NHD Dec 14/ Jan 15 Issue 100 by NH Publishing Ltd

New name Improved formula

>033 :665 ),*64

Why? Because we listen to you The same trusted and effective1† 100% hypoallergenic, amino acid-based formula for infants with severe cow’s milk allergy (CMA) or multiple food allergies, but with added benefits. • Easier to distinguish from our extensively hydrolysed formula, Nutramigen LIPIL • 33% MCT oil added to facilitate fat absorption • Certified kosher and halal • No change in mixing instructions or order codes There’s a reason we’re No. 1 in the world in CMA management** Find out more at www.nutramigen.co.uk/puramino Reference: 1. Burks W et al. J Pediatr 2008;153:266–271. †This study was conducted with Nutramigen AA without MCT oil. **Data on file. IMPORTANT NOTICE: Breastfeeding is best for babies. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. *Trademark of Mead Johnson & Company, LLC. © Mead Johnson & Company, LLC. All rights reserved.

This material is for healthcare professionals only. EU14.510 November 2014

from the editor December is a month of celebration!

Chris Rudd NHD Editor Chris Rudd’s career in continuous dietetic service has spanned 35 years. She is now working part time with the Sheffield PCT Medicines Management Team, as a Dietetic Advisor.

@NHDmagazine

Christmas planning and social occasions are evolving. Many of you may be invited to a large number of activities be it Christmas lunches, dinners, nights out as well as preparing for the festive holiday period. When you are invited to eat out at that Christmas ‘do’, do you, like me, check out the pudding options first before selecting the starter and main course? If so, may I suggest that you go straight to the Final helping, on the penultimate page of NHD, served by Neil Donnelly. If you would like to contribute to the draft manifesto for UKOP please contact us. Our proactive New Year resolution could be to ‘tackle the obesity tsunami’. NHD is now 100 and I hope that you will enjoy the large selection of articles. Can you remember when NHD first landed in your letter box nearly 10 years ago? NHD has developed over the years and even in the six years that I have been Clinical Editor and now Editor it has become a larger small digest! My thanks go to the NHD team that have made this possible, all of you who have contributed to NHD as well as the 6,000 plus who read it! What else is on the 100th Issue NHD menu? Many of you may know Edith Elliott, number 001 within the BDA. As member number 076 I have worked with Edith over the years and you can Editor Chris Rudd RD Features Editor Ursula Arens RD Design Heather Dewhurst Sales Richard Mair richard@networkhealthgroup.co.uk Publisher Geoff Weate Publishing Assistant Lisa Jackson

find out more about her achievments by reading Ursula’s account – that could be your starter. Moving on to the main menu of articles, you are spoilt for choice this month. Sheila Turner offers Eating disorders: a case study, Jacqui Lowden informs us about Cystic fibrosis in paediatrics, and Julie Leaper and Susie Hamlin tempt us with the development of outcome measures which can be implemented for evidence of dietetic impact and effectiveness within a viral hepatitis setting. Also to tempt you are articles on folic acid, Attention Deficit Hyperactivity Disorder, prebiotics and a taster from the Conference report: 4th Enhanced Recovery after Surgery UK, held on the 14 November 2015. Maybe you would like to ‘get your teeth into’ Gluten-free products: to prescribe or not to prescribe by Eirini Koutroulis – this really could be food for thought! Whichever article you choose, there is a full plate of information before you, some of which will be new. Finally, may I wish you all a very happy Christmas and hope that 2015 is a good year for you. May I suggest a New Year resolution for you? Please send me an email to chriscatrudd@ aol.com if you would like to write an article for NHD in 2015. All enquiries will be gratefully received.

Address Suite 1 Freshfield Hall, The Square, Lewes Road, Forest Row, East Sussex RH18 5ES Phone 0845 450 2125 (local call rate) Fax 0870 762 3713 Email info@networkhealthgroup.co.uk www.NHDmag.com www.dieteticJOBS.co.uk

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

NHDmag.com December 2014 / January 2015 - Issue 100

Contents

Liver disease

News

39 Gluten-free

19 Cystic fibrosis

44 Folic acid

24 Prebiotics

46 Legends of dietetics

27 ERAS

48 dieteticJOBS

31 ADHD

50 Events and courses

37 Eating disorders

51 The final helping

Editorial Panel Chris Rudd Dietetic Advisor

Jacqui Lowden Paediatric Dietitian

Neil Donnelly Fellow of the BDA

Michèle J Sadler Director, Rank Nutrition Ltd

Ursula Arens Writer, Nutrition & Dietetics

Julie Leaper Senior Specialist Dietitian

Dr Emma Derbyshire Nutritionist, Health Writer

Susie Hamlin Senior Specialist Hepatology, Liver Transplant & Critical Care Dietitian

Dr Carrie Ruxton Freelance Dietitian

Stephanie Allen Advanced Research Dietitians

Emma Coates Senior Paediatric Dietitian

Liz Wells Advanced Research Dietitians

Kate Harrod-Wild Specialist Paediatric Dietitian

Sheila Turner Community Dietetic Lead (Retired)

NHDmag.com December 2014 / January 2015 - Issue 100

Based on a real-life UK case study1 Important notice: Breastfeeding is best for babies, and is recommended for as long as possible during infancy. Similac Alimentum is a Food for Special Medical Purposes and should be used under the supervision of a healthcare professional. Reference +H[H VU ÄSL (IIV[[ 3HIVYH[VYPLZ 3[K (Similac Alimentum Case Studies). +H[L VM WYLWHYH[PVU 6J[VILY 9?(50

news

Cranberries for Christmas?

Dr Emma Derbyshire PhD RNutr (Public Health) Nutritional Insight Ltd

Cranberries (Vaccinium macrocarpon) are a rich source of phenolic phytochemicals which have been linked to an array of health benefits. Now, a new trial has looked into how these are used in the body. Ten healthy older adults were provided with a low-calorie cranberry juice (54 percent juice) and the absorption and excretion of flavonoids, phenolic acids and proanthocyanidins (PACs) were measured. Results showed that phenolic compounds in cranberry juice were highly bioavailable, with plasma levels peaking between eight and 10 hours after ingestion. Plasma antioxidant levels also correlated positively with levels of phenolic compounds. These findings indicate that phenolic compounds in cranberry juice are bioavailable and have antioxidant properties in healthy older adults. While studies on lay populations are needed, having the odd cranberry juice at Christmas may go some way towards providing some of these benefits. For more information, see: McKay DL et al (2015). Food Chemistry. Vol 168, pg 233-40 [Epub ahead of print].

Omega-3 research

Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health. www.nutritionalinsight.co.uk hello@nutritionalinsight.co.uk

Some interesting new studies have looked at omega-3 fatty acids in relation to aspects of health and behaviour. Firstly, new data from the second Nurses’ Health Study, a large prospective cohort, has found that the consumption of two weekly servings or more of fish significantly reduced hearing loss risk when compared with women who rarely ate fish. These are interesting findings, with omega-3 fatty acids thought to play a role. Now more work is needed to investigate possible mechanisms of action. Another paper using results from two meta-analyses (25 studies in total) found that omega-3 blood levels were significantly lower in children with attention deficit hyperactivity disorder (ADHD). Further analysis also showed that omega-3 supple-

NHDmag.com December 2014 / January 2015 - Issue 100

Antibiotics in early life and obesity link

The disruption of gut microbiota has been linked to obesity in previous publications. However, as this is established early in life, new research has now looked into whether infant antibiotic use could be linked to obesity in childhood. Using healthcare records logging antibiotic use and anthropometric measurements at age 9 years (n=616) and 12 years (n=431), results were analysed from a Canadian cohort study conducted from birth. Results found that infants receiving antibiotics in the first year of life were more likely to be overweight at 12 years of age (P=0.002). However, after adjusting for factors such as birth weight and breastfeeding, this association only persisted in boys. While obesity is a complex condition, these results indicate that infant antibiotic exposure could be another underpinning risk factor. Further work is now needed to investigate mechanisms behind this. For more information, see: Azad MB et al (2014). International Journal of Obesity (London). Vol 100(5), pg 1290-8.

mentation seemed to improve symptoms, particularly alongside ongoing therapies. Finally, a meta-analysis of 12 randomised controlled trials looking at omega-3 supplementation and cognitive function has found that while lower doses of omega- 3 fatty acids (<1.73g per day) significantly reduced cognitive decline, similar trends were not seen using higher doses. These are interesting findings, suggesting that smaller doses of omega-3 fatty acids could be more beneficial for cognitive well-being. For more information, see: Curhan SG et al (2014). American Journal of Clinical Nutrition. Vol 100 (5), pg 1371-7; Hawkey E & Nigg JT (2014). Clinical Psychology Review 34(6), pg 496-505 and Abubakari AR et al (2014). International Journal of General Medicine. Vol 7, pg 463-73

Are you sure UK toddlers are getting enough vitamin D?

The Reference Nutrient Intake (RNI) for toddlers 1-3 years of age is 7µg per day. The average UK toddler is only getting 27% of this from their current diet1. 1. Bates B, et al. National Diet and Nutrition Survey: Headline results from Years 1 and 2 (combined) of the Rolling Programme: London: HMSO, 2010.

www.in-practice.co.uk

news

New work on folate absorption

Unfortunately, not all of the folate that we ingest is utilised by the body. Now, a new trial has looked into this further, estimating ‘how much’ folate tends to be absorbed across the colon. A small sample of healthy adults took either a capsule containing 400μg of folate (as 5-formyltetrahydrofolate) or received this as an intravenous injection after a minimum washout period of four weeks. Tests carried out on six subjects showed that the rise in plasma folate levels was faster for the capsule compared with intravenous delivery (0.33 versus 5.8nmol per hr). Mean colonic absorption was around 46 percent. These results highlight that while folate is absorbed across the colon, due to the time spent in the colon, other factors such as dietary fibre, probiotics, size and composition of gut flora are likely to affect absorption. Further studies are now needed to investigate these aspects in more detail. For more information, see: Lakoff A et al (2014). American Journal of Clinical Nutrition. Vol 100. No 5, pg 1278-86.

Probiotics for constipation

Constipation can be a painful and unbearable condition, with certain dietary adjustments, such as increasing fibre and fluid intakes, helping to prevent and manage this condition. Now, a new meta-analysis has looked into the role of probiotics. Data from 1,182 subjects (extracted from randomised controlled trials) was analysed. Overall, probiotics reduced gut transit time by 12.4 hours, increased stool frequency by 1.3 bowel movements per week and improved stool consistency, particularly in the case of Bifidobacterium lactis. These results point towards probiotics having a potential role in helping to prevent and manage constipation. However, larger randomised controlled trials are needed, testing different doses and strains of probiotics. For more information, see: Dimidi E et al (2014). American Journal of Clinical Nutrition. Vol 100(4), pg 1075-84. 8

NHDmag.com December 2014 / January 2015 - Issue 100

product / industry news

FOODLINK COMPLETE - NEW PACKAGING, WEBSITE ANd RE-APPrOVED BY ACBS Foodlink Complete has been re-approved by ACBS and is now in new livery. Mixed with 200ml whole milk, Foodlink Complete provides 383kcals of energy. The most economical ONS available, so why not give it a try, see our new website and get your free sample and shaker. www.foodlinkcomplete.com

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Food trends look positive

Given that we are an ageing population, it is important to consider this when looking at changes in patterns of food consumption. Analysis of dietary intake data (n=989) from the Medical Research Council National Survey on Health and Development spanning over 30 years has now looked into this. It was found that the consumption of white bread, whole milk, fats and oils, meat and meat products, alcoholic drinks, coffee, sugar, preserves and confectionary had significantly declined. On the other hand, consumption of wholemeal and granary bread, semi-skimmed milk, fish, fruit and vegetables had significantly increased. On the whole, these findings look positive, indicating that ageing populations may be complying with dietary recommendations, although some of this may be attributed to report bias. For more information, see: Pot GK et al (2014). European Journal of Clinical Nutrition [Epub ahead of print].

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1. Children between the ages of 6 months to 5 years receiving less than 500ml of infant milk formula each day should take a daily supplement containing vitamin D to help them to meet the requirement set for this age group (at least 7µg per day). Letter from UK Chief Medical Officers. Available at https://www.gov.uk/government/publications/vitamin-d-advice-on-supplements-for-at-risk-groups [Accessed January 2014]. 2 x 150ml beakers of Cow & Gate Growing Up Milk provides 9.3 µg of Vitamin D.

www.in-practice.co.uk

70 years. 70 studies. Only Nutramigen. Up to 6 months

From 6 months

References: 1. Dupont C et al. Br J Nutr 2011:1–14. 2. Canani R et al. J Allergy Clin Immunol 2012; 129:580–582. 3. Lothe L, Lindberg T. Pediatrics 1989; 83:262–266. 4. Koletzko S et al. J Pediatr Gastroenterol Nutr 2012; 55(2):221–229.

First for cow’s milk allergy

Help them leave their cow’s milk allergy behind Nutramigen LIPIL is the only specialised infant feed with published clinical evidence of reaching oral tolerance to cow’s milk • Short term symptom relief 1 and tolerance to cow’s milk 2 • Tolerance supports improved quality of life for both mother and child 3 • Tolerance can avoid unnecessary healthcare costs by reducing treatment time 4 Nutramigen – new research, setting new standards for the management of CMA

IMPORTANT NOTICE: Breastfeeding is best for babies.The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Parents should always be advised by an independent healthcare professional regarding infant feeding. Products of Mead Johnson must be used under medical supervision. EU 11.564. * Trademark of Mead Johnson & Company. LLC. © 2013 Mead Johnson and Company. LLC. All rights reserved.

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liver disease

Viral hepatitis Development of outcome measures which can be implemented for evidence of dietetic impact and effectiveness within a viral hepatitis setting.

Julie Leaper

Susie Hamlin

Julie Leaper is a Senior Specialist Dietitian covering hepatology, liver transplant and critical care at St James’s Hospital, Leeds. A recent master’s module has enabled her to develop tools for measuring outcomes within the viral hepatitis service. Susie Hamlin is a Senior Specialist Hepatology, Liver Transplant and Critical Care Dietitian working on the Liver Transplant Unit at St James’s University Hospital, Leeds.

Outcome measures are being increas- The use of outcome measurements ingly used and embedded into clinical within this setting could provide data practice in order to assess effective- to identify the effectiveness of the diness of care. The government white etetic input on patient outcomes. paper ‘Equity and Excellence: Liberat- A prospective study by Fioravante ing the NHS’ established a vision for et al (3) investigated the nutritional putting patients at the centre of their status and dietary intake of 42 patients own healthcare where decisions are referred for peginterferon alfa and ribmade jointly between clinician and avarin treatment. None of the patients patient (1). experienced a sig. . . it is the first study Using patient nificant decrease in feedback regardresting energy exto demonstrate how ing their own penditure (p= 0.67). health outcome However, there was preventive nutrition in and experience a 14 percent deof care, seeks to crease in energy inhepatitis C treatment can drive increased take (p=0.012) with quality and efsignificant weight impact on clinical fectiveness, as loss (p=<0.001). The well as monitorweight loss expeoutcomes. ing traditional rienced consisted clinical outcome mainly of fat mass. targets, ensuring When considering that the National outcome measures Health Service (NHS) becomes more from a clinical perspective, weight, anaccountable. thropometry and change in nutritional Hepatitis C infection is a serious intake should, therefore, be collected. public health issue, with approxi- If these measures can be improved, or mately 216,000 people chronically reductions slowed or halted with diinfected in the UK (4). Currently, the etetic intervention, evidence of effecrecommended treatment for this clini- tiveness can be demonstrated. cal condition uses peginterferon alfa A randomised controlled trial by and ribavarin which can last for up to Huisman et al (5), studied the use of 48 weeks dependent on the response preventive versus on-demand nutrito treatment (8). Side effects of treat- tional support during antiviral treatment which may impact on nutritional ment for hepatitis C. Fifty-three patients status, include lethargy, decreased ap- with the hepatitis C virus on treatment petite and weight loss (11). Treatment were randomised to either dietary adshould be within a multidisciplinary vice from a specialised nutritionist on setting, with the prime aim of sus- meal patterns and late evening suppletained viral response (SVR) aided by ment (preventive group), or the same good compliance with treatment (2). advice after experiencing more than NHDmag.com December 2014 / January 2015 - Issue 100

liver disease

If patients do not achieve their intake, the most useful data to collect would also be the reasons or barriers to meeting this targets . . . five percent weight loss (on-demand group). The results demonstrated a significant decrease in weight with the on-demand group (5.4kg, p<0.001) compared to the preventive group (0.3kg, p=n.s). Handgrip measurements were also significantly reduced for the on-demand group (40.3+/-15.5kg to 32+/-13.1kg, p<0.001) but not in the preventive group (40.7+/-10.4kg to 39.7+/-8.9kg, p=n.s). Whilst the study could be criticised for a relatively low cohort, it is the first study to demonstrate how preventive nutrition in hepatitis C treatment can impact on clinical outcomes. When considering clinical outcome measures this further supports that weight and anthropometry must be included. Vietri et al (12) studied the burden of hepatitis C from the perspective of the patient relating work output, loss of activity, health-related quality of life questionnaires and use of medical resources to their associated costs. Results demonstrated that patients with hepatitis C had significantly impaired work output (p<0.01), greater restriction of non-work based activities (p<0.05), increased number of medical appointments (p<0.001) and lower health-related quality of life using validated tools. These all impacted on a significantly increased economic cost (p<0.01) compared to matched controls. This study clearly demonstrates the impact of hepatitis C on the patient prior to initiation of treatment. Patients who undergo Pegylated interferon alfa treatment have been shown to have a further decline in these impairments, with patient reported outcomes considered the best method to assess their experience of the disease and treatment (14). Significant side effects may lead to a poor patient experience of treatment with a lower compliance rate. If the dietetic advice and nutritional care of the patient in clinic can show improved markers as stated above, this will demonstrate clinical effectiveness of the service provided to this group of patients. 14

NHDmag.com December 2014 / January 2015 - Issue 100

The dietitian can assess change to dietary intake through the well-established 24-hour dietary recall method. This can provide estimated current dietary intake, particularly of energy and protein, whilst acknowledging that this method has recognised restrictions on accuracy (15). Tracking whether the patient achieves their estimated nutritional requirements for energy and protein alongside objective measurements of weight and anthropometry, could establish effectiveness of dietetic intervention. If patients do not achieve their intake, the most useful data to collect would also be the reasons or barriers to meeting this targets, providing further feedback to the dietitian on whether their episode of care has been effective, but also what areas can be changed in order to facilitate further success. Coding barriers to change allows the user to establish why goals have only been partially met or not met at all. This patient feedback could be just as important as the outcome data in order to establish changes to processes which may improve outcome measures. For example, a patient may not take their oral nutritional supplements advised due to difficulty paying for prescriptions, rather than intolerance to the supplement. Patient reported outcome measures (PROMS)

PROMS in hepatitis C should review those which have been validated in this group of patients. The only study which demonstrates content validity in the hepatitis C population and used appropriate qualitative research according the Kleinman et al (6) was carried out 15 years ago by Ware et al (13). The Hepatitis Quality of Life Questionnaire (HQLQ) used the SF-36 health related questionnaire and disease specific questions being completed at baseline, 12 and 24 weeks on and then off treatment. Results demonstrated a significant decline in

liver disease Dietetic Outcomes Recording Sheet - Viral Hepatitis Op Clinic Dietetic Outcomes Recording Sheet Initial Treatment Date Viral Hepatitis Op Clinic A = achieved NHS No Final Treatment Date PT = progression towards NA = not achieved + barrier code DOB SVR Yes/No M = maintained NO = not applicable Goal: To improve nutritional status following assessment, treatment planning and monitoring of diet and anthropometry from referral to discharge. Patient name

Aim

Goal/ Starting measurement

Review date:

Meet energy requirements (kcal) Meet protein requirements (g) Increase or maintain dry weight (kg) Improve physical function

Handgrip (kg) TSF (mm) MAC (cm) MAMC (cm)

Aid compliance with advice

Eating pattern of 50g CHO LES Compliance with ONS

physical, general health and vitality scores. Practical difficulties with using this questionnaire could relate to the need to have a license to use the product via an American website (Quality metrics). Further information is now required regarding licence cost, use and funding if appropriate via the hepatology service. Patient reported experience measures (PREMS)

Patient experience feedback of services provided can allow both minor and major changes to the facility where the patient becomes the centre of the care provided. The Framework for measuring impact is a web based tool developed for allied health professionals to look at how to measure the impact of their service with guidance on the identification and use of various outcome tools (9). Providing a structured framework to identify which validated and reliable tools could be used in the practitioners clinical area, provides a starting point for collecting outcome data. By using this guidance, patient-centred care can be identified using the Consultation and Relational Empathy

(CARE) measure, which has been extensively validated and tested for reliability by Professor Stewart Mercer and colleagues (7). Advantages of this tool include its measurement of the amount of empathy the patient has received during the individual consultation. This could also help assess the impact of the behavioural change skills and training that a dietitian has received. Benefits of the tool also include the ease and speed of completion within 10 minutes, with the patient completing this questionnaire after the first appointment away from the dietitian and leaving it in a dedicated box within the clinic setting. As long as the patient receives adequate explanation regarding the reason for the questionnaire, there should be a high response rate. The tool is recommended for use by an individual dietitian for feedback on over 50 consultations and not over several clinic settings. Changes suggested as a result of the feedback can be imposed quickly, if only minor, and, therefore, patients would identify alterations as a result of their own feedback, as they often attend for 12 months or more. NHDmag.com December 2014 / January 2015 - Issue 100

liver disease

The CARE measure obtains feedback on the consultation, but PREM measures can also be extended to capture specific questions a dietitian may wish to know.

The CARE measure obtains feedback on the consultation, but PREM measures can also be extended to capture specific questions a dietitian may wish to know. Previous patient experience days within the hepatology service have provided interesting feedback with patients prioritising basic comforts, effective communication, being listened to and having easy access to professionals as required most important. PREM questions would allow these patient concerns to be checked. Simplicity of collection and ease of completion would enable a high response rate and direct patient feedback.

Summary

For the hepatitis C outpatient setting, clinical outcomes will include weight change, anthropometric measurements, ability to meet estimated energy and protein requirements and sustained viral response. PROMs should be collected via the disease specific HQLQ after further discussion with the liver service regarding funding for licence requirements, with PREM collection using the CARE measure. Specific PREM questions can also be developed to provide feedback from the patient experience days previously held.

References 1 Department of Health (2010). Equality and excellence: Liberating the NHS. London: TSO 2 European Association for the Study of the Liver (2014). EASL Clinical Practice Guidelines: Management of hepatitis C virus infection. Journal of Hepatology, 60, pp392-420 3 Fioravante M, Alegre SM, Marin DM, Lorena SLS, Pereira TS and Soares EC (2012). Weight loss and resting energy expenditure in patients with chronic hepatitis C before and during standard treatment. Nutrition, 28, pp630-634 4 Health Protection Agency (2012). Hepatitis C in the UK. London: Health Protection Agency 5 Huisman EJ, van Hoek B, van Soest H, van Nieuwkerk KM, Arends JE, Siersema PD and van Erpecum KJ (2012). Preventive versus ‘on-demand’ nutritional support during antiviral treatment for hepatitis C: A randomised controlled trial. Journal of Hepatology, 57, pp1069-1075 6 Kleinman L, Mannix S, Yuan Y, Kummer S, L’Italien G and Revicki D (2012). Review of patient reported outcome measures in chronic hepatitis C. Health and quality of life outcomes, 10 (92), pp1-10 7 Mercer SW, Maxwell M, Heaney D and Watt GCM (2004). The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Family Practice, 21: 701-707 8 National Institute for Health and Care Excellence (2013). Peginterferon alfa and ribavarin for the treatment of mild chronic hepatitis C. NICE technology appraisal guidance 106. England: NICE 9 Nursing, Midwifery and Allied Health Professionals Research Unit (2012). Framework for Measuring Impact [Online]. Stirling: Stirling University. Available from: www. measuringimpact.org [accessed 28 March 2014] 10 Quality Metric (n.d.). An excerpt from the User’s Manual for the SF-36v2 Health Survey, Second Edition [online]. Quality Metric. Available from: www.qualitymetric. com/Portals/0/Uploads/Documents/Public/Which%20Survey%20To%20Use.pdf [accessed 9 March 2014] 11 Seyam MD, Freshwater DA, O’Donnell, K and Mutimer DJ (2005). Weight loss during pegylated interferon and ribavirin treatment of chronic hepatitis C. Journal of Viral Hepatitis, 12, pp531-535 12 Vietri J, Prajapati G and Khoury A (2013). The burden of hepatitis C in Europe from the patients perspective a survey in five countries. BMC Gastroenterology, 13 (1), pp1-8 13 Ware JE, Bayliss MS, Mannocchia M, Davis GL and the International Hepatitis Interventional Therapy Group (1999). Health-Related Quality of Life in Chronic Hepatitis C: Impact of Disease and Treatment Response. Hepatology, 30 (2), pp550-555 14 Younossi ZM, Stepanova M, Henry L, Gane E, Jacobson IM, Lawitz E, Nelson D, Nader F and Hunt S (2014). Minimal impact of sofosbuvir and ribavarin on healthrelated quality of life in chronic hepatitis C (CH-C). Journal of Hepatology, 60 (4), pp741-747 15 Yunsheng MA, Olendzki BC, Pagoto SL, Hurley TG, Magner RP, Ockene IS, Schneider KL, Merriam PA and Hébert JR (2009). Number of 24-Hour Diet Recalls Needed to Estimate Energy Intake. Annals of Epidemiology, 19 (8), pp553-559

NHDmag.com December 2014 / January 2015 - Issue 100

TASTE. A RECIPE FOR RECOVERY Independent research shows that 70% of people prefer the taste of Ensure Compact to that of the leading competitor.1* And since taste is most important when it comes to patients taking their ONS,2 it’s no surprise that Ensure Compact also boasts 99% compliance,3** which supports patient recovery.4

1. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Palatability Research). 2. kasHȘSP ;. et al. Turk J Gastroenterol 2013;24(3):266-272. 3. Data on File. Abbott Laboratories Ltd., 2013 (Ensure Compact Compliance Research). 4. /\IIHYK .7 et al. Clin Nutr 2012;31:293-312. ,UZ\YL *VTWHJ[ ]Z -VY[PZPW *VTWHJ[ ]HUPSSH ÅH]V\Y W# "U$ 6SKLY HK\S[Z HZRLK [V KYPUR IV[[SLZ WLY KH` MVY KH`Z U$ +H[L VM WYLWHYH[PVU! 4HYJO ͂͂9?(50

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cystic fibrosis

Cystic fibrosis in paediatrics Important advances in the treatment and management of cystic fibrosis (CF) have resulted in huge improvements in the health of people with CF. Individuals born with CF in the 21st century are now expected to live into their mid-50s, even in the absence of developments in the treatment of the underlying genetic defect (1). Jacqui Lowden Paediatric Dietitian - Team Leader Critical Care, Therapy & Dietetics, RMCH

One of the advances in CF management that has demonstrated the prevention of severe malnutrition and improvement in long-term growth, is new-born screening (2) which was introduced nationally in 2007. Maximising nutritional status has, however, long been considered a crucial element, being inextricably linked with lung function. The level of malnutrition has been demonstrated to predict survival (3). As the disease progresses, increased nutritional support is normally required. Dietary fortification, oral nutritional supplements and enteral tube feeding are all used. Infants with CF

Presently team leader for Critical Care and Burns, Jacqueline previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqueline has a great interest in paediatric public health.

Even with the benefits of infant screening, deficits in weight, length z score, total body fat and lean body mass have all been demonstrated in screened infants with CF at diagnosis (2, 4). A higher than normal intake of protein and energy has also been shown to be required in these infants in order to achieve normal rates of weight gain and growth (5). It is vital that infants with CF thrive, as achieving optimal nutritional intake and catch-up in weight gain within the first two years of diagnosis in children with CF has been shown to be the single strongest predictor of lung function improvement at six years of age, which is correlated to reduced morbidity and mortality (6). Most infants with CF thrive on breast milk or normal infant formulae until the commencement of complementary feeding. If the infant is unable to achieve the required amount and/or weight gain is

insufficient, a nutrient dense infant formula can be used. There is no evidence for the use of a protein hydrolysate formula in screened infants with CF (7). For infants with CF who have undergone bowel surgery due to meconium ileus, the choice of feed will depend on: 1. the extent of the small intestinal resection; 2. the site of the ileostomy; 3. parental choice to breastfeed. First choice is expressed breast milk whilst establishing breastfeeding, second a protein hydrolysate with a combination of MCT/LCT and thirdly, a standard infant formula. Another factor to take into account is sodium depletion, as this can inhibit growth (9). All infants with CF are at risk of sodium depletion. Particularly at risk are those with ileostomies as the sodium content of the output can be high. European Cystic Fibrosis Society guidelines suggest that ‘sodium chloride supplementation (2.0mmol kg/ day) should be considered for all CF infants, and increased during periods of hot weather and with other causes of high salt loss (for example, diarrhoea, fever and ileostomy)’ (8). Older children

Definitions of nutritional failure The intervention required will be dependent on clear definitions of what is classed as nutritional failure. Presently, there are three sets of national reference standards (Table 1). For children

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cystic fibrosis Table 1 UK CF Trust 2002

< 5yrs

5-18yrs

> 18yrs

ECFS 2002

< 2yrs

2-18yrs

> 18yrs

Normal nutritional state preventative counselling

%wt/ht 90-110%

BMI 19-25 or no recent wt loss

Dietetic referral Consider supplements

Any degree of faltering growth*

% wt/ht 85-89% wt loss 4-6 months wt plateau >6 months*

BMI <18.5(ECFS) BMI <19 (UK CF Trust) or >5% wt loss over <2 months

Invasive nutritional support

Faltering growth despite oral supplementation

Supplements tried & either %wt/ht <85% or wt fall of 2 centile positions

Supplements tried & BMI <18.5 (ECFS) BMI <19 (UK CF Trust) or >5% wt loss over <2 months

North American CF Foundation 2008

<2yrs

2-20yrs

> 18yrs

Defined targets to avoid nutritional failure

BMI percentile >/= 50th

Woman: BMI >/= 22 Man: BMI >/= 23

Table 2 Organisation

Recommendations

UK CF Trust 2002 200% RNI protein

120-150% EAR energy

European Guidelines 2002

North American CF Foundation 2008

with CF, achievement of a BMI centile equal to or above C 50th is associated with lung function above 90 percent predicted (10). Dietary recommendations At present, UK standards recommend that we aim for 120 to 150 percent of estimated average requirements for energy and 200 percent of the reference nutrient intake (RNI) of protein. Forty percent of the energy should come from fat (11). Table 2 provides a summary of the present dietary recommendations. What are children with CF actually eating? It has been documented that achieving the dietary recommendations is not always possible. In those with mild lung disease, published mean energy intakes have been consistently below the UK recommendations, 99 to 116 percent (12, 13, 14, 15). Also, 20

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Normal energy requirements in presence of good lung function >120% EAR for malnourished individuals No protein recommendations 110-200% energy No protein recommendations

only 11 to 39 percent have been able to achieve the dietary recommendations , suggesting that there appears to be an upper limit to the amount of food that can be eaten (15, 16). Although the aim is for an increased energy intake, aiming for 40 percent energy from fat, a moderate fat intake has been documented and the children have simply eaten more of all nutrients, compared to children of the same age, without CF (14, 17). Nutritional support in CF

In undernourished children with CF, oral nutritional supplements and enteral tube feeding have been shown to: 1. increase nutritional intakes; 2. improve growth; 3. improve lung function; 4. positively impact upon life expectancy. (18, 6, 19, 20, 21)

cystic fibrosis The most recent evidence concludes that enteral tube feeding has the strongest evidence base, with all studies demonstrating significant weight gain and a reduction in the rate of decline of lung function (22). However, it is not without its complications, with gastro-oesophageal reflux and diabetic onset being the most common. Gastro-oesophageal reflux incidence can be as high as 30 percent (23) and diabetic incidence from five percent to 50 percent (8, 23, 24, 25, 26), within one to two years follow up. Pancreatic Insufficiency (PI)

With a direct relationship between pancreatic function and nutritional status in CF, it is essential that maximal absorption of food is attained, with the appropriate use of pancreatic enzyme replacement therapy (PERT). At present, there are no studies determining the optimal dose, or if indeed there is a dose-response association (27, 28). Individual requirements vary, but generally, it should not exceed 10,000 IU lipase/kg body weight/day. Table 3 outlines present recommendations. As there are many factors that affect the efficacy of PERT, doses need to be individually advised and reassessed regularly. Vitamins

The fat soluble vitamins A, D, E and K should be given from diagnosis onwards in PI patients. An-

The treatment and management of CF is dependent upon the use of multiple medications and therapies, which can be complex and time-consuming for the patient and their family. nual monitoring is recommended as a minimum for all patients and doses adjusted individually. Current recommendations do exist and do vary between countries (see Table 4). Adherence and management

The treatment and management of CF is dependent upon the use of multiple medications and therapies, which can be complex and time-consuming for the patient and their family. This can result in non-adherence (33, 34) and poor level of competence, resulting in detrimental health outcomes (33). The CF team therefore need to be able to provide treatment that is patient/family centred and holistic that provides a balance between optimum treatment and quality of life (35).

Table 3 European CF Society (8)

USA Guidelines (27, 28)

Australian Guidelines (29)

Infants - 2,000 IU lipase/ 100ml feed Not to exceed 10,000 IU lipase/ kg/day

Newborn infants - 2,000-5,000 IU lipase/120mls feed Not to exceed 2,500 IU lipase/kg body wt/feed

Infants - 500-1,000 IU lipase/g fat The lowest effective dose should be used

< 4 yrs - 1,000 IU lipase/kg /meal > 4 yrs - 500 IU lipase/kg/meal, max of 2,500 IU lipase/kg/meal

500-4,000 IU lipase/g fat for a child The lowest effective dose should be used

Table 4: Recommended starting doses per day Vitamin

Recommendation

Vitamin A

< 1 yr 1,500 IU (455ug) (8) > 1 yr 4,000-10,000 IU (1,200-3,000ug) (31)

Vitamin E

< 1 yr 10-50mg > 1 yr 50-100mg (31)

Vitamin D

< 1 yr 1,000-2,000 IU (25-50ug) > 1 yr 1,000-5,000 IU 925-125ug/day) (30)

Vitamin K

< 2 yrs 300ug/kg to nearest mg > 7 yrs 10mg (32) NHDmag.com December 2014 / January 2015 - Issue 100

cystic fibrosis Summary

It is well established that nutritional status in CF is inextricably linked with lung function and that the level of malnutrition has been demonstrated to predict survival. As the disease progresses, increased nutritional support is normally required, with enteral tube feeding having the strongest evidence base, demonstrating significant weight

gain and a reduction in the rate of decline of lung function. Whilst life expectancy and outcomes for CF have made significant advances, it remains a life-limiting condition, placing a huge burden of care onto families and the children as they grow. It is, therefore, essential that the advice provided is specific to that child and their family rather than to the disease itself.

References 1 Dodge JA, Lewis PA, Stanton M, Wilsher J. CF mortality and survival in the UK: 1947-2003. Eur Respir J 2007; 29:522-526 2 Farrell PM et al (2001). Early diagnosis of CF though neonatal screening prevents severe malnutrition and improves long-term growth. Pediatrics; 107 (1): 1-13 3 Sharma R, Florea VG, Bolger AP, Doehner W, Coats AJS, Hodson ME, Anker SD, Henein MY (2001). Wasting as an independent predictor of mortality in CF. Thorax; 56:746-70 4 Greer R et al (1991). Evaluation of growth and changes in body composition following neonatal diagnosis of CF. J Ped Gastr Nutr; 13(1) 52-8 5 MS Marcus et al (1991). Nutritional status of infants with CF associated with early diagnosis and intervention. Am J Clin Nutr; 54:3; 578-585 6 Lai HJ, Shoff SM, Farrell PM. Wisconsin Cystic Fibrosis Neonatal Screening Group. Recovery of birth weight z score within 2 years of diagnosis is positively associated with pulmonary status at 6 years of age in children with cystic fibrosis. Pediatrics 2009; 123:714-22 7 Ellis et al (1998). Do infants with CF need a protein hydrolysate formula? A prospective, randomised, comparative study. J Pediatr; 132(2) 270-6 8 Isabelle Sermet-Gaudelus, Sarah J Mayell, Kevin W Southern. Guidelines on the early management of infants diagnosed with cystic fibrosis following newborn screening. Journal of Cystic Fibrosis 9 (2010) 323-329 9 Haycock GB (1993). The influence of sodium on growth in infancy. Pediatr Nephrol; 7(6); 871-5 10 Sinaasappel M, Stern M, Littlewood J et al (2002). Nutrition in patients with CF: a European consensus. J Cystic Fibrosis, 1:51-75 11 Littlewood J, Taylor C, Beckles Wilson N, Morton A, Watson H, Wolfe S (2002). Nutritional management of CF. CF Trust Publication. Bromley, Kent, UK 12 Kawchak DA, Zhao H, Scanlin TF, Tomeskjo JL, Cnaan A, Stallings VA (1996). Longitudinal prospective analysis of dietary intake in children with CF. J Pediatr 29: 119-128 13 Tomeskjo JL, Stallings VA, Scanlin TF. 1991. Dietary intake of healthy children with CF compared with normal control children. Pediatrics 547-553 14 White H, Wolfe SP, Foy J, Morton AM, Conway SP, Brownlee KB (2007). Nutritional intake and status in CF: does age really matter? J Pediatr Gastr Nutr 44: 116-123 15 Powers SW, Patton SR, Byars KC, Mitchell MJ, Jelalian E, Mulvihill MM, Hovell MF, Stark LJ (2002). Caloric intake and eating behaviour in infants and toddlers with CF. Pediatrics 109: 5; 1-10 16 Daniels L, Davidson GP, Martin AJ (1987). Comparison of the macronutrient intake of healthy controls and children with CF on low fat or non-restricted fat diets. J Pediatr Gastr Nutr 6: 381-386 17 Anthony H, Bines J, Phelan P, Paxton S (1998). Relation between dietary intake and nutritional status in CF. Arch Dis Child 78: 443-447 18 Steinkamp G, Wiedemann B. Relationship between nutritional status and lung function in cystic fibrosis: cross sectional and longitudinal analyses from the German CF quality assurance (CFQA) project. Thorax 2002; 57: 596-601 19 Lai HJ, Shoff SM, Farrell PM; Wisconsin Cystic Fibrosis Neonatal Screening Group. Recovery of birth weight z score within 2 years of diagnosis is positively associated with pulmonary status at 6 years of age in children with cystic fibrosis. Pediatrics 2009; 123: 714-22 20 Chaves CR, Britto JA, Oliveira CQ et al. Association between nutritional status measurements and pulmonary function in children and adolescents with cystic fibrosis. J Bras Pneumol 2009; 35: 409-14 21 Corey M, McLaughlin FJ, Williams M et al. A comparison of survival, growth and pulmonary function in patients with cystic fibrosis in Boston and Toronto. J Clin Epidemiol 1988; 41: 583-91 22 Walker SA, Gozal D. Pulmonary function correlates in the prediction of long-term weight gain in cystic fibrosis patients with gastrostomy tube feedings. J Pediatr Gastroenterol Nutr 1998; 27: 53-56 23 Woestenenk JW, Castellins SJ, Vand der Ent CK, Houwen RH (2013). Nutritional intervention in patients with CF: a systematic review. J Cystic Fibrosis 12: 102-115 24 Oliver MR, Heine RG, Ng CH, Volders E, Olinsky A (2004). Factors affecting clinical outcomes in gastrostomy-fed children with CF. Pediatr Pulmonol 37: 324-329 25 Efrati O, Mei-Zehav M, Rivlin J, Kerem E, Blau H, Barak A, Bujanover Y, Augarten A, Cochavi B, Yahav Y, Modan-Moses D (2006). Long-term nutritional rehabilitation by gastrostomy in Israeli patients with CF: clinical outcome in advanced pulmonary disease. J Pediatr Gastroenterol Nutr, 42: 222-228 26 Kane RE, Black P (1989). Glucose intolerance with low-, medium- and high-carbohydrate formulas during night time enteral feeding in CF patients. J Pediatr Gastroenterol Nutr 27: 53-56 27 White H, Pollard K, Etherington C, Clifton I, Morton AM, Owen D, Conway SP, Peckham DG (2009). Nutritional decline in CF RD: the effect of intensive nutritional intervention. J Cystic Fibrosis 8: 179-185 28 Stallings VA, Stark LJ, Robinson KA, Quinton H. Clinical Practice Guidelines on Growth and Nutrition Sub Committee: Ad Hoc Working Group (2008) Evidencebased practice recommendations for nutrition-related management of children and adults with CF and pancreatic insufficiency: Results of a systematic review. Journal of the American Dietetics Association 108: 832-839 29 Borowitz D, Robinson KA, Rosenfield M et al (2009). Cystic Fibrosis Foundation evidence-based guidelines for the management of infants with CF. Journal of Pediatrics 155: S73-93 30 Anthony H, Collins CE, Davidson G et al (1999). Pancreatic enzyme replacement therapy in CF: Australian guidelines. Paediatric Gastroenterological Society and the Dietitians Association of Australia. Journal of Paediatrics and Child Health 35: 125-129 31 Sermet-Gaudelus I, Bianchi ML, Garabedian M et al (2011). European CF bone mineralisation guidelines. Journal of CF 10: S16-S23 32 CF Trust Nutrition Working Group (2002) Nutritional Management of CF. London CF Trust 33 CF Trust (2007). Bone Mineralisation in CF. UK CF Trust Bone Mineralisation Working Group. Bromley: CF Trust 34 Sawicki GS, Tiddens H. Managing treatment complexity in CF: challenges and opportunities. Pediatr Pulmonol 2012; 47: 523-533 35 Bregnballe V, Schoitz PO, Boisen KA, Pressler T, Thastum M. Barriers to adherence in adolescents and young adults with CF: a questionnaire study in young patients and their parents 2011 36 Duff AJA, Oxley H. Psychological aspects of CF. In: Bush A, Bilton D, Hodson M (Eds). Hodson and Gedde’s Cystic Fibrosis. Third edition. London: Taylor Francis; 2014

NHDmag.com December 2014 / January 2015 - Issue 100

means giving the whole family something to smile about

Alfamino® is a hypoallergenic amino acid based formula, for the dietary management of severe/complex CMA For more information on Alfamino visit www.smahcp.co.uk Supporting you to support mums

Designed for tolerance and compliance in infants with cows’ milk allergy

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prebiotics

Prebiotics

Stephanie Allen

Liz Wells

Advanced Research Dietitians HONEI, Hull York Medical School, University of Hull

Stephanie Allen is an Advanced Research Dietitian working for the Hull York Medical School at the University of Hull. She originates from Australia where she trained and worked as an Accredited Practising Dietitian. Liz Wells is an Advanced Research Dietitian working at the Hull York Medical School. Prior to entering the world of academia she worked as a critical care specialist and a Macmillan Oncology Dietitian.

In the past, research and interest has been predominantly focused on probiotics but in the context of human health the future looks bright for prebiotics, with a wealth of information being gathered in the last two decades (1). They are considered attractive to researchers and industries, not only due to their nutritional benefits, but also their economic benefits and are used in food, particularly in the production of functional foods (2). Prebiotics are defined as ingredients that selectively stimulate the growth and/or activity of one or a limited number of species/genera of bacteria in the microbiota, thereby providing benefits to the health and well-being of the host (2). According to Gibson et al (3), a food component must meet the following requirements to be considered prebiotic: • be resistant to salivary, pancreatic and intestinal enzymes; • be fermentable by the intestinal microbiota; • selectively stimulate the growth and/ or activity of intestinal bacteria to contribute to health and well-being. Currently, only non-digested carbohydrate molecules, a range of di-, oligo- and polysaccharides, resistant starches and sugar polyols have been claimed to have prebiotic properties (4). Once prebiotics have reached the colon, they are hydrolysed to small oligomers and monomers which are then further metabolised by anaerobic bacteria (5). This process, known as fermentation, serves the bacteria, as it provides energy for proliferation and results in the production of short chain fatty acids (e.g. acetate, propionate, butyrate and L-lactate). The process also yields production of gases (H2, CO2, CH4) which are metabolically useless to the host, but now assist us in determining the degree to which these prebiotics are broken down, using the method of breath testing (6).

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Benefits of prebiotics

The list of prebiotic effects on the human body is growing as more is discovered about their mechanism and a deeper understanding is gained. It is postulated that prebiotics can influence the immune system, aid blood lipid control, aid mineral absorption and prevent the development of colon cancer. Lipid profiles

Prebiotics may have a role in the prevention of chronic diseases as they play a role in lipid level controls. Deranged lipid profiles, along with smoking and hypertension, is one of the key risk factors for cardiovascular disease. It is estimated that half of British adults have raised serum cholesterol levels, which rises with age. One of the by-products of fermentation of prebiotics is acetate, a gluconeogenic substrate, which might contribute to inhibition of cholesterol synthesis and regulation of adipose. It has been demonstrated mainly by a reduction in triglyceridaemia and only a relatively slight decrease in cholesterolaemia mostly in (slightly) hypertriglyceridaemic conditions (7). Gastrointestinal

Prebiotics are also thought to have a positive effect on bowel health as they specifically stimulate the growth of Bifidobacteria and Lactobacilli in the microbiota. Lactobacilli aids lactose digestion, resistance to infections such as Salmonellae, prevents travellers’ diarrhoea, helps relieve symptoms of irritable bowel syn-

prebiotics drome and decreases constipation (8). Bifidobacteria stimulates the immune system, produces B vitamins, inhibits pathogen growth, decreases blood ammonia, decreases blood cholesterol and helps promote gut flora returning to normal after antibiotic use (9). However, it must be noted that evidence exists to suggest that excessive consumption of non-digestible oligosaccharides may cause intestinal discomfort, flatulence or even diarrhoea. It is suggested that galacto-oligosaccharide consumption higher than 20g/day and fructo-oligosaccharide consumption higher than 40g/day are reported to cause diarrhoea (6). Mineral Absorption

The primary site for calcium absorption is via the small intestine, but it is thought that secondary absorption occurs throughout the length of the gut. It is hypothesised that prebiotics enhance calcium absorption by decreasing the pH of the gut lumen and by increasing the bioavailability of calcium by extending the site of mineral absorption towards the large intestines. The most active product for enhancing calcium and magnesium absorption is oligofructose-enriched inulin. Prebiotics have also been found to improve the absorption of iron, zinc and magnesium (10). Colon cancer

Colon Cancer is the second most common cancer after lung cancer in the United Kingdom. The aetiology is not fully understood but genetics, smoking, diet and inactivity have all been implicated. Specific dietary factors such as low fruit and vegetable intake, high red meat and a high processed food intake have been implicated. When substrates such as non-digestible oligosaccharides, fibre, undigested proteins or endogenous secretions enter into the large colon, their transit time slows allowing time for the microbiota to begin acting on them. It is speculated that prebiotics may protect against colon cancer via two methods. Short chain fatty acids, such as butyrate, are produced in the colon when prebiotics are fermented. Butyrate decreases the risk of colon cancer through stimulating apoptosis in colon cell cancer lines. Known butyrate producers in the colon are clostridia and eubacteria. Butyrate is largely metabolised by the colonic epithelium serving as a major energy substrate for healthy colonocytes as well as a regulator of cell growth and differentiation (1).

The second mode of action of prebiotics in colon cancer prevention is the subversion of colonic metabolism from protein and lipid metabolism. Protein degradation in the colon increases toxic substances such as ammonia and amines, which is linked to colon cancer and Inflammatory Bowel Disease. Prebiotics shift bacterial metabolism in the colon towards more benign end products (7). Why are prebiotics popular with the food industry?

The caloric value of non-digestible oligosaccharides, such as galacto-oligosaccharides, fructo-oligosaccharides and lactulose has been estimated to be 1.02.0kcal/g, which is approximately 30 to 50 percent of digestible carbohydrates such as sucrose (please note that lactulose is a disaccharide that possess similar properties to the oligosaccharides). Specifically, galacto-oligosaccharides have a caloric value of 1.73kcal/g (11). Due to their small caloric value, they are often added to low-calorie diet foods and can be used to mask the aftertastes produced by some of these intense sweeteners (12). Fermentable sugars, such as sucrose, are significant contributors to dental decay, as their digestion is started by the salivary enzymes. This results in residual food in the oral cavity which can provide an energy source for cariogenic bacteria (13). Unlike starch and simple sugars, non-digestible oligosaccharides are not utilised by the mouth microflora and, therefore, do not produce acids or polyglucans (cariogenic compounds). This enables them to be used as low cariogenic sugar substitutes in food products and, as a result, are often added to confectionary, chewing gums, yoghurts and drinks (12). Human milk oligosaccharides

During the first months of life, infants rely on milk as their sole source of nutrition, whether this is from infant formula or human milk. Breastfeeding has been shown to improve the development of the immune system of the newborn, resulting in protection against enteric and respiratory infections (14). The beneficial effects of human milk cannot be solely attributed to a single ingredient, but it is generally accepted that human milk oligosaccharides (HMO) play a key role (14). HMOs are the third largest component of human breast milk and are produced in the mammary gland where several monosaccharides are added to NHDmag.com December 2014 / January 2015 - Issue 100

prebiotics a lactose core by action of specific transferases (15). It is generally accepted that HMO are comprised of five monosaccharides: D-glucose, D-Galactose, Nacetyl-glucosamine, L-fucose and sialic acid (16). The intestinal microbiota of breastfed infants is generally dominated by Bifidobacteria and lactic acid bacteria, whereas the intestinal microbiota of formula-fed infants is more similar to that of adults, in that it contains heavier loads of bacteroides, clostridia and enterobacteriaceae (17). It is thought that this intestinal microbiota is partially due to the special composition of HMOs which makes it inaccessible to intestinal enzymes and, therefore, renders it indigestible, and satisfying the criteria for prebiotics (18).

Due to their complexity, oligosaccharides with structures identical to human milk, are not available as dietary ingredients (14). In a recent review it was noted that even though great progress has been made in synthesizing kilograms of HMO, the technology has not yet reached its full potential to consistently and efficiently produce large amounts of HMO that could, therefore, be added to infant formulas [19]. Instead of HMOs, galactooligosaccharide (GOS) and/or fructo-oligosaccharides (FOS) are often added to infant formulas with the expectation that they will produce the prebiotic effect which will help promote bacterial microflora (16, 20).

Table 1: Probiotics vs prebiotics (21) Probiotics

Prebiotics

Probiotics are living non-pathogenic micro-organisms which, when ingested, exert a positive influence on host health or physiology

Prebiotics are non-digestible food ingredients that benefit the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, that have the potential to improve host health

Probiotics are susceptible to environmental stresses such as heat damage during manufacturing processes or gastric acid and bile salts in the GI tract

Prebiotics are not affected by environmental stresses and do not get damaged whilst in transit to the colon

Probiotics cannot thrive without prebiotics

Prebiotics provide the fuel for the probiotic bacteria to flourish on

The major source of probiotics for humans is dairy-based foods containing intestinal species of Lactobacillus or Bifidobacterium

Prebiotics are readily available in fruits, vegetables, wheat products and pulses

References 1 Roberfroid M, Gibson G, Hoyles L, McCartney A, Rastall R, Rowland I, Wolvers D, Watzl B, Szajewska H, Stahl B et al. Prebiotic effects: metabolic and health benefits. Br J Nutr 2010, 104 Suppl 2:63 2 Scheid MMA, Moreno YMF, Maróstica Junior MR, Pastore GM. Effect of prebiotics on the health of the elderly. Food Research International 2013, 53:426-432. 3 Gibson GR, Probert HM, Loo JV, Rastall RA, Roberfroid MB. Dietary modulation of the human colonic microbiota: updating the concept of prebiotics. Nutrition Research Reviews 2004, 17:259-275. 4 Al-Sheraji SH, Ismail A, Manap MY, Mustafa S, Yusof RM, Hassan FA: Prebiotics as functional foods: A review. Journal of Functional Foods 2013, 5:1542-1553. 5 Delzenne NM, Roberfroid MR. Physiological Effects of Non-Digestible Oligosaccharides. LWT - Food Science and Technology 1994, 27:1-6 6 Mussatto SI, Mancilha IM. Non-digestible oligosaccharides: A review. Carbohydrate Polymers 2007, 68:587-597 7 Roberfroid MB. Introducing inulin-type fructans. Br J Nutr 2005, 93 Suppl 1:S13-25. 8 Gibson GR, Roberfroid MB. Dietary Modulation of the Human Colonic Microbiota - Introducing the Concept of Prebiotics. Journal of Nutrition 1995, 125:1401-1412. 9 Gibson GR, Roberfroid MB. Dietary modulation of the human colonic microbiota: introducing the concept of prebiotics. J Nutr 1995, 125:1401-1412. 10 Delgado GTC, Tamashiro WMDSC, Marostica MR, Moreno YMF, Pastore GM. The putative effects of prebiotics as immunomodulatory agents. Food Research International 2011, 44:3167-3173 11 Sako T, Matsumoto K, Tanaka R. Recent progress on research and applications of non-digestible galacto-oligosaccharides. International Dairy Journal 1999, 9:6980 12 Crittenden RG, Playne MJ. Production, properties and applications of food-grade oligosaccharides. Trends in Food Science & Technology 1996, 7:353-361 13 Hodoniczky J, Morris CA, Rae AL. Oral and intestinal digestion of oligosaccharides as potential sweeteners: A systematic evaluation. Food Chemistry 2012, 132:1951-1958 14 Rijnierse A, Jeurink PV, van Esch BCAM, Garssen J, Knippels LMJ. Food-derived oligosaccharides exhibit pharmaceutical properties. European Journal of Pharmacology 2011, 668, Supplement 1:S117-S123 15 Wainwright L. Does the addition of prebiotics to infant formula have beneficial effects for the baby? Journal of Neonatal Nursing 2006, 12:130-137 16 Han NS, Kim T-J, Park Y-C, Kim J, Seo J-H: Biotechnological production of human milk oligosaccharides. Biotechnology Advances 2012, 30:1268-1278 17 Bruzzese E, Volpicelli M, Squeglia V, Bruzzese D, Salvini F, Bisceglia M, Lionetti P, Cinquetti M, Iacono G, Amarri S, Guarino A. A formula containing galacto- and fructo-oligosaccharides prevents intestinal and extra-intestinal infections: An observational study. Clinical Nutrition 2009, 28:156-161 18 Barile D, Rastall RA. Human milk and related oligosaccharides as prebiotics. Current Opinion in Biotechnology 2013, 24:214-219 19 Casado B, Affolter M, Kussmann M. OMICS-rooted studies of milk proteins, oligosaccharides and lipids. Journal of Proteomics 2009, 73:196-208 20 Courts F, Wells LK, Allen SK and Jones HJ. In Oligosaccharides: Food Sources, Biological Roles and Health Implications. Edited by Krebs LSSaSJ: Nova Publishers 2013 21 Marteu P. Prebiotics and probiotics for gastrointestinal health. Clinical Nutrition 2001, 20, Supplement 1:41-45

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eras

Dr Fiona Carter BSc PhD, Manager of ERAS-UK

Expanding the scope and exploring the journey of Enhanced Recovery After Surgery

Mrs Imogen Fecher-Jones BSc MSc2, ERAS facilitator

Conference report: 4th Enhanced Recovery after Surgery UK at the Hub, City College, Southampton on 14th November 2014.

Mrs Pat Darty2, Conference co-ordinator

The Enhanced Recovery after Surgery Society (UK) was set up in 2010 with the aim of improving patient recovery after surgery by promoting knowledge, understanding and research regarding optimal outcomes. Each year, ERAS UK holds a national conference to highlight and share best practice and emerging techniques. This meeting provided a valuable opportunity for ERAS teams to network and discuss common challenges. This year, our conference was co-hosted by a multi-disciplinary team from University Hospitals Southampton, led by Professor Michael Grocott. Held at the Hub, City College, Southampton, this event welcomed almost 200 participants from across the UK and beyond. The organising group had agreed on five main themes for the 2014 meeting: 1 Exploring transitions of care 2 Non-elective or non-surgical care 3 The impact of new technology or new techniques on ERAS 4 Measurement of ERAS outcomes 5 Tackling the challenges of sustainability

Professor Michael Grocott BSc MBBS MD FRCA FRCP FFICM2, Conference chairman Nader K Francis MBBS PhD FRCS (Gen Surg)1, ERAS-UK Chairman

Affiliations Enhanced Recovery After Surgery Society (UK)

University Hospital Southampton NHS Foundation Trust

In addition to invited speakers, there were also 27 abstracts accepted for presentation, with seven of these given as oral presentations. In line with previous events, ERAS UK awarded prizes for the top three posters and oral presentations. Exploring transitions of care

There is increasing awareness that much more work needs to be done to improve both the prehabilitation process and the

longer recovery period after discharge. Dr Charles Alessi (Chairman of the National Association of Primary Care) set the scene for the day by describing the challenges of managing patients with multi-morbidity and the need to develop personalised care. Developing metrics that can reflect the activity across different sectors of healthcare will become increasingly important Developments in prehabilitation were highlighted by Mr Babu Naidu (Clinical Scientist, University of Birmingham) where rehabilitation pathways for Chronic Obstructive Pulmonary Disease patients have been adapted for the pre-operative period for lung cancer surgical patients. This involves pulmonary exercise classes, smoking cessation, patient education and assessment of nutrition, with dietary input if necessary. A patient story that highlights this approach is available online at http:// Vimeo.com/61707728. A reduction in pulmonary complications from 16 percent to nine percent, together with a reduction in readmission from 12 percent to four percent has been achieved through this approach. Dr Rachael Barlow, a Clinical Academic from Cardiff University, discussed the role of ERAS UK in research in the future and the formation of a research development group. A recent NIHR funded study highlighted the need for more multicentre randomised controlled trials and a greater focus on the evidence for cost-effectiveness for ERAS. The lengthy delays in essential treatment for cancer patients after discharge were highlighted by Mr Nader Francis (Consultant Colorectal Surgeon, Yeovil Dis-

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eras trict Hospital & Chair of ERAS UK). In particular, this study detailed the significant variation in timing of chemotherapy for colorectal cancer patients after discharge, indicating that ERAS benefits do not extend beyond the hospital admission. The final talk in this session was an abstract on ERAS ‘plus’ for frail elderly patients, from Dr Elizabeth MacDonald (NHS Lothian). This interdisciplinary project covers the patient journey from prehabilitation to discharge, with specific frailty markers embedded in the pathway. There was a significant percentage of frail surgical patients and that their needs were not always addressed by the conventional care pathways. Some aspects of frailty, such as comorbidity and polypharmacy, are more obvious than others (such as cognitive decline). Enhanced care can be targeted at the people who need it to provide better quality of care and improved outcomes for these frail elderly patients. Non-elective or non-surgical care

This session was opened by Dr Martin Kuper, Medical Director of Homerton Hospital, who described the process of setting up an enhanced recovery hospital. The conference chairman, Professor Michael Grocott, provided an overview of enhanced recovery following emergency laparotomy. Recent studies have shown impressive results, such as a reduction in 30-day mortality for the highest risk patients from 27 percent to 16 percent through use of these protocols. The national emergency laparotomy audit highlighted the lack of essential resources in some centres, such as lack of 24-hour access to emergency theatres, endoscopy or interventional radiology. Action plans and pathways form the best performing centres are being shared in an attempt to raise quality. Professor Grocott then outlined the EPOCH study and explained the cluster approach of this research, which uses the National Laparotomy Audit data collection tool as a cost-effective means of measurement (find out more here: www.epochtrial.org/ epoch.php?page=about). He concluded with the important point that the principles of enhanced recovery (multi-disciplinary collaboration, measurement of interventions and continuous improvement) can be applied to almost any aspect of healthcare. The ambitious project of redesigning pathways across a whole health board in Wales was described by Dr Rachel Barlow, who emphasised that ERAS 28

NHDmag.com December 2014 / January 2015 - Issue 100

should be seen as a quality initiative which opens up capacity and improves cost effectiveness. One of the major issues is that staff often do not realise the part that they play within ERAS pathways and this lack of awareness must be challenged by local ERAS leads and champions. Mr Tim Batchelor (Bristol Royal Infirmary) presented his initiatives in using ERAS for non-elective thoracic surgery patients, who are disadvantaged by the lack of access of the pre-operative ERAS pathways and undergo a functional decline as a result of prolonged hospitalisation and waiting for transfer to his tertiary centre for treatment. Ensuring that these patients are encouraged to follow a multidisciplinary pathway before surgery should result in improved post-operative outcomes. Two oral abstract presentations closed this session, with the first from Mr Tom Wainwright (Bournemouth University), who discussed the huge potential impact of applying enhanced recovery to fractured neck of femur patients nationally. Applying modelling to data extracted from Hospital Episode Statistics, Tom predicted that over 86,000 bed days could be saved if all centres could reduce their length of stay to the current national mean (19.6 days). The second abstract presentation was delivered jointly by Josie Caffrey and Rachel Thomas (Royal Berkshire NHS FT), who described the implementation of an elderly care pathway across five wards. They demonstrate an improvement in patient experience, staff attitudes and team working. The impact of new technology or new techniques on ERAS

Our third session was opened by Dr William Fawcett (Royal Surrey County Hospital) who provided an update on analgesia techniques that are relevant for enhanced recovery. He began by emphasising the importance of good analgesia in peroperative care in that it can allow earlier mobilisation, reduced organ dysfunction and stress response, earlier return to normal eating and drinking and faster discharge. This is largely achieved by multimodal analgesia and avoidance of opioids. Mr Tom Wainwright then presented his second abstract of the day, on a novel device (gekoTM) to reduce post-operative oedema. This device works by stimulating the extensor muscles in the calf and results in increased venous return. Use of the gekoTM as opposed the conventional TED stockings resulted

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eras in a significant reduction in lower limb volume in the postoperative period. The impact of technology on colorectal surgery was discussed by Professor David Jayne (Leeds Teaching Hospitals), starting with the introduction of laparoscopic surgery in the 1990s which significantly reduced post-operative pain, increased mobilisation and more rapid return to normal activity. These benefits, when combined with ERAS protocols have been examined in two RCTs (LAFA study: www.ncbi.nlm.nih. gov/pubmed/21597360, ENROL trial: http:// jco.ascopubs.org/content/early/2014/05/05/ JCO.2013.54.3694). Professor Jayne described the increasing use of robotic surgery, particularly for rectal cancer resections, where the surgeon’s control of the operative image and greater precision of the instrumentation reduce the likelihood of conversion to open surgery. Newer developments, such as single port surgery, may confer cosmetic benefits to the patient, but currently have no demonstrable benefits on outcomes. Professor Jayne closed by looking to the future technologies, in particular endoluminal or trans-anal surgery, which will be important as patient demographics change in the coming years. Ms Marielle Nobbenhuis (Royal Marsden Hospital) and Mr Anthony Koupparis (Southmead Hospital) both gave excellent talks on the impact of robotics on gynaecological oncology surgery and urology surgery respectively. Measurement of ERAS outcomes

Vaneesha Short (University of Bristol) started this session with an abstract presentation on a qualitative study of perioperative nutrition in patients undergoing colorectal surgery. The outcomes of this study could identify potential barriers and facilitators to feeding during the colorectal patient journey. Use of ERAS in patients having liver resection was the next abstract presented by Charlotte Hitchens (Derriford Hospital), reported a reduction in length of stay by two days for this group of patients. The final abstract presentation of the day was from Jennifer Mason (Yeovil District Hospital) about the factors that can predict 30-day readmission after colorectal surgery. It was interesting to note that poor compliance with the post-operative elements of the ERAS pathway significantly increased the likelihood of readmission. 30

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The current progress with widespread implementation of ERAS in Wales, together with national reporting systems was set out by Dr Rachael Barlow and this was then followed by an update on the Scottish national data collection programme by Mr David McDonald (Scottish Government). Mr Nader Francis presented the last talk in this session with a brief overview of a recent survey of ERAS UK members looking at what aspects of ERAS are being measured locally and what sort of tools are used to do this. Whilst a majority of centres are recording compliance with specific ERAS elements, most teams are using local databases or spreadsheets for this purpose, making benchmarking virtually impossible. Tackling the challenges of sustainability

The final session commenced with a debate on the topic: ‘What is delaying recovery?’ with Dr Mike Scott (Royal Surrey County Hospital) arguing that poor individualised fluid management is the main culprit. Mr Julian Smith (University Hospitals Southampton) presented his views that the culture of care was the main cause for delay and Mrs Imogen Fecher-Jones concluded the debate with her views that support at weekends, issues in critical care and challenges with patient’s social circumstances were the main barriers to recovery. Fiona Dalton, Chief Executive of University Hospitals Southampton gave the final address of the conference, with a powerful overview of the challenges facing the NHS and some insight into future directions for sustaining ERAS. In summary, the 4th National ERAS UK conference was very positively perceived by the feedback from the delegates, faculty and the 12 industrial sponsors. The full conference programme and many of the presentations are available to view on ERAS UK website (www.erasuk. net). The 5th ERAS UK conference will be held in Scotland on 6th November. Suggestions for content are very welcome and you can get involved via the website. Acknowledgements ERAS UK is grateful to the following companies who kindly provided financial support for this event: BBraun, Convatec, Deltex, Edwards, Halyard Health, Lidco, Massimo, MSD, Napp, Nutricia, Smith & Nephew and Vitaflo. In addition, ERAS UK would like to thank all the members of the organising committee and staff from the UHS service improvement department for their support on the day.

adhd

Diet Therapies for ADHD Attention Deficit Hyperactivity Disorder (ADHD) is a debilitating behavioural disorder which can have an adverse effect on family relationships and quality of life. While conventional treatments are typically used to manage ADHD symptoms, studies suggest that diet therapy can also be helpful. Carrie Ruxton PhD, RD, Freelance Dietitian, Nutrition Communications

Emma Derbyshire PhD, RPHNutr, Freelance Nutritionist, Nutritional Insight

Dr Carrie Ruxton is a freelance dietitian who writes regularly for academic and media publications. A contributor to TV and radio, Carrie works on a wide range of projects relating to product development, claims, PR and research. Her specialist areas are child nutrition, obesity and functional foods. Dr Emma Derbyshire is a freelance nutritionist and former senior academic. Her interests include pregnancy and public health.

This article discusses the scientific evi- patient, hyperactivity and impulsivity dence behind various dietary interven- take their toll on academic achievements tions for ADHD, particularly those re- and friendships (2)2. ADHD has been lating to elimination diets and fatty acid found to significantly reduce quality of supplementation which seem to offer life, with the risk of depression possibly the most promise. having some involvement in this (5). ADHD is a condition that can lead to In terms of treatments, pharmacoinattention, impulsivity, over activity and logical approaches are well established disruptive behaviour (1) as shown in Table and effective, but can lead to side effects 1. Although ADHD is (6). The cumulatypically classified as tive expense of carIn terms of treatments, a childhood disorder ing for individuals as it tends to present with severe forms of pharmacological approaches ADHD represents a in the first six years of life, it persists into significant cost for are well established and adulthood in 30 to social and healthcare 70 percent of cases services (7), while effective, but can lead to (2), with the worldbeing reported as wide prevalence in unsatisfactory or unside effects. adults estimated to acceptable in some be around 2.5% (1, 2). instances (8). The causes of A growing ADHD are multibody of literature faceted, but are believed to result from a points towards dietary change as an complex interplay between genetic and alternative way of addressing ADHD non-genetic factors, although more aetio- symptoms, either alone or as adjunct logical data is needed (4). What is known therapies. For example, Western-style is that the long-term and challenging diets, high in sugars and certain fatty nature of this condition can place con- acids have been associated with a higher siderable strain on families while, for the risk of ADHD symptoms (7) while cerTable 1: Common problems associated with ADHD Aggression Clumsiness Immature language Literacy problems Mood swings

Non-compliant behaviour Sleep disturbances Temper tantrums Unpopularity with peers

Source: Ruxton and Derbyshire (3)

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adhd

Beliefs that artificial food additives and dyes may contribute to hyperactivity in children were originally espoused in the 1970s by Dr Benjamin Feingold and are now enjoying a revival tain supplementation programmes, e.g. using fatty acids, zinc, magnesium and phytochemicals, have reasonable benefits for ADHD cases (9). Another advantage is that they encourage self-care in patients and families. Taking these points into consideration, this article will review the use and efficacy of various dietary and supplement regimes for ADHD. Exclusion/elimination diets

Beliefs that artificial food additives and dyes may contribute to hyperactivity in children were originally espoused in the 1970s by Dr Benjamin Feingold and are now enjoying a revival (10). A meta-analysis (11) of 24 studies looking at the effects of food colours and 10 studies on dietary restrictions found that diets restricting food colours provided some benefits for children with ADHD. However, it was noted that several were subject to publication bias. Equally, the INCA study (12) (Impact of Nutrition on Children with ADHD; n=100), a randomised controlled trial (RCT) found that exposure to high or low immunoglobulin G (IgG) foods led to a relapse of ADHD symptoms in 63 percent of children when introduced after a five-week elimination diet. This implies that elimination diets are useful in establishing whether ADHD symptoms are food-induced. Earlier work by the same research team found that 70 percent of children randomised to an elimination diet exhibited at least a 50 percent improvement in their behaviour (13). Overall, elimination diets in the form of reducing food colourings appear to be helpful in the management of ADHD symptoms. 32

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Low sugar diets

Although the causes of ADHD are largely unknown, one theory relates to disruptions in dopamine signalling as observed in various rewarddeficiency syndromes, such as drug addiction. Subsequently, it has been proposed that excessive sugar intakes could have similar effects, contributing to ADHD symptoms (14). The Raine Study (15), a prospective observational survey following 2,868 live births over 14 years, found that a ‘Western’-type dietary pattern, characterised by high intakes of refined sugars, was significantly associated with increased ADHD risk. Similarly, another study (16) found that high intakes of sweetened desserts were associated with a greater risk of learning, attention and behavioural problems in Korean children with ADHD. Although not conducted specifically on children with ADHD, findings from a cross-sectional study (17) of 3,361 German children showed that increased consumption of confectionary was associated with a greater likelihood of emotional symptoms. Other work (18) has revealed that choosing low glycaemic index foods, e.g. for breakfast, can improve markers of cognition in teenagers, such as memory and attention. However, as all of these studies are observational, they cannot be used to determine cause and effect and further controlled research is required before assuming that adaptations to sugar intake or GI could influence ADHD symptoms. Fatty acid supplements

It is now well accepted that omega-3 and omega-6 polyunsaturated fatty acids are needed for normal brain and nervous system function, with low intakes of omega-3s, in particular, being linked to

adhd Table 2: Other dietary interventions to consider Foods to avoid

Preferred foods

Takeaway fast foods

Fish, particularly oily

Processed meats

Lean red meat

Crisps, potato chips

Fresh fruits and vegetables

Soft drinks

Wholegrains

Foods with a high sugar content e.g. confectionary

Low-fat dairy products, nuts, seeds, dried fruit

Source: Adapted from Millichap & Yee (7) and Howard et al. (15).

neurocognitive disorders such as ADHD (19). A meta-analysis of 10 trials involving 699 children found that omega-3 supplementation, particularly eicosapentaenoic acid, was modestly effective in ADHD treatment and could help to augment pharmacological treatments (20). These findings are supported by other studies. For example, in a 12-month RCT (21), 90 children with ADHD were randomised to take an omega-3/6 supplement (Equazen eye q™), methylphenidate (a medication used to treat ADHD by increasing brain dopamine levels), or omega-3/6 supplementation, plus methylphenidate. It was found that the supplements offered similar benefits to the medication, although the combined effect of the supplement, plus medication was most effective. Similarly, an earlier study (22), which randomised 75 children with ADHD to take an omega-3/6 supplement versus a placebo for three months, followed by a period of open phase supplementation, showed that plasma fatty acid composition significantly improved in responders (defined as those who had a 25 percent reduction in ADHD symptoms after six months). Other work randomising children already on methylphenidate to take an omega-3/6 supplement versus placebo for six months showed that signs of inattention, impulsiveness and cooperation with teachers/parents significantly improved in the group receiving the omega-3/6 supplement (23). Vitamin and mineral supplements

There is accumulating evidence that iron deficiency may contribute to ADHD symptoms. This assumption makes sense given that iron is needed for nerve cell function in the brain (the dopaminergic system) and can influence cognitive

function (24). A cross-sectional study (25) of 713 children and teenagers with ADHD found that hyperactivity scores were significantly inversely associated with ferritin levels. Similar findings were seen in a study where children with low ferritin levels (≤30ng/ml; six to 14 years of age) were treated with ferrous sulphate (4.0mg/kg/day) for three months. The intervention was found to successfully manage ADHD symptoms in those cases categorised as inattentive (24). In a RCT (26) on ADHD children aged five to eight years with low ferritin levels, ADHD symptoms significantly improved in children randomised to take 80mg/day ferrous sulphate for 12 weeks compared with a control group. Iron therapy was well tolerated. The impact of iron on ADHD, as well as cognitive function in healthy children, is worth exploring further, given that iron deficiency affects 13 percent of preschool children and four percent of older children, while low ferritin levels are seen in up to 18 percent of children (27). In terms of other programmes, a RCT (28) of 80 adults with ADHD, allocated to take either a vitamin-mineral or placebo supplement for eight weeks, showed that micronutrient supplementation improved ADHD symptoms, especially amongst those with depression at baseline. Discussion

Interest has been growing in the potential of diet therapies to benefit ADHD patients, either alone or alongside conventional drug treatments, not least because of the risk of side effects with ADHD drugs. As identified in this review, elimination diets (particularly for food additives/colourings), supplementation with omega-3/6 fatty acids and iron supplementation, appear to offer the most promise NHDmag.com December 2014 / January 2015 - Issue 100

adhd for reducing ADHD symptoms in children. That said, further rigorously designed RCTs are needed, given that baseline nutrient/fatty acid status could influence the efficacy of dietary interventions. Other dietary modifications that may be of benefit to children with ADHD are suggested in Table 2. Given the increased awareness and diagnosis of ADHD, health professionals can support ADHD patients and their parents/carers by offering evidence-based advice on the potential of diet therapies, as well as identifying which interventions are of most relevance to individuals. While sugar reductions and avoidance of certain food additives could prove challenging for many families, particularly those that rely on processed foods, supplementation with fatty acids or iron could represent a simple, achievable option. However, as with other conditions, advice on supplementation and dietary modification should

be sought from healthcare professionals to ensure that they complement other treatments. In addition, the evidence suggests, at least for omega-3/6 supplements, that dietary therapies seem to work best when used alongside medication. Conclusion

In conclusion, ADHD is a complex behavioural condition, often impacting on work, family relationships and social interactions with peers (9). There is growing evidence that dietary modifications may help to support the management of ADHD with the most promising results seen in trials of fatty acid supplementation, iron supplementation and avoidance of certain food additives. Acknowledgement This work was supported by Equazen eye q. The views expressed are those of the authors.

References 1 Gaynes BN et al (2014). Attention-deficit/hyperactivity disorder: identifying high priority future research needs. J Psychiatr Pract 20(2),104-17 2 Chen JY et al (2014). Factors affecting perceptions of family function in caregivers of children with attention deficit hyperactivity disorders. J Nurs Res 22(3),165-75 3 Ruxton CHS and Derbyshire E (2013). Fatty acids in the management of ADHD. Complete Nutrition, 13(4), 85-87 4 Tarver J et al (2014). Attention-deficit hyperactivity disorder (ADHD): an updated review of the essential facts. Child Care Health Dev [Epub ahead of print] 5 Seo JY et al (2014). Mediating effect of depressive symptoms on the relationship between adult attention deficit hyperactivity disorder and quality of life. Psychiatry Investig 11(2), 131-6 6 Schneider BN et al (2014). Managing the risks of ADHD treatments. Curr Psychiatry 16(10), 479 7 Rommelse N et al (2013). Is there a future for restricted elimination diets in ADHD clinical practice? Eur Child Adolesc Psychiatry, 22(4), 199-202 8 Millichap JG et al (2012). The diet factor in attention-deficit/hyperactivity disorder. Pediatrics 129(2), 330-7 9 Curtis LT et al (2008). Nutritional and environmental approaches to preventing and treating autism and attention deficit hyperactivity disorder (ADHD): a review. J Altern Complement Med 14(1), 79-85 10 Kanarek RB et al (2011). Artificial food dyes and attention deficit hyperactivity disorder. Nutr Rev 69(7), 385-91 11 Nigg JT et al (2012). Meta-analysis of attention-deficit/hyperactivity disorder or attention-deficit/hyperactivity disorder symptoms, restriction diet and synthetic food colour additives. J Am Acad Adolesc Psychiatry 51(1), 86-97 12 Pelsser LM et al (2011). Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Lancet 377(9764), 494-503 13 Pelsser LM et al (2009). A randomised controlled trial into the effects of food on ADHD. Eur Child Adolesc Psychiatry 18(1), 12-9 14 Johnson M (2011). Attention-deficit/hyperactivity disorder: is it time to reappraise the role of sugar consumption? Postgrad Med 123(5), 39-49 15 Howard AL (2011). ADHD is associated with a ‘Western’ dietary pattern in adolescents. J Atten Disord 15(5), 403-11 16 Park S (2012). Association between dietary behaviours and attention-deficit/hyperactivity disorder and learning disabilities in school-aged children. Psychiatry Res 198(3), 468-76 17 Kohlboeck G (2012). Food intake, diet quality and behavioural problems in children: results from the GINI-plus/LISA-plus studies. Ann Nutr Metab 60(4), 24756 18 Cooper SB (2012). Breakfast glycaemic index and cognitive function in adolescent school children. Br J Nutr 107(12), 1823-32 19 Schuchardt JP et al (2010). Significance of long-chain polyunsaturated fatty acids (PUFAs) for the development and behaviour of children. Eur J Pediatr 169(2), 149-64 20 Bloch MH et al (2011). Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry 50(10), 991-1000 21 Barragan E et al (2014). Efficacy and Safety of Omega-3/6 fatty acids, methylphenidate, and a combined treatment in children with ADHD. J Atten Disord [Epub ahead of print] 22 Johnson M et al (2012). Fatty acids in ADHD: plasma profiles in a placebo-controlled study of omega-3/6 fatty acids in children and adolescents. Atten Defic Hyperact Disord 4(4), 199-204 23 Perera H et al (2012). Combined omega-3 and omega-6 supplementation in children with attention-deficit hyperactivity disorder (ADHD) refractory to methylphenidate treatment: a double-blind, placebo-controlled study. J Child Neurol 27(6), pp747-53 24 Soto-Insuga V (2013). Role of iron in the treatment of attention deficit-hyperactivity disorder. An Pediatr 79(4), 230-5 25 Oner P (2012). Ferritin and hyperactivity ratings in attention deficit hyperactivity disorder. Pediatr 54(5), 688-92 26 Konofal E (2008). Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol 38(1), 20-6 27 Bates B et al (2014). National Diet and Nutrition Survey. Rolling programme years 1-4. Public Health England/Food Standards Agency 28 Rucklidge JJ et al (2014). Broad-spectrum micronutrient treatment for attention-deficit/hyperactivity disorder: rationale and evidence to date. CNS Drugs [Epub ahead of print]

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eating disorders

Eating disorders: case study This case study is based on my experiences with several patients, although there was one who features more strongly. Details have been altered to preserve the confidentiality of the patients concerned, as well as giving an authentic overview of the challenges of in-patient treatment for people who are seriously ill with restrictive eating disorders.

Sheila Turner Sheila retired from her post as Community Dietetic Lead a year ago and continues to provide and develop a private dietetic service within a residential clinic for women and adolescents.

Patient: Female, aged 23. Median weight: 63.3 kg with fat 21 per cent or more. Diagnosis: Restricting type of anorexia nervosa of seven years duration. Medication: Mirtazapine, Forceval Liquid, Movicol, ADCal, initially thiamine and strong B for 10 days.

Treatments: • Initial 17-day assessment with refeeding, treatment for physical health and key worker sessions. • At day 17 review, decision to add CBT and Body Image Therapy at BMI 15. • Weekly review in multidisciplinary meeting. Family therapy added after four months.

Extracts from Dietetic Reports BMI 13.8 (kg/m2) Weight 35kg (Ht =1.59m) Fat 3%

March

Admission to specialised residential clinic for treatment of eating disorders. Admission was from a community service where there was a diet plan, but she had been able to follow that and most of her admitted intake was salad and some starch. Weight had been managed by restriction of food, physical activity and some purging, although purging was limited by her financial position where she would be unable to afford to waste the food. Laxatives x 2 a week claimed to be for constipation. Some superficial cutting, but not contemplating self-harm at admission. Blood sugars low normal and urea high normal, other electrolytes within normal range. Big fear food was cheese and “anything greasy”. Vegetarian. Although the refeeding risk was limited by her previous intake, it was planned that she would start on quarter portions and no snacks, milk at bedtime. If the refeeding risk had been higher, she would have started on 20 percent of 1,400 kcals, including milk, so would have been offered about the amount she was prepared to eat.

16.3.

One meal increased to half, but very little being eaten.

17.3.

Breakfast and tea now half. Eating a bit better, but refusing anything sweet including jam on toast.

18.3.

All meals to half. Accepting all eight drinks.

Wt 34.5kg Urea now normal

20.3.

Beginning sequential increase to full portions under guidance of key nurse. Refusing yoghurt.

No signs of refeeding syndrome

1.5.

Spends all her time thinking about food and much of contact time arguing against increase or even current amount. Keeps talking about her fear of grease and noncompliance about cheese. Monosyllabic and easily offended. Finds it difficult to socialise with other patients

Wt 36.5kg BMI 14.4 (kg/m2) Fat 3%

5.6.

Managing full diet apart from problems with cheese and compound dishes like lasagne. Still focusing on fat especially in cooked meals. Introduced savoury snacks of 250 to 300 kcals – rather limited without cheese. Still determined to avoid sweet foods because she “does not deserve nice things”. Will sometimes eat yoghurt and banana. To try dried fruits.

Wt 38.3kg, BMI 15.1 (kg/m2),Fat 3.5% Allowed to use stairs and offered five minutes activity a day

15.7.

Patient agreed to try mindfulness with a sweet food of her choice along with myself and her support key worker.

July

Continuing to gain weight on full portions with two savoury snacks. Very slow with some non-compliance and some inadequate snacks. As planned, reluctantly tried mindfulness using yoghurt raisins. Achieved four raisins and felt she may have enjoyed them a bit.

Wt 40.3kg BMI 15.9 (kg/m2)

NHDmag.com December 2014 / January 2015 - Issue 100

eating disorders July/Aug

Tried mindfulness again with support worker, but very reluctant to try any other foods, aim to try chocolate at some point. BMI over 16 and therefore home leave and short periods of meaningful activity have been introduced. Allowed to go on trips with other patients to do craft or visit cinema etc.

Wt 42kg BMI 16.6 (kg/m2) Fat 5.9%

Sept

Unable to eat either raisins or banana at home in her single flat. Eating too little altogether because she feels she has no money for food. Starting to make plans to re-enter education, but realises she needs to step up recovery to start this year. Initial motivation to change, but problems with finance and continued difficult disordered thoughts gradually wore motivation away again. Unfortunate interactive event with a perceived breach in confidentiality by a support worker led to increased non-compliance.

Wt 40kg BMI15.1 (kg/m2) Fat 4%

Oct-Dec

Returned to clinic to complete treatment. Activity and home leave in relation to improvement in weight and psychological health. Discharged before Christmas into care of community team. Still having problems with cheese and sweet foods, but able to manage a diet that is nutritionally adequate and maintains weight.

Wt increased to 46kg BMI 18.1(kg/m2) Fat 15%

Reflections

• Treatment for prevention of refeeding syndrome. History given at assessment a few days before admission would have indicated that there would be little risk of refeeding. However, the value of diet assessment face to face as soon as possible after admission was shown by the reported diet and weight loss for those few days. Although her safety would have been fairly assured because of her lack of ability to eat, this would confirm our policy of offering a quarter portion of the first meals and refeeding protocol vitamins until a clearer picture, including admission blood tests, is obtained. In this case, there was indication of dehydration rather than water loading, so there wasn’t the false higher BMI due to excess water that we often see. Refeeding would be at 20 percent of assumed BMR of 40 cals per kg. If the patient is compliant, this is increased each day so that at five days they will be taking around three half portions of meals and a glass of milk, depending on initial weight. • Allowing changes from set plan for her anorexic problems around sweet foods. It is

hard to say whether she would have managed sweet things better if encouraged more strongly to take them from the beginning. It would have been easy for me to prescribe them in the diet, but her argumentativeness would probably have led to inconsistency in support workers’ enforcing of the menu, which would have made it harder still to get her to a BMI where she was able to engage in therapy. The challenge of cheese and determination to stick with the vegetarianism that developed with her illness, seemed to be the limit of everyone’s negotiations. • Mindfulness. The mindfulness trial seemed to work in that she ate something outside her rigid plan at a time when she would not usually eat. She was able to participate in much the same way as the very heavy people did with whom I have tried this, but her thoughts were of course around eating something and more quickly rather than the contrary. It was good that the support worker managed to repeat the exercise and found that this deflected her from continuing to argue round in circles about her diet plan.

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NHDmag.com December 2014 / January 2015 - Issue 100

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gluten-free

Gluten-free products: to prescribe or not to prescribe? There has been much debate regarding gluten-free (GF) product prescriptions and some Primary Care Trusts have limited the types of products to the most necessary, such as bread varieties, pasta and flour. Nevertheless, these prescriptions are estimated to have cost the NHS 27million pounds in 2013 (1). Eirini Koutroulis Dietitian

This cost is bound to increase as the number of people being diagnosed with coeliac disease (CD) grows. With this in mind, the following questions arise: Are food prescriptions really necessary? What other alternatives are there to food prescriptions for the dietary management of coeliac disease? Coeliac disease

For article references please email: info@network healthgroup.co.uk

Eirini Koutroulis is a dietitian working in the NHS, with experience in media and an interest in research and public health.

CD is an autoimmune disease where the ingestion of gluten results in inflammation of the small intestine and villous atrophy in genetically susceptible people. Some of the symptoms include macroand micro-deficiencies, gastrointestinal symptoms, increased risk of bowel cancer, infertility and growth problems in children. The types of symptoms vary and can be mild to severe, with some people having no obvious signs. It is believed to be present in one in 100 people and increases to one in 10 where a firstdegree family member has the condition (2). Those suffering from other autoimmune diseases, such as Type 1 diabetes and autoimmune thyroid disease, may be at a higher risk of developing CD. Dermatitis Herpetiformis is a skin condition linked to CD and occurs in one in 10,000 people (2). It is estimated

that only 24 percent of people with CD have officially been diagnosed and there has been a fourfold increase in incidence in the UK over the past 22 years (3). Diagnosis

Serological tests and a gut biopsy are required to confirm diagnosis (4). Prior to testing, ≥3 g gluten (two slices of wheat bread) per day must be consumed for a minimum of two weeks to avoid a false negative result (4). Treatment

The only treatment currently available is a strict adherence to the lifelong exclusion of gluten from the diet. This involves not only avoiding gluten in food, but also sterilising surfaces to avoid cross-contamination with gluten-containing products. Gluten is a protein naturally present in wheat, barley, rye and cereal hybrids, such as triticale. Some guidelines also suggest avoiding oats for the first six to 12 months due to sensitivity to the gluten-like protein called avenins (5). The remaining list of naturally GF grains and staple foods is quite long (Table 1), so what are the difficulties in choosing naturally GF foods?

Table 1: List of some naturally gluten-free staple foods and grains

Gluten-free grains and staple foods

Amaranth, buckwheat, cassava, corn, rice, wild rice, potato, gram flour, hemp, maize, millet/bajra, polenta, quinoa, soya, tapioca, teff, urd/urid/urad flour, uncontaminated oats, sorghum All unprocessed meat, diary, fish, vegetables, fruit, nuts, seeds, beans and pulses and uncontaminated products of these foods. NHDmag.com December 2014 / January 2015 - Issue 100

gluten-free Table 2: Policies in other countries to assist in the dietary management of coeliac disease. These include partial coverage of the cost of foods, tax deductions/relief for the cost of GF foods, delivery expenses and even conference costs.

Country

Policy

Considerations

New Zealand (8)

Part-subsidy on gluten-free product list.

Patients pay part of the cost of the product. No new products will be added to the list in the future. Need to take into account the extra charges for GP prescription, possible pharmacy charges and cost of products to assess cost effectiveness.

Tax deduction as a medical expense

Includes: • the difference in price between a GF product and the non GF equivalent product; • the full cost of items used for GF home baking, which would otherwise not be used, i.e. xanthan gum; • a part of the travel costs to stores for GF foods, including tolls and parking fees; • the full cost of delivery expenses for GF food made by mail order; • admission and transportation to a medical conference related to coeliac disease. However, aggregated medical expenses need to reach 7.5% of adjusted gross income before becoming eligible to write off the excess (IRS Publication 502).

Canada (10)

Tax deduction as a medical expense

Includes: • the average incremental cost of a food between the GF and the non-GF variety; • full cost of intermediate items to make a GF food (e.g. Rice flour, GF spices).

Ireland (11)

Tax relief

Able to claim back the standard rate on special dietary GF products (not foods that are naturally gluten-free) from taxes. Since September 2012, gluten-free foods are no longer available on the Medical Card or Drug Payment Scheme.

United States (9)

The risk of cross-contamination of naturally GF foods during the manufacturing process and the presence of gluten-containing grains or additives in processed foods, are two of the main concerns when choosing a food product. Quite often there is ambiguity and inadequate information on the food labels, so patients need to refer to the Coeliac UK Food and Drink Directory (database of GF products) or call Coeliac UK, or the food company itself for clarification. For example, barley malt extract is derived from a gluten-containing grain, but can be tolerated in small amounts and, unfortunately, the quantity is not indicated on the food label. If the level of gluten in the final product is ≤20ppm, then it is considered GF, according to a new law from the European Commission (EC41/2009). These products may be indicated with the Cross Grain Symbol on food packaging, but the use of this symbol is optional. This ambi40

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guity may limit a patient’s diet to the most familiar and clearly indicated GF products, and could increase dependence on GF product prescriptions, as these appear to be the safest option. Dietary management in the UK

Currently in the UK, the NHS offers GF products on prescription. Patients are able to choose from an approved list of products and each GF product equates to a certain number of units. Each patient has an allowance of units per month according to the National Prescribing Guidelines (6). These are based on information from the National Diet and Nutrition Survey and it is assumed that other naturally GF staple foods are consumed as well. However, the area prescribing policies, which come from the local Clinical Commissioning Group, may differ and, ultimately, the number of units prescribed will depend on the clinical deci-

Beef & Gravy

with mashed potato and peas

Staying well-nourished can be a challenge for patients who have Blended atdifﬁculty chewing or swallowing. Thosehome on a puréed for diet are faced with: • Messy and with dissatisfying results people

dysphagia • Reduced nutritional content

• Time-consuming food preparation • The danger of not blending to a safe consistency • Reduced choice – unable to enjoy high risk foods, such as peas Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether. The good news is there is a more appetising alternative.

Made in a blender at home Staying well-nourished can be a challenge for patients who have difﬁculty chewing or swallowing. Those on a puréed diet are faced with: • The danger of not blending to a safe consistency • Messy and dissatisfying results • Reduced nutritional content • Time-consuming food preparation • Reduced choice – unable to enjoy high-risk foods like peas Unsurprisingly, patients can often lose their desire to eat and may try to avoid mealtimes altogether.

The good news is there is a more appetising alternative…

gluten-free

Dietetic consultations not only educate patients on how to avoid gluten in the diet, but also ensure sufficient intake of nutrients, vitamins, fibre and calcium sion of each individual GP. Eighty percent of CD patients are receiving GF food prescriptions (3), which is costing the NHS approximately 27 million pounds; however, investigations by the BBC have suggested that the cost may be a lot higher if handling and delivery charges are included (7). Gluten-free product prescriptions

The use of the GF food prescriptions started in the 1960s when GF staple foods, such as flour and bread, where not as readily available in stores and food labels were less informative. Availability is still an issue today for gluten-free versions of wheat based products, particularly in rural areas and in the smaller stores (12), and the information on food labels is quite often still inadequate. The cost of these products is estimated to be 80 percent to 500 percent more expensive than the gluten-containing equivalent (12), making them unaffordable for those on a low-income. Since 2011, some areas have introduced restrictions to GF prescriptions. A recent study in Scotland showed significant under-prescribing of GF products amongst 16 GP practices, when compared to the Coeliac UK guidelines (13). The impact of these changes was examined in a recent research project commissioned by the British Specialist Nutrition Association (14). The findings show that the greatest negative impact on patients was financial. Patients also experienced difficulties in finding GF products and were unsure of their suitability. These factors may affect compliance and the nutritional value of the diet. A survey conducted by the University of Chester, comparing the GF diet with the Estimated Average Requirements in the UK, highlighted inadequate intake of calcium, non-starch polysaccharides and vitamin D and stressed the importance of GF fortified products for a nutritionally complete diet (15), however, GF products are not always fortified (16). Consuming fortified GF products may not be the only way of creating a nutritionally complete 42

NHDmag.com December 2014 / January 2015 - Issue 100

diet. Using alternative naturally GF grains can significantly improve the nutrient profile of the diet (17). There are also other low cost products, such as fortified supermarket own-brand breakfast cereals (e.g. Rice Krispies and Corn Flakes), which can be included in the diet and are not prescription products. Dietetic consultations not only educate patients on how to avoid gluten in the diet, but also ensure sufficient intake of nutrients, vitamins, fibre and calcium (18). Also, dietetic input and regular follow-ups appear to be key factors in compliance with a GF diet (19, 20), but dietetic support may be underprovided in the UK (21). Moving forward

Improving people’s understanding of food labels and knowledge of alternative GF grains and foods may be achieved with store tours and cooking classes. These group sessions could potentially provide more frequent contact with dietitians, improve patients’ confidence in choosing the right products on a budget, increase the variety of foods consumed by exposing patients to less familiar foods, and possibly reduce dependence on food prescriptions, while creating a more nutritious and varied GF diet. A study investigating the cost and the accessibility/availability of uncontaminated naturally GF foods and grains in stores would help with the development of such a program. It may also highlight the difficulties in using food labels alone to determine product suitability in a GF diet, and suggest improvements. GF food prescriptions have been reduced in both variety and quantity over the past few years, which has left patients feeling unsupported financially and in many other ways (14). It would be interesting to assess the effectiveness of store tours and cooking classes as a supplementary treatment, or as an alternative to food prescriptions, to ensure that patients have adequate support in following a nutritionally complete GF diet.

Beef & Gravy

with mashed potato and peas

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folic acid

EU Disease Risk Reduction Health Claim for Folic Acid Further to publication of the list of authorised EU health claims (3), a glaring omission has been a claim for the benefit of folic acid supplements prior to pregnancy and reduced risk of neural tube defects (NTD), such as spina bifida and anencephaly, in the foetus. This was despite conclusive evidence for this important health benefit, which is a global WHO health recommendation (4). Michèle J Sadler Rank Nutrition Ltd

Michèle is Director of Rank Nutrition Ltd, which provides nutrition consultancy services to the food industry. Michèle has a BSc in Nutrition (University of London), a PhD in Biochemistry and Nutritional Toxicology (University of Surrey), and is a Registered Nutritionist.

Since publication of the conclusive MRC trial in 1991, which demonstrated that supplementary folic acid can help to reduce the risk of NTDs by up to 72 percent (5), women who might become pregnant have been recommended by the Department of Health to take a daily supplement of 400mcg folic acid, prior to conception and until the 12th week of pregnancy. Certain groups have a higher risk of an affected pregnancy and these include women or their partner who have spina bifida, women with a previously affected pregnancy or with a family history of NTD, women who are diabetic, take anti-epilepsy medication, have coeliac disease or have a BMI above 30 kg/m2. These groups are recommended to take 5.0mg folic acid a day, which requires a prescription. Since this recommendation was introduced, women’s awareness of this message has remained generally low. In 2011, Shine (1), the UK’s spina bifida and hydrocephalus charity, initiated its ‘Go Folic!’ campaign to help raise awareness among women of the need to take folic acid before they become pregnant, and a commitment to the primary prevention of NTD. Uptake of folic acid supplements

A study exploring the rationale behind women’s decision-making on folic acid supplement use (6), invited 292 women attending routine health visitor-led baby clinics to take part, of whom 211 women provided information on supplement use relating to their most recent preg-

NHDmag.com December 2014 / January 2015 - Issue 100

nancy. Of these, only 67 (31 percent) reported having taken folic acid supplements as recommended, 118 (56 percent) took them only during pregnancy (22 or 18 percent only intermittently), and 26 (12 percent) had not taken folic acid at all. Discussion in focus groups revealed that though the rationale behind the current recommendation was generally known, folic acid use was often linked with morning sickness, and busy lives; competing priorities for concern and poor memory were given as reasons for intermittent use. A more general survey in January 2012 of 10,000 consumers from the general UK population indicated that the uptake of folic acid supplements by women remains very low. Only 3.3% of the women respondents reported taking a folic acid supplement and, whilst this figure was slightly higher for women in the critical 18 to 34 age group, it is still worryingly low at four percent (7). EU health claim for folate

Under the initial round of EU health claim authorisations (3), up until now supplement manufacturers have only been able to claim on packaging and in other consumer communications that ‘folate contributes to maternal tissue growth during pregnancy’. This was viewed as a missed opportunity to help educate and inform women about the vital role of folic acid taken preconceptionally and during the early stages of pregnancy, and it was recognised that a stronger health claim was needed.

folic acid Disease risk reduction claim

During 2012, three dietary supplement trade associations in the UK (HFMA, PAGB and CRNUK) (2) came together, in conjunction with Shine, with the support of the Department of Health, to prepare an application for an Article 14.1(a) disease risk reduction claim for folic acid, under the Nutrition and Health Claims Regulation (8). The reason for Shine’s commitment to this claim is the high incidence of NTD-affected pregnancies in Europe: • A recent report Act against Europe’s Most Common Birth Defects: One Year On - Defining Neural Tube Defect prevention strategies in Europe (9) has identified that there are 4,500 pregnancies affected by NTD each year in Europe, of which an estimated 72 percent are terminated following prenatal diagnosis. The condition is not usually diagnosed until the 20-week scan, causing much distress to the mother if it is decided to terminate the pregnancy as this is classed as ‘late term’. • Up to 70 percent of NTDs could be avoided by ensuring adequate folate status before conception in women of childbearing age. • A European Commission report Communication of Rare Diseases: Europe’s Challenges (10) recognises that NTDs are one of the few rare diseases for which the incidence could be reduced. Reduction of risk is very straightforward - the intake of folic acid supplements prior to pregnancy and hence all available means to communicate this crucial message should be utilised. • In the UK, The Food Standards Agency has previously estimated that the economic cost associated with NTDs in the UK runs to almost £136 million per annum. Hence across Europe the costs are substantial. A claim application was submitted in the early part of 2013 via the UK Competent Authority, the Department of Health. The application was awarded a positive EFSA opinion, which was published on 26th July 2013 (11). The claim was then subject to the ensuing authorisation procedures which included discussion by the Commission working group on claims (Member States, expert level) and by the Standing Com-

mittee, which awarded the claim a positive vote in April 2014. The claim was notified to the WTO, discussed by the European Council and was finally subject to a three-month scrutiny period by the European Parliament. The Regulation authorising the claim was published in the Official Journal on 24th October 2014 (12), and the claim came ‘into force’ on 18th November 2014. The health claim is based on low maternal folate status as the risk factor for NTD in the foetus. EFSA commented that folate in serum or plasma is a sensitive marker of early changes in folate status, and that red blood cell folate is considered a reliable biomarker of long-term folate status as it reflects tissue folate stores, and decreases only weeks or months after the initial reduction of folate intake and the fall in serum folate concentrations (11). The authorised wording of the claim is consistent with all the other authorised disease risk reduction claims to date and states that, ‘Supplemental folic acid intake increases maternal folate status. Low maternal folate status is a risk factor in the development of neural tube defects in the developing foetus.’ The conditions of use are restricted to folic acid supplements and state that the claim may only be used for folic acid supplements that provide at least 400mcg of folic acid per daily portion. Use of the claim should be accompanied with information stating that the target group is women of childbearing age and that the benefit is obtained with a supplemental folic acid daily intake of 400mcg for at least one month before and up to three months after conception. Conclusion

Obtaining an authorised EU disease risk reduction claim that can be used on products and in advertising is a much needed initiative that will be in the public interests of European consumers, as it will enable manufacturers to explain to women why folic acid is beneficial. The claim is an important step forward in helping to raise awareness of this vitally important public health message. For article references please email: info@network healthgroup.co.uk NHDmag.com December 2014 / January 2015 - Issue 100

legends of dietetics

The number one dietitian There were not enough trumpet-blasts and popping champagne corks to celebrate the launch of the fifth edition of The Manual of Dietetic Practice (fantastically edited by Joan Gandy), published in the summer of 2014.

Ursula Arens Writer; Nutrition & Dietetics

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the British Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews.

Although this is more a dipping-into rather than a reading-through kind of book, there is a wonderful first page to this issue of MDP. It is a dedication to the outstanding and continuing contribution to dietetics of BDA member number 001: Edith Elliot. Of course, Edith is not the first member of the BDA; in fact, her period of chairmanship coincided with the 50th anniversary of the foundation of the BDA. The special number simply represents a point in time, while she was honorary chairman of the BDA, when the records of membership were transferred from lots of cards in an over-fulfilling cabinet, onto a computer database. But the special number of 001 is a fitting tribute to a very constant champion of our profession. Before dietetics was the defined and structured profession that it is today, it was a merging of professionals with interests in diet and health and with primary qualifications in nutrition, in nursing, in domestic science, or in catering management. Edith qualified as a nurse and as a midwife in 1960. Her first job was as a staff nurse at the Royal Infirmary of Edinburgh, and she observed with interest the occasional instructions of consultants as to what foods particular patients should be given. Very rarely, some women come onto the ward to discuss foods with the consultant, or with the ward sister and then special plated foods arrived for particular patients. These women, Edith found out, were dietitians. What would have been rare encounters between a junior nurse and a dietitian, became more frequent as Edith went to work in ward 21, which was the pioneering metabolic and renal unit of the hospital. This was the work base for dietitians in

NHDmag.com December 2014 / January 2015 - Issue 100

the hospital and Edith was able to observe closely the field she became more and more interested in. Her nursing qualification was recognised as a valid basis for entry onto the 18-month course leading to a diploma in dietetics, which she completed in 1963 at the Northern Polytechnic in London (now, the London Metropolitan University). Edith then returned to ward 21 of the Royal Infirmary of Edinburgh. Although she was now qualified as a dietitian, she continued to carry out many nursing duties as well and her job title was ‘sister/dietitian’. Her next job at the Victoria Hospital in Kirkcaldy also required balancing dietetic and nursing responsibilities. At some stage, career development required a focus on one or the other duty. Edith chose to jump fully into dietetics, because she enjoyed the subject and also because she felt it would allow her more patient contact (whereas highergrade nursing would have become increasingly administrative). Edith knew London from her student days doing her diploma in dietetics and, in 1972, she accepted the post of Chief Dietitian at St Mary’s Hospital. This was not a happy time professionally for Edith, as there was little support and recognition for the role of dietetics, which was lost somewhere between the controls of the medical consultant and the catering manager and, three years later, Edith accepted the post of District Dietitian in Nottingham. In August 1996, more than 20 years later, Edith retired from the NHS, and professional dietetics. But it is really Edith’s other career that is as inspirational. While she was a dietitian in Nottingham, her colleague asked whether she could ‘help out’ as assistant treasurer for the BDA; this would

legends of dietetics be a monthly half-day in Birmingham to fill a few bills and check a few cheques. When motherhood pulled away the Treasurer at the time, Edith accepted promotion to the post. 1976 was not the easiest time to be Treasurer of the BDA. There was a backdrop of inflation rates of nearly 20 percent and terms of the IMF bail-out required a UK government agreement to austerity = public sector wage maintenance. Counter to the normal laws of economics, dietetic salaries were very poor, despite a great shortage, and BDA subscriptions had not been increased for a while, leaving BDA finances very tight. Further, there was great membership support for plans to expand BDA activities, such as employment of additional administrative staff and the newly agreed newsletter (which has now become the monthly Dietetics Today). Edith presented the case that annual subscriptions needed to be increased very significantly, from £12.75 to £20.50. In ‘today’s money’, this would be as though there was a proposal to increase the current full annual subscription from £284 to £455! Needless to say, there was a lot of debate and Edith as treasurer was the centre of both an extraordinary council meeting and an extraordinary members meeting. The counter view was that such steep increase in fees would lead to so many non-renewals, that the total income from subscriptions could, in fact, be reduced. Clearly Edith’s figures were persuasive enough to demonstrate the case and members voted to support the increased subscriptions (and there were very few non-renewals). In 1985, Edith became honorary chairman of the BDA. Because the BDA became a listed trade union in 1983, there had been an increase in work, and the decision was made to employ a professional administrator. Mr John Grigg was appointed in February 1985, and was in post to support the significant 50th year ‘Golden Jubilee’ celebrations of the BDA in 1986. The BDA annual conference that year was an International Symposium held at the Barbican in London and enjoyed by more than 450 delegates (more than 100 of whom were international attendees). On completion of her chairing responsibilities, Edith became Treasurer for the European Dietitians Association (EFAD) for 12 years until 2000. Her many years of experience and her many European contacts also put Edith in a strong position to support the Edinburgh hosting of the International

Confederation of Dietetic Associations (ICDA) congress in 2000. Professional retirement from her post at the University Hospital in Nottingham may have happened in 1996, but Edith’s activities for the BDA continue to a degree that can hardly be matched. Edith is the current archivist of the BDA and, for many years, has systematically sorted into keep-or-dump piles, all paper records of BDA history up to 2000. All back copies of newsletters, all council minutes and briefing papers, all committee records, all branch and group annual reports and any other documents of possible interest. “I don’t want the past to be lost,” explains Edith and, without doubt, future researchers wanting to access any aspect of BDA history will be grateful to her, for the thorough and meticulous sorting of the records of our profession. This summer (July 2014), 69 sealed boxes were sent to the professional care of the archiving department of the Wellcome Institute; any future researcher will find the dietetic family tree easy to access. Of course, dietetics in the future will be different, but Edith has no concerns over the essential strengths and contributions that our profession makes to human health and welfare (the themes of her professional life). “Where there is a coming together of foods and people, as individuals, as families, as groups or as communities, there will always be the need for support and advice on how to best do this, to protect health. This is what dietitians have done, and will continue to do.” A great endorsement for the optimistic future of dietetics, from someone who has seen its’ development over a long time. Edith Elliot’s support for our profession has been constant and practical. Of course she would be the first to insist that there have been others equally dedicated. But it is nonetheless a small, but valid recognition that she is dietitian number one and that the current tome of MDP is dedicated to her. The BDA career of Edith Elliot Honorary Treasurer; 1976-1981 Honorary Vice-Chair; 1984; 1988 Honorary Chairman; 1985-1987 Trustee: BDA General and Education Trust; 2000-2012 BDA Archivist; 2000-

NHDmag.com December 2014 / January 2015 - Issue 100

career

To place a job ad here and on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) dieteticJOBS.co.uk

COMPANY DIETITIAN TILLERY VALLEY Up to £40,000 dependent on experience; plus car, flexible benefits and bonus. We are currently recruiting for the rewarding and interesting role of Company Dietitian. The role involves providing nutrition and dietetic expertise to Tillery Valley Foods Limited, the leading producer of chilled and frozen prepared meals to the UK healthcare sector. The purpose of this role is to advise Tillery Valley Foods of relevant nutrition and dietetics issues; providing in-house nutrition and dietetic expertise to the production, technical and sales teams. You will be determining client needs in order to ensure appropriate nutritional and dietetic targets are incorporated into all new products and existing product reformulation. Through predicting trends in nutrition and dietetics you will help to develop the business in such a way to achieve a ‘market edge’ whilst advising on product range suitability. You will also be providing assistance to customers regarding compliance with UK nutritional standards, menu planning, special diet provision and also to respond to technical queries. For more information: www.sodexojobs. co.uk/jobs/job/Company-Dietitian/13584. Closing date: 15th December 2014 (This vacancy may close early if suitable applications are received prior to the closing date.) Locum Dietitian Children’s Centres London A London NHS hospital is looking for a Locum Dietitian to cover an interesting role working in children centres. The Dietitian requires experience working with children and families in the community and in children centres in the central London area. Starting Monday 1st December until 24th December with possible extension. Excellent Rates offered for the right Dietitian. Please call 01277 849 649, or email hayley@eliterec.com for more information on this role. www.elitedietitians.com

NHDmag.com December 2014 / January 2015 - Issue 100

Band 6 Dietitian Herts Hertfordshire NHS Trust are looking for a Band 6 experienced Dietitian to cover a four-day-a-week role, covering outpatients clinics and three GP surgeries, home visits including patients on home enteral nutrition and inpatient adult ward work across Hertfordshire. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com Community Food Worker NHS London A London NHS hospital is looking for a community food worker to work alongside dietitians in the children’s centre in delivering practical cook and eat sessions. The role is full time starting December for one month. For this or other dietetic vacancies with Elite, please contact Hayley on 0800 023 2275/01277 849 649 or email your CV and interest to hayley@ eliterec.com www.elitedietitians.com Band 6 Dietitian Birmingham A Birmingham NHS Trust is looking for a Band 6 Dietitian to commence work from Monday 5th January, full time for an ongoing duration. The role covers community hospitals and home visits with experience in nutritional support required. Call 0800 023 2275 or 01277 849 649, or email hayley@ eliterec.com. Please follow us on Twitter @elitedietitians or visit our website www.elitedietitians. com for up-to-date Jobs. Band 6 Dietitian London A London NHS hospital is looking for a Band 6 Dietitian to cover a community and acute role in West London starting in December as an ongoing role. Covering Elderly care and Neuro rehab in community hospitals and home visits. To be considered for this role, please email Hayley@eliterec.com or call 01277 849 649. www.elitedietitians.com

career Community Dietitian - North London A London NHS Trust is looking for a Band 6 Dietitian to cover a full-time role as a Community Dietitian in North London. Must have home enteral feeding experience and have transportation. Starting ASAP for two months. Excellent rates offered for the right dietitian. Please call 01277 849 649, or email hayley@eliterec.com for more information on this role. www.elitedietitians.com Two Dietitians Wanted - Band 5 and 6 Staffs A Staffordshire NHS Trust is looking for two Dietitians Band 5 and 6 to cover an acute role across different hospitals in the area. Starting ASAP, this role will possibly run until the end of March 2015. Call 0800 023 2275/01277 849 649, or email hayley@eliterec.com. Please follow us on Twitter @elitedietitians or visit our website: www.elitedietitians.com for up-to-date Jobs. Company Paediatric Dietitian - Full Time A commercial company is looking for a Paediatric Dietitian to join its current team on a fixed-term contract helping to build relationships with clients and to promote its products. The role is field based and

full time starting January 2015. To be considered for this role, please email Hayley@eliterec.com, or call 01277 849 649. www.elitedietitians.com Specialist Dietitian - Eating Disorders Band 6 Specialist Dietitian with experience of Eating Disorders for an ongoing contract from December. This is a hospital-based post in the South of England. For this and similar jobs, please contact Patrice at PJ Locums on 0800 032 0454 or 020 8874 6111. Email your CV to registration@pjlocums. co.uk. Our rates are competitive in the current market; we offer assistance with relocation and hospital accommodation. We provide you with a current CRB, full occupational health check and can organise your mandatory training. PJ Locums is an NHS Government Procurement and LPP framework approved supplier for Allied Health, Health Science personnel and nurses.

www.dieteticJOBS.co.uk 0845 450 2125

We urgently require dietitians for immediate vacancies To find out your options call or email Freephone: 0800 032 0454 Registration@pjlocums.co.uk

• PJ Locums is an NHS Buying Solutions framework approved supplier for allied health • Our aim is to find you the right person and the right job • We offer inpatient and community UK & NI coverage • Competitive rates

www.pjlocums.co.uk NHDmag.com December 2014 / January 2015 - Issue 100

career

events and courses Obesity- A National Epidemic Nutrition Society Winter Meeting 2014 Organised jointly with the Royal Society of Medicine Nutrition and age-related muscle loss, sarcopenia and cachexia’ 9-10 December 2014 Royal Society of Medicine, London, UK www.nutritionsociety.org/winter-meeting-2014 The meeting will explore the importance of nutrition in preventing and treating sarcopenia and cachexia. Attendees will learn about current research and clinical perspectives on the impact of skeletal muscle on human health, and how nutrition influences this. They will have the opportunity to network with colleagues from basic science, nutrition, dietetics, public health and industry. The programme will include a variety of plenary sessions, Original Communications, the Cuthbertson Medal Lecture and opportunities for networking.

New Frontiers in Fibre - British Nutrition Foundation half-day symposium 29th January 2015 - 12.30 to 16.30 This insightful half-day event will explore the relationship between fibre and health and will include individual presentations by experts in the field followed by a facilitated Q&A panel discussion. The symposium will look at emerging research on the role of fibre and novel fibres in mineral absorption, immunity, cardiovascular disease and obesity. It will also cover the implications of increasing fibre in the diet generally and in certain clinical groups. Full programme details and booking information can be found at: www.nutrition.org.uk/bnfevents/events/new-frontiers-in-fibre

University of Nottingham - School of Biosciences Modules for Dietitians and other Healthcare Professionals • Understanding Behaviour Change Module 12th February 2015 • IBS & the Use of the FODMAPs Diet Study Day 18th March 2015 For further details please email marie.e.coombes@ nottingham.ac.uk, tel: 0115 951 6238 or check out the University website at www.nottingham.ac.uk/biosciences and click on short courses then ‘for practising dietitians’.

8th December Conference The Mermaid Conference & Events Centre, London http://obesity-conference.govtoday.co.uk/programme

Early Years: High Impacts for Health 9th December The Mermaid Conference & Events Centre, London www.infanthealthconference.co.uk/programme

Behaviour Change

19th-21st January 2015 Venue: Derby For further details www.ncore.org.uk

Survival in the Health and Care Landscape

26th-27th January 2015 Clinical Leadership, Quality Service Improvement and Commissioning for Dietitians Venue: Derby www.ncore.org.uk

New Frontiers in Fibre

29th January 2015, 12.30 to 16.30 British Nutrition Foundation half-day symposium Governors Hall, St Thomas’ Hospital, London SE1 7EH www.nutrition.org.uk/bnfevents/events/new-frontiers-in-fibre

To promote your courses or events here please please call 0845 450 2125 (local rate)

dieteticJOBS.co.uk The UK’s largest dietetic jobsite To place a job ad in NHD Magazine or on www.dieteticJOBS.co.uk please call 0845 450 2125 (local rate) 50

NHDmag.com December 2014 / January 2015 - Issue 100

the final helping For those of you who haven’t read the previous ‘Helping’, (shame on you), I focused on my somewhat increasing frustration with the apparent lack of original thought/innovation being given to tackling the obesity epidemic/tsunami/time bomb. This is especially so in relation to its proportionally growing effect on the overstretched resources of the organisation I worked for as a dietitian for 37 years: our embattled National Health Service. Neil Donnelly

Neil is a Fellow of the BDA and retired Dietetic Services Manager. His main areas of interest are weight management and eating disorders.

I voiced the idea of a United Kingdom Obesity Party (UKOP). This has created almost as much interest as the then Junior Health Minister Edwina Currie did in 1988 when she told ITN News that, “most of the egg production in this country, sadly, is now affected with salmonella”, Phew! As I write this, the now former politician continues to keep things on the boil in the ‘Celebrity Jungle’. It is interesting how just one comment from someone in a position of responsibility can affect public opinion (the ‘eggs debate’ also being well before the likes of Facebook and Twitter). Let’s look at the options. We can carry on listening to the latest offerings on the benefits of the Mediterranean diet etc, combined with increasing our activity, or we can rattle a few political cages by accepting all the Social Media likes and dislikes. Enter UKOP. Years ago a party was formed called The Official Monster Raving Loony Party. It is still a registered political party today and was narrowly defeated in the recent byelection at Rochester and Strood by just 198 votes by the Lib Dems( currently part of the coalition), coming sixth out of 13. They are a happy party. They are a win-win party. A UK Obesity Party has much to offer, but very little time to act before the NHS succumbs to the funding pressures exerted on it and resort to extensive support from the private sector to manage its ever-burgeoning obesity-related health issues. This will change the face of healthcare provision in this country and, make no mistake, will affect us all, whatever weight we are. Can/should this publication attempt to recruit support from health professionals/individuals/organisations to draw up

a draft manifesto in record time (Polling Day is 7th May 2015)? Will there be time to launch a candidate(s) at the General Election next year? Are YOU interested? If you are, then maybe the impossible will become possible. Could a tiny voice get the main parties talking about the following? • a dedicated NHS-linked innovative Obesity Management Strategy; • a pre-tax profits contribution to support the above from national food manufacturers, large food retailers, fast food outlets etc; • a National Weight Control Registry as in the USA; • an incentivised healthy weight/healthy staff NHS employee programme; • a link between schools and hospitals so that parents and children can see at first hand the damaging effects of this epidemic on our shores, etc, etc. The fat of the matter is that we have all become too comfortable in our own skin. Two in every three of us are overweight or obese. It’s the norm. We have had numerous warnings, all to no avail, from every conceivable report on obesity over the last 10 to 15 years that we cannot sustain this disproportionate growth in girth. Let’s take a good look at ourselves. With all the political parties currently in such disarray and the likelihood of a new, but different coalition government, which does not bear thinking about, what have we got to lose? Your NHS of course. If you are in any way interested (what would you put on the manifesto?) and wish to help with the above, please email the Editor. Thank you.

NHDmag.com December 2014 / January 2015 - Issue 100

Here’s to choice Only Nutricia offers the widest range of compact nutrition, including Fibre and Protein

Fortisip Compact also has the widest range of flavours, from banana to forest fruit, which may aid patient compliance.1 Reference: 1. Hubbard GP et al. Clin Nutr 2012:31;293–312. Nutricia Ltd., White Horse Business Park, Trowbridge, Wilts. BA14 0XQ. Tel: 01225 751098. www.nutriciaONS.co.uk SCC2650-11/14

Still #1 when it comes to choice and flavour range

NHD Dec 14/ Jan 15 Issue 100

Articles inside

Events and courses

The final helping

dieteticJOBS

Legends of dietetics

Gluten-free

Eating disorders

Folic acid

Prebiotics

ADHD

News

ERAS

Cystic fibrosis