains that the atmosphere on the maternity ward throughout was one of positivity and resilience, particularly as both she and so many of her colleagues were unable to see friends and family who either lived far away, or simply couldn’t visit due to the high-risk nature of work in maternity. As a result, the maternity ward staff became their own support group and bubble. “What you might be picking up on, is that essentially we had no choice but to get through it,” Olivia tells The Digest. “Babies keep being born.” Statistics from the maternity unit show that from 23/03/20 until 4/07/20 there were 1,671 live births plus 10 stillbirths. From now on, she explains, it’s all about trying to adapt to what everyone’s calling ‘the new normal’ and finding new ways to move forward. Aside from the huge

amount of support and camaraderie between staff on the wards, Olivia says she would not retain any of the changes instated from lockdown. While, for example, phone triaging and online appointments have had their benefits to primary care, she reckons that any degree of distance between health visitors and new or expectant mothers is only detrimental. The hardest thing remains not knowing what the future holds. For Olivia, she intends to take her recently acquired postgraduate degree in perinatal mental health and specialise. Many of the women she encounters on her rounds have mental health issues. She cites the MBRRACE report, a piece of ongoing research conducted by Oxford University, titled Saving Lives, Improving Mother’s Care, and their findings on maternal deaths linked to mental health. The research shows that “mental health conditions remain the leading cause of pregnancy associated deaths between six weeks and a year after giving birth (30%)”. It also point out “other causes of maternal deaths up to six weeks after pregnancy include infection (10%), deaths relating to mental health conditions (10%) and cancer (4%)”. In these unstable times, maternal mental health has never been so important and we have yet to discover the long-term impacts of Covid-19.

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FEATURE

The changing face of medicine – a new era for women Dr Lily Lamb

I became involved with the Changing Face of Medicine (CFoM) leadership group over two years ago. Led by Professor Pali Hungin, this project aims to shape a vision for the future of medicine, to prepare for that future and provide a sense of direction for those in the profession. I thoroughly appreciated being part of this ‘think tank’ of clinicians, key stakeholders and lay people, and the opportunity to consider the future doctor in a fast-changing world, thinking beyond the problems we face today. As a woman in medicine, a leader and a mother, I feel strongly that female leaders must be nurtured and supported in order to provide a sustainable future for those who follow. Women now make up more than half of all medical students, 44% of registered doctors are female (The King's Fund, 2014), and there are more female than male GPs. Through bringing a ‘transformative perspective’, female leaders are often catalysts for culture change, capable of creating better career experiences for the medical workforce (Alwazzan and Al-Angari, 2020).

I took on roles in my local faculty of RCGP and in my NHS organisation. I participated in the Next Generation GP programme and a clinical leadership scheme run by my employer, Northumbria Healthcare NHS Trust. These gave me an understanding of the importance of developing leadership skills as a doctor, and the difference effective leadership can make.

44%

re gi st e

My path to medicine was somewhat unusual. I had my first child while studying A-levels and started medical school when he was three years old. I had always been passionate about being a doctor, and despite the challenge of being a single teenage mum I remained focused on my goal. I went on to meet my husband and have two more children during GP specialty training. As I progressed in my training, I found myself in leadership roles, driven by a desire to represent women, mothers and those from different backgrounds, to speak up for the challenges we face and to be part of a movement towards a sustainable future in medicine.

ct o r

m s are fe

The CFoM project discussed the importance of visionary medical leaders reflecting the population and workforce they serve, of leaders acting with humanity and creating a sense of higher purpose among their team. The project identified the courage that is required to focus on creating a culture and approach that fosters long-term success rather than short-term goals, with nurturing of the team and leader wellbeing seen as crucial. The literature suggests that women, particularly, struggle to prioritise self-care, but leaders must pay attention to this – failing to do so can lead to compassion fatigue and burnout. Juggling caring and leadership responsibilities can make looking after one’s own wellbeing difficult, particularly in a culture of being ‘always on’, where part-time working often means replying to emails and catching up on work on days off, as well as for many home-schooling during the pandemic. The Covid-19 pandemic has required a new kind of leadership, and we have seen many females stepping up and leading successfully in these challenging times. The acceptability of home working and joining meetings remotely has removed many boundaries for leaders with caring responsibilities. The wellbeing of the team has been of paramount importance in facing this significant adversity, and leaders have in many cases been supported and resourced to take care of those in their charge. As we move forward post-pandemic, I hope we will remember the lessons we have learnt, the leadership styles which are effective and the importance of the wellbeing of the workforce. As women make up a significant proportion of that workforce, the environment in which they work and lead must be supported so that their true potential can be met, they can provide positive role models for other women and they can remain both clinicians and leaders in a new era. References Alwazzan, L. & Al-Angari, S. S. 2020. Women’s leadership in academic medicine: a systematic review of extent, condition and interventions. BMJ Open, 10, e032232. The King’s Fund. 2014. Women and medical leadership [Online]. The King’s Fund. Available: https://www.kingsfund.org.uk/audio-video/women-and-medical-leadershipinfographics [Accessed 26/2/2021 2021].

This project, for the first time, brings together representatives from across the medical profession, patient groups and commercial organisations to look at the role of the doctor in the future. https://thecfom.org.uk/

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PCSG Research Network launch www.pcsg.org.uk/about/pcsg-research-network/

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FEATURE

How eating disorders hide in plain sight Jess Griffiths

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CHARITY SPOTLIGHT

A young woman presents to healthcare professionals with gastrointestinal symptoms and is treated for them. Later, she has the same issue; this time, her symptoms have become worse, with no obvious explanation for why she’s experiencing them in the first place. The cause lies somewhere many clinicians wouldn’t think to look – she’s being compelled to behave in a way that causes her serious physical harm and that, if not treated in time, may kill her. Eating disorders are often poorly understood. There’s a prevailing stereotype about what eating disorders ’look like’, with the media regularly presenting pictures of emaciated young women, highlighting body weights that are clearly dangerously low and diets that are plainly too restrictive to live on. This can and does happen, but eating disorders present in myriad other ways too. It’s much easier than we may be led to believe for these serious mental illnesses to hide in plain sight. What is an eating disorder? In short, a way that people may cope with, control or otherwise process difficult thoughts, feelings, and situations. At Beat, the UK’s eating disorder charity (see foot of next page), we hear from people who rigidly control what they eat because other aspects of their life feel out of control, or who binge because it numbs emotions they are struggling with. These maladaptive coping mechanisms may help temporarily, but the behaviours they force people to engage in – restricting food intake, binge eating, purging, or some combination of the three – often leave people feeling guilty and ashamed, worse about themselves, and very often compelled to push themselves even further. Often someone with an eating disorder will describe it as something separate from themselves – a voice that may comfort, cajole, manipulate or bully, but whose goal is always to force the person further and further into their illness. The eating disorder, whether it feels like a separate entity or not, often strips a person of their selfesteem and self-worth. It can convince them that they do not deserve or do not need help, that they are not ill, or just not ill enough. It can be exceptionally hard for someone with an eating disorder to tell a healthcare professional, or anyone else, what is happening to them. Often people struggle for years before accessing treatment for their eating disorder, and the longer it is before they get the help they need, the less likely it is that they’ll be able to make a full recovery. But people with eating disorders often do use the healthcare system for things that may at first seem unrelated. In fact, despite delays to seeking help for the eating disorder itself, people with eating disorders may access healthcare services more frequently than others.

The behaviours involved with eating disorders can cause problems in every system of the body, so people with eating disorders may present to any part of the healthcare system. Often it isn’t obvious that their symptoms are caused by a mental health condition. Every part of the gastrointestinal system may be affected, from sialadenosis and damage to the oesophagus caused by vomiting, to intestinal damage due to laxative misuse, and the effects on the whole body of either seriously restricting or regularly bingeing (and in some cases both). Treating these symptoms may alleviate discomfort or even

There is a lot of stigma and shame associated with these illnesses, and this is often made worse by the perception that it’s not an illness they should be going through – men can often take even longer to ask for help, likely due in part to this perception.

be life-saving, but without treating the underlying thoughts and feelings causing the eating disorder, it’s unlikely that the treatment will permanently fix the problem, and even more unlikely that the person will be able to stop engaging in the behaviour putting so much strain on their body. As well as treating the physical symptoms, help for their mental health – usually some variation of cognitive behavioural therapy – is essential. It’s not always easy to tell whether the reason that someone is experiencing gastrointestinal symptoms is an eating disorder. Often people work very hard to hide their illness, whether consciously or unconsciously – they may not even realise that they are ill. But there are some key signs to look out for. Eating disorders are often characterised as a “female illness”, and it’s estimated that around 75% of those who experience them are indeed women. However, anyone of any gender can have an eating disorder. There is a lot of stigma and shame associated with these illnesses, and this is often made worse by the perception that it’s not an illness they should be going through – men can often take even longer to ask for help, likely due in part to this perception. Age, too, can be a factor that leads to people being overlooked: while a high proportion of people do first develop an eating disorder during adolescence, it can continue through, or may first develop at, any stage of life. Other unexplained physical symptoms, such as problems with the heart, circulation, teeth, skin, or endocrine system, in conjunction with gastrointestinal issues the person may be having, could be a sign that the underlying cause is an eating disorder. Weight, often imagined as the most obvious physical

symptom of eating disorders, is actually within a ’normal’ or high range in around 80 – 85% of cases (Fairburn & Harrison 2003). However, weight that has suddenly decreased, increased, or fluctuates within a ’normal’ range could be a sign of an eating disorder. When someone develops an eating disorder, the first changes will be to their thinking and behaviour. The presence of other mental health conditions, such as depression, anxiety, OCD or bipolar disorder, may make it more likely that someone has an eating disorder. Concerns about weight and shape, mentions of exercise that seems excessive, difficulty sleeping or concentrating, and indications that the person has lost interest in activities that they used to find enjoyable, has withdrawn socially or is otherwise isolating themselves, are all things to look out for. Eating disorders regularly impact someone’s self-esteem and sense that they are deserving of help; they may downplay symptoms even though they need treatment. Concern about proposed dietary requirements, such as that the food being suggested contains too many calories, could also indicate an eating disorder. As difficult as it can be to tell whether an eating disorder is what’s causing someone’s physical symptoms, it’s important to address a suspected eating disorder as quickly as possible, referring the person to a specialist eating disorder service. The sooner someone gets help for an eating disorder, the more likely it is that they’ll be able to fully recover. Beat offers a training course, Beyond the Symptoms, for healthcare professionals who might encounter someone with an eating disorder in various parts of the healthcare system. You can find out more about this course at beateatingdisorders. org.uk/training-cpd. Photo: WAYHOME studio/Shutterstock.com

Beat is the UK’s eating disorder charity. We support anyone affected by eating disorders, including those with personal experience and anyone caring for them in a personal or professional capacity. If you’re concerned for someone, you can contact our Helpline on 0808 805 0677 or at help@beateatingdisorders.org.uk, from 9am – 8pm weekdays and 4pm – 8pm weekends and bank holidays.

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PCSG MEMBER BENEFITS CONCERNING THE DIGEST: Automatic subscription to The PCSG Digest eMagazine

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Good health begins with a balanced gut GP perspective on irritable bowel syndrome

Can Real World Data deliver? The PCSG and Operation Raptor! Public satisfaction with GP services - the Chair’s view

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