News

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]. 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.

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

OmEgA-3 rESEArCH ANtiBiOtiCS iN EArLy LiFE AND OBESity LiNk

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 supplementation 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

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.

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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.

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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VirAl hePAtitiS

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.

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

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-

Using patient . . . it is the first study nificant decrease in feedback regard- resting energy exing their own to demonstrate how penditure (p= 0.67). health outcome However, there was and experience preventive nutrition in a 14 percent deof care, seeks to crease in energy indrive increased hepatitis C treatment can take (p=0.012) with quality and ef- significant weight fectiveness, as impact on clinical loss (p=<0.001). The well as monitor- weight loss expeing traditional outcomes. 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

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.

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

Patient name

NHS No

DOB

Dietetic Outcomes Recording Sheet Viral Hepatitis Op Clinic

A = achieved PT = progression towards NA = not achieved + barrier code M = maintained NO = not applicable

Initial Treatment Date

Final Treatment Date

SVR Yes/No

Goal: To improve nutritional status following assessment, treatment planning and monitoring of diet and anthropometry from referral to discharge.

Aim Goal/ Starting Review date: Review date: Review date: Review date:

measurement

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.

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

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

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